S uden : Danielle Maloney
ADVISOR: ITZHAK LEVAV
Fac o s ha de e mine he le el o ca e
child en and adolescen s expe iencing
men al diso de s ecei e
MASTER’S DISSERTATION
Deg ee: In e na ional Mas e s in Men al Heal h Policy and Se ices
Yea o Comple ion: 2015
Uni e sidade NOVA de Lisboa,
NOVA Medical School / Faculdade de Ciências Médicas;
Wo ld Heal h O ganiza ion, Depa men o Men al Heal h and Subs ance Dependence.
Acknowledgemen s
I would like o hank bo h
P o esso Phillip Hazell, Conjoin P o esso o Child and Adolescen Psychia y wi h he
Sydney Medical School, Uni e si y o Sydney, and
D Ann Wignall, P incipal Clinical Psychologis , No he n Sydney Local Heal h Dis ic
o helping me o cla i y my hinking a ound how Child and Adolescen Men al Heal h
Se ices (CAMHS) a e s uc u ed.
Summa y
P o ision o imely, e ec i e, e idence based men al heal h se ices o child en and adolescen s can
p e en long e m impai men , bu hey a e c i ically unde unded ac oss he globe. The e is an
impe a i e o ensu e his p ecious esou ce is no was ed. Go e nmen s and o he ele an men al
heal h s akeholde s need o know he men al heal h s a us o he popula ion, wha esou ces a e
a ailable and how bes o use he esou ces a ailable o guide e ec i e policy and decisions abou
se ice le els.
Aim:
The aim o his pape is o explo e he ole o acui y, se e i y and complexi y in de e mining he
specialis men al heal h ca e ha child en and adolescen s expe iencing men al diso de s ecei e.
Me hods:
This s udy is explo a o y in ol ing a sys ema ic scan o he li e a u e. A key wo d sea ch was
conduc ed using da abases PSYCHINFO, EMBASE, PUBMED and MEDLINE. G ey li e a u e was also
sea ched o ocus on sys emic, o ganisa ional and policy app oaches o he o ganisa ion and
commissioning o CAMHS. Only documen s w i en in English we e selec ed.
Th ee coun ies Belgium, UK and he US all wi h e y di e en models o se ice o ganisa ion o
CAMHS we e e iewed o in es iga e how well he concep s o acui y, se e i y and complexi y we e
used o de e mine he le el o ca e deli e ed in hei se ice design.
Findings:
Nei he he Belgium no he US model o CAMHS se ice o ganisa ion appea o align wi h he key
concep s d i ing in ensi y o le el o se ice p o ision. The UK CAMHS se ice sys em mos closely
aligns wi h he concep s. I has a mo e balanced esou ce alloca ion be ween hospi al and
communi y. I s down all is in i s lack o lexibili y be ween se ice le els and i s lack o suppo o
he p ima y ca e sec o .
Conclusions:
The a iabili y in esou ce alloca ion o di e en se ice le els (inpa ien , ou pa ien , communi y)
wi hin specialis CAMHS and he di e ing model o se ice s uc u e ac oss coun ies indica es an
inconsis ency in how child en and adolescen s p esen ing o CAMHS a e alloca ed o he ca e hey
ecei e. This pu s in o ques ion whe he child en and adolescen wi h men al diso de s a e ecei ing
a le el and ype o ca e commensu a e wi h hei needs.
In commissioning and designing CAMHS sys ems a numbe o key p inciples ha should be
conside ed a e discussed. The pe ec sys em howe e , is ye o be ound.
Key Wo ds: CAMHS, Se e i y, Complexi y, Se ice O ganisa ion, Models o Ca e
Resumo
Uma p es ação de se iços de saúde men al pa a c ianças e adolescen es (CAMHS) opo una, e icaz
e baseada na e idência pode e i a incapacidade a longo p azo. No en an o, es es se iços são
c i icamen e sub- inanciados em odo o mundo. É um impe a i o ga an i que es e p ecioso ecu so
não seja despe diçado. Os go e nos e ou as pa es in e essadas ele an es na á ea da saúde men al
p ecisam de conhece o es ado de saúde men al da população, quais os ecu sos disponí eis e como
melho u iliza os ecu sos disponí eis pa a o ien a uma polí ica e decisões e ec i as sob e os ní eis
de se iços.
Obje i o:
O obje i o des e a igo é explo a o papel da acuidade, g a idade e complexidade na de e minação
dos cuidados em saúde men al especializados ecebidos po c ianças e adolescen es que so em
pe u bações men ais.
Mé odos:
Es e es udo é explo a ó io en ol endo uma e isão sis emá ica da li e a u a. Foi ealizada uma
pesquisa com pala as-cha e u ilizando bases de dados PsychINFO, EMBASE, PubMed e MEDLINE. A
li e a u a cinzen a ambém oi in es igada com um en oque nas abo dagens sis émicas,
o ganizacionais e polí icas pa a a o ganização e comissionamen o de CAMHS. Fo am selecionados
apenas documen os esc i os em Inglês.
T ês países, Bélgica, Reino Unido e Es ados Unidos, odos eles com modelos mui o di e en es de
o ganização de CAMHS, o am e is os pa a in es iga de que o ma os concei os de acuidade,
g a idade e complexidade o am u ilizados na sua concepção de se iços pa a de e mina o ní el da
assis ência p es ada.
Resul ados:
Nem a Bélgica, nem o modelo no e-ame icano de CAMHS o ganização de se iço pa ecem es a
alinhados com os p incipais concei os na de e minação do ní el de p es ação de se iços. O sis ema
de se iços do Reino Unido de CAMHS es á mais es ei amen e alinhado com esses concei os e em
uma alocação de ecu sos mais equilib ada en e o hospi al e a comunidade. O seu pon o aco es á
na al a de lexibilidade en e os ní eis de se iço e na al a de apoio pa a com o sec o dos cuidados
de saúde p imá ios.
Conclusões:
A a iabilidade na alocação de ecu sos a di e en es ní eis especializados de CAMHS (em egime de
in e namen o, ambula ó io, e na comunidade) e o modelo di e en e de es u u a de se iços en e
os países es udados indica uma inconsis ência na o ma como as c ianças e adolescen es que
ap esen am aos CAMHS são e e enciados pa a os cuidados que ecebem. Is o põe em ques ão se as
c ianças e adolescen es com pe u bações men ais es ão a ecebe o ní el e ipo de cuidados
conco dan es com as suas necessidades.
A concepção e o comissionamen o de sis emas de CAMHS le am-nos à discussão de uma sé ie de
p incípios undamen ais que de em se conside ados. O sis ema pe ei o no en an o, ainda es á
pa a se encon ado.
Pala as-cha e: CAMHS, g a idade, complexidade, o ganização de se iços, modelos de cuidados
Suma io
P es ación de opo una, e icaz y basado en la e idencia de se icios de salud men al pa a los niños y
adolescen es pueden p e eni el de e io o a la go plazo, pe o es án insu icien emen e inanciado
c í icamen e odo el mundo. Es impe a i o ga an iza que es e p ecioso ecu so no se despe dicia.
Los gobie nos y o as pa es in e esadas pe inen es de salud men al necesi an conoce el es ado de
salud men al de la población, lo que es án disponibles y la mejo mane a de u iliza los ecu sos
disponibles pa a o ien a la polí ica y las decisiones ace ca de los ni eles de se icio e icaz de los
ecu sos.
Obje i o:
El obje i o de es e abajo es explo a el papel de la agudeza, la g a edad y la complejidad en la
de e minación de la a ención de salud men al especialis a que los niños y adolescen es que su en
as o nos men ales eciben.
Mé odos:
Es e es udio es explo a o io e implica una explo ación sis emá ica de la li e a u a. Una búsqueda de
la palab a cla e se ealizó u ilizando las bases de da os PSYCHINFO, EMBASE, PubMed y MEDLINE.
Li e a u a g is ambién ue egis ada pa a cen a se en los en oques de los sis émica, ins i ucional y
polí ica de la o ganización y la comisión de CAMHS. Sólo se selecciona on los documen os esc i os
en Inglés.
Los es países de Bélgica, Reino Unido y los Es ados Unidos, odas con di e en es modelos de
o ganización de se icio pa a CAMHS ue on e isados pa a in es iga qué an bien los concep os de
la agudeza, la g a edad y la complejidad se u ilizan pa a de e mina el ni el de la a ención en egada
en su diseño de se icios.
Resul ados:
Ni o ganización de se icios modelos CAMHS en Bélgica o los EE.UU. pa ecen alinea se con los
concep os cla e de la conducción ni el in ensi o de la p es ación de se icios. El sis ema de se icios
de CAMHS de Reino Unido alinea más es echamen e con los concep os. Cuen a con una asignación
de ecu sos más equilib ada en e el hospi al y la comunidad. Su caída se encuen a en su al a de
lexibilidad en e los ni eles de se icio y su al a de apoyo al sec o de la a ención p ima ia.
Conclusiones:
La a iabilidad en la asignación de ecu sos de di e en es ni eles de se icio (pacien e hospi alizado,
ambula o io, comuni a ios) den o CAMHS especialis a y el modelo di ie e de la es uc u a de
se icio de los dis in os países indica una inconsis encia en cómo los niños y adolescen es que
acuden a CAMHS se asignan a la a ención que eciben. Es o pone en ela de juicio si los niños y
adolescen es con as o nos men ales es án ecibiendo un ni el y ipo de a ención aco de con sus
necesidades.
En la comisión y el diseño de sis emas CAMHS, se discu en una se ie de p incipios undamen ales
que deben se conside ados. El sis ema pe ec o, sin emba go, aún no se ha encon ado.
Palab as cla e: CAMHS, la g a edad, la complejidad, la O ganización de se icio, modelos de
a ención

Table o Con en s
Summa y ............................................................................................................................................ i
Resumo ............................................................................................................................................. ii
Suma io ............................................................................................................................................ iii
In oduc ion ...................................................................................................................................... 1
Aims and Objec i es ...................................................................................................................... 2
Magni ude o he P oblem ................................................................................................................ 2
P e alence o Men al Diso de s in Child en and Adolescen s ......................................................... 2
Issues in de e mining magni ude ................................................................................................... 4
Clinical men al heal h needs o child en and adolescen s .............................................................. 5
Me hodology ..................................................................................................................................... 5
Resou ces alloca ed o child and adolescen men al heal h ............................................................... 6
S uc u e o CAMHS .......................................................................................................................... 8
CAMHS placemen in he se ice spec um .................................................................................. 10
Le els o CAMHS ca e .................................................................................................................. 10
In luencing ac o s on le el o CAMHS ca e p o ided ............................................................... 12
Whe e do coun ies p io i ise hei CAMHS esou ces?................................................................ 13
CAMHS se ice p essu e poin s ................................................................................................ 16
When a e CAMHS specialis se ices equi ed? ............................................................................ 18
Se e i y ................................................................................................................................... 18
Acui y ...................................................................................................................................... 21
Complexi y .............................................................................................................................. 21
Models o CAMHS Se ice O ganisa ion ........................................................................................... 22
Pa hways in o ca e ...................................................................................................................... 23
En y h ough he P ima y Ca e Sec o ..................................................................................... 24
CAMHS Se ice Sys ems............................................................................................................... 29
Belgium model o CAMHS ca e ................................................................................................ 29
US model o CAMHS ca e ......................................................................................................... 30
UK model o CAMHS ca e ......................................................................................................... 32
Compa ing he models o CAMHS se ice s uc u e ................................................................. 35
Conclusions ..................................................................................................................................... 36
Limi a ions o he s udy ............................................................................................................... 39
Key P inciples in Designing CAMHS .............................................................................................. 39
Re e ences ...................................................................................................................................... 40
Lis o Tables
Table 1. . A ailabili y o men al heal h acili ies o unde 18 yea olds by coun y……………………….14
Table 2. Compa ison o CAMHS beds a es, se ice models and e e al c i e ia be ween Belgium,
England and he US ………………………………………………………………………………………………………..………….. 29
Table 3. S eng hs and limi a ions o he model o CAMHS se ice s uc u e o Belgium, US and
UK…………………………………………………………………………………………………………………………………………………35
Lis o Figu es
Figu e 1. Common pa h o de e minan s in luencing ea men ...…………………………………………………8
Figu e 2. T ea men le els o ca e o child en and adolescen s expe iencing men al heal h
p oblems……….………………………………………………………………………………………………………………………………9
Figu e 3. Se ice le el demand d i e ………………….……………………………………………………………………….12
Figu e 4. Se ice spec um ension………………………….…………………………………………………………………..17
Figu e 5. Use ’s low……………………………………………..…………………………………………………………………….18
Figu e 6. CAMHS e e al esponse ailu e…………………………………………………………………………………..28
Figu e 7. UK Na ional Heal h Se ice ie ed CAMHS model o se ice deli e y…………………............33
1 | P a g e
In oduc ion
In e na ionally, public men al heal h se ices do no ha e su icien unds o mee demand o
se ices1. Commissione s and se ice p o ide s mus make decisions no only abou wha le els o
men al heal h ca e hey can p o ide wi h he limi ed esou ces a ailable bu also who hey can
se ice and who hey canno . Specialised men al heal h se ices in many coun ies a e bound by
legisla ion o deli e ca e, in some case howe e , o he sec o s such as p ima y heal h ca e,
educa ion, social se ices, communi y se ices, jus ice and e en police a e le o se ice a la ge
po ion o he popula ion wi h men al diso de s in he young.
The bulk o men al heal h unding a ound he globe is spen on adul se ices1. Many coun ies ha e
ound i di icul o es ablish child and adolescen men al heal h se ices (CAMHS) as hey gene ally
ecei e a small po ion o he men al heal h budge , i any a all. The e is some imes a mis aken
no ion ha child en do no de elop se ious men al diso de s. Wi h adul men al heal h se ices
al eady unde unded compa ed o he es o heal h se ices, his means he esou ces a ailable o
CAMHS is e y low. Decisions ega ding he ype o se ice deli e y, he model o ca e, and who ge s
access o ha se ice become e en mo e c i ical in he child and adolescen space wi h i s e y
limi ed pool o esou ces o ensu e sca e esou ces a e no was ed.
I is now widely accep ed ha men al heal h dis u bances a a young age can lead o con inuing
impai men in adul li e2. I he e is inadequa e unding o ea men se ices o child en and
adolescen s wi h men al heal h p oblems hen we will con inue o see high le els o need o adul
men al heal h se ices o ch onic condi ions. Child en and adolescen s wi h men al diso de s, i
ea ed ea ly, could po en ially ha e a di e en li e ajec o y, a oiding ch onic disabili y and
impai men , p e en ing hem om en e ing he adul men al heal h sys em al oge he .
The p o ision o men al heal h se ices o child en and adolescen s has an added le el o
complexi y o deli e ing men al heal h se ices o adul s. While amily membe s a e encou aged o
play a ole in he ca e o he adul s wi h men al illness, hey play a c ucial ole in he deli e y o
men al heal h se ices o child en and young people. The e may also be a numbe o o he agencies
which play a ole in he young pe son’s li e, deli e ing se ices which impac on he men al heal h o
he young pe son such as schools, social se ices and ju enile jus ice. While hese agencies can
impac on he men al heal h o he young pe son, hey a e also in ol ed in ca ing o he young
pe son. Coo dina ing ca e be ween all hese playe s adds a laye o complexi y o deli e ing men al
heal h ca e o he young pe son.
Go e nmen s need o make decisions ega ding he dis ibu ion o CAMHS esou ces, such as how
hey a e s uc u ed, whe e hey a e loca ed and how hey will be s a ed. All hese can ha e
impo an implica ions o child en, adolescen s and hei amilies, o se ice p o ide s, o se ice
sys ems in heal h, o he agencies and o socie y in gene al.
The le els o men al heal h ca e p o ided o child en and adolescen s wi h men al heal h p oblems
a e ypically de ined in e ms o inpa ien , day p og am, ou pa ien o communi y. Each o hese
le els o ca e has a di e ing le el o in ensi y and he e o e di e ing implica ions o bo h he
se ice p o ide bu also he se ice use . The e is howe e , e y li le in o ma ion on wha
de e mines wha le el o in ensi y o men al heal h ca e child en and adolescen s ecei e. Policy
documen s and c i e ia o specialised se ice en y commonly desc ibe he de e minan s o
in ensi y o ca e as ei he acui y, se e i y, complexi y and/o a combina ion o all h ee; howe e
he e is e y li le in o ma ion on how hese concep s a e de ined and applied in selec ing
app op ia e ca e. Wi hou cla i y i is di icul o decision make s, se ice commissione s o se ice
2 | P a g e
p o ide s o plan o and ensu e ha child en and adolescen s ecei e he igh le el o men al
heal h ca e o add ess hei needs. How each o hese se ices le els a e o med o make a
comp ehensi e CAMHS se ice s uc u e can be a ec ed by hese de ini ions. I is no su p ising
hen ha models o se ice s uc u e in child and adolescen men al heal h look e y di e en no
only om coun y o coun y bu can also be di e en om ju isdic ion o ju isdic ion wi hin a
coun y.
Aims and Objec i es
Aim
The aim o his pape is o explo e he ole o acui y, se e i y and complexi y in de e mining he
specialis men al heal h ca e ha child en and adolescen s expe iencing men al diso de s ecei e.
Objec i es
1. To in es iga e he de ini ions o acui y se e i y and complexi y in child en and adolescen s
expe iencing men al diso de s and wha ole hese ac o s play in de e mining he le el o
in ensi y o men al heal h ca e hese child en, adolescen s and hei amilies ecei e om
he specialised men al heal h se ices.
2. To in es iga e how selec ed coun ies apply he ac o s o acui y, se e i y and complexi y in
hei models o CAMHS se ice s uc u e and whe he i makes a di e ence o he
specialised men al heal h ca e ha child en, adolescen s and hei amilies ecei e.
Magni ude o he P oblem
Go e nmen s and o he ele an men al heal h s akeholde s need o know he men al heal h s a us
o he popula ion and wha esou ces a e a ailable o guide e ec i e policy and decisions abou
se ice le els. I is di icul o ailo se ice p o ision o he demands o he popula ion wi hou
unde s anding no only he size o he p oblem, bu also he social and economic impac o he
mo bidi y associa ed wi h psychia ic condi ions in child en and adolescen s and wha he
popula ion eels abou he p oblem and wan s o do abou he p oblem.
P e alence o Men al Diso de s in Child en and Adolescen s
A numbe o epidemiological s udies ha e been ca ied ou in es iga ing he p e alence o men al
diso de s in child en and adolescen s howe e , global da a is pa chy. The Wo ld Heal h O ganiza ion
A las s udy o 2005 epo ed ha o hei 192 membe s a es, less han hal had CAMHS da a2. The
au ho s sugges ha his e lec s he b oade p oblem o app op ia e sys ems o ga he ing da a,
bu also an absence o ocus on CAMHS a a na ional le el. The epidemiological da a om a ailable
s udies indica es ha he a e age p e alence a e o men al diso de s in child en and adolescen s is
app oxima ely 20 pe cen 3.
9 | P a g e
“inpa ien ea men ” can include a a ie y o ea men componen s p o ided in an inpa ien
se ing. Figu e wo is an example o ea men le els a ailable.
Figu e 2. T ea men le els o ca e o child en and adolescen s expe iencing men al heal h p oblems
Acco ding o he Wo ld Heal h O ganiza ion he p opo ion equi ed in he a ious le els is oughly
he same ac oss coun ies1. In comp ehensi e se ices, hese le els a e no disc e e. Apa om he
p ima y ca e sec o , he es o he le els o ca e a e p o ided by specialis CAMHS ei he in he
communi y, including ambula o y clinics o in he hospi al se ing including day hospi al, non-acu e,
acu e and specialis inpa ien uni s.
The goal o good se ice planning is o ha e a ange o se ices o inc easing in ensi y and
complexi y o mee he needs o child en and adolescen s wi h men al heal h p oblems and ideally
he bulk o he se ices should be p o ided in he communi y38 The model should e lec he needs
equi ed a each le el o ca e. Child en and adolescen s may low be ween he le els dependen on
hei symp oms, deg ee o disabili y and wha ca e is a ailable a each le el and o he ac o s. E en
wi hin a se ice le el he in ensi y o he ea men p o ided may change. Fo example an in ensi e
communi y ea men eam may go om daily con ac o a ew imes a week as a young pe son’s
symp oms imp o e acco ding o e idence/s anda ds.
SPECIALIST
INPATIENT UNITS
e.g.Fo ensic Hospi al
CAMH INPATIENT UNITS
Acu e & Non-Acu e
Acu e Consul a ion Liasion
e.g.Paedia ic wa ds in gene al hospi als,
Adul men al heal h uni s
DAY PROGRAMS
COMMUNITY BASED CAMHS
PRIMARY CARE

10 | P a g e
CAMHS placemen in he se ice spec um
Child en and adolescen s a e o en no ecognised as ha ing se ious men al diso de s which can lead
o misunde s anding he impo an ole CAMHS can play in he deli e y o specialis men al heal h
ca e. Child and adolescen men al heal h is a sub-special y o men al heal h, which in u n is a
specialis heal h a ea.
CAMHS can be dismissed as being an ea ly in e en ion se ice and he e o can be mis aken as no
ha ing a cu a i e ole. This is dependen on he de ini ion o ea ly in e en ion. Ea ly in e en ion
can mean de ec ing and ea ing a diso de ea lie as is e iden in he ollowing de ini ion:
“Ea ly ecogni ion and in e en ion: de ec ing a p oblem o illness a an ea lie s age and
inc easing access o e ec i e ea men , e.g., ea lie de ec ion and ea men o dep ession
o psychosis”39.
I can also mean indi iduals who a e a - isk o de eloping a p oblem and i in he ca ego y o
selec i e p e en ion in e en ions in he Men al Heal h Spec um Model. Ea ly in e en ion in child
and adolescen psychia y does no equa e wi h p ima y ca e p o ision. Child en and adolescen s
can ha e se e e diso de s equi ing qui e in ensi e specialis mul idisciplina y expe ise.
A scan o English speaking coun y’s e e al c i e ia om CAMHS se ices ac oss Aus alia, Canada,
England, I eland, New Zealand, Sco land and he US desc ibe CAMHS as se icing child en and
adolescen s who ha e “complex and se e e men al heal h p oblems”, “mode a e o se e e men al
heal h p oblems” o “signi ican men al heal h p oblems” (o e 50 speci ic se ices c i e ia we e
accessed ia he in e ne ). The e ms ‘se e e, ‘complex’ o ‘signi ican ’ appea ed in e e y e e al
c i e ia, gene ally wi hou de ini ion. The age se iced by CAMHS is up o 18 yea s o age gene ally.
This can a y a ound he uppe and lowe age limi s. Fo he pu poses o his pape he s anda d age
o up o 18 will be adop ed.
The assump ion is ha he needs o his popula ion iden i ied in he e e al c i e ia ha equi e
en y in o specialis CAMHS canno be me in he p ima y ca e sec o .
Le els o CAMHS ca e
The le els o men al heal h se ices p o ided o child en and adolescen s wi h men al heal h
p oblems a e iden i ied in he py amid in Figu e 2.
P ima y based ca e
A signi ican p opo ion o men al heal h se ices a e p o ided h ough he p ima y ca e sec o ,
especially in coun ies wi h e y limi ed esou ces whe e i may be he only esou ce a ailable The
p ima y ca e sec o can include a ange o p o essionals including gene al p ac i ione s, school
counsello s, paedia icians, and p ima y heal h o communi y heal h nu ses o name a ew. Wi h
limi ed esou ces in men al heal h he e is a push in e na ionally o ea common men al diso de s
wi h less complex needs in he p ima y ca e sec o . Cau ion mus be aken as expe ience has shown
ha p ima y le el p o ision does no necessa ily educe demand o specialis CAMHS se ices40, i
may ac ually inc ease. This inc ease may be due o highe de ec ion a es as p ima y ca e
p o essionals become mo e awa e o men al p oblems as he push o ha e hem deli e se ices
inc eases.
11 | P a g e
The Aus alian You h Men al Heal h s udy15 epo ed on se ice ype a ended by he le el o
emo ional o beha iou al p oblems expe ienced by he child o adolescen . Th ee qua e s o hose
a ending specialis men al heal h se ices epo ed e y high le els o p oblems and app oxima ely
60 pe cen o hose a ending p ima y ca e p o essionals epo ed e y high le els o p oblems. In
compa ison only 2.5 pe cen a ending specialis men al heal h se ices epo ed a low le el o
p oblem.
Su eys conduc ed in he UK epo ed ha child en wi h psychia ic diso de s we e mo e likely o be
seeking help o men al heal h p oblems om social se ices, special educa ion and ju enile jus ice
as well as CAMHS33. This demons a es ha young people wi h men al heal h p oblems will be seen
by mul iple se ice p o ide s ac oss a b oad spec um o se ices. These se ices mus wo k
oge he in a coo dina ed amewo k o he bes ou comes o he child o adolescen and hei
amily. The o ganisa ion o se ice sys ems can ei he hinde o enhance hese wo king ela ionships
be ween sec o s.
Communi y based specialis CAHMS ca e
Communi y based specialis CAMHS includes ou pa ien se ices. The majo i y o specialis CAMHS
ca e can be deli e ed in he communi y. These se ices adi ionally a e less in ensi e as hey do no
equi e ound he clock ca e. They a e deli e ed by specialis child and adolescen p o essionals.
Hospi al based CAMHS ca e
A he high in ensi y end o he spec um o ca e a e all he inpa ien se ices desc ibed in Figu e 2.
They a e conside ed high in ensi y because apa om he Day Hospi al hey equi e ound he clock
ca e. The pu pose o b ie inpa ien ea men includes: p o ec ion; diagnosis and ea men
planning; and s abiliza ion41. Hospi alising in men al heal h beds o de e mine diagnosis is
con en ious, bu is s ill used by some. Jus wa ching he young pe son o cla i y a diagnosis is no
likely o cla i y he diagnosis and is using an expensi e esou ce wi h po en ially e y li le gain.
The c i e ia o en y in o a CAMHS inpa ien uni is simila in many coun ies and ends o include
he common c i e ia o being a dange o him o he sel ; unable o p o ec him/he sel om
common dange s o a end o basic needs; o is likely o de e io a e unless he o she we e ecei ing
close obse a ion; and hei needs a e no able o be sa ely me in he communi y. Fo example a
new ea men may be es ed which may be sa e o s a in he sa e en i onmen o he hospi al
se ing whe e hey can be closely moni o ed.
The p inciples o hospi al based ca e o child en and adolescen s wi h men al heal h p oblems
a icula ed in he policy di ec i e o NSW Heal h in Aus alia42 which is based on men al heal h
legisla ion, includes he ollowing: ca e should be p o ided in he leas es ic i e en i onmen
possible; ca e should be deli e ed as close o home as possible; and ca e should be based on
e ec i e ea men s. While mos men al diso de s in child en and adolescen s can be ea ed
e ec i ely in he communi y, some child en will s ill need hospi al based ca e and is impo an ha
he beds a e a ailable o he g oup ha need hem he mos .
12 | P a g e
In luencing ac o s on le el o CAMHS ca e p o ided
In heo y, as igu e 3 below shows he men al heal h s a us o he young pe son is an impo an
ac o ha should d i e demand o le el o ca e38,41. This howe e can be di e en o he eali y o
ca e o many young people, wi h many young people no ecei ing he ca e le el equi ed based on
hei need. The design o se ice sys ems can in luence he le el o ca e ecei ed.
Figu e 3. Se ice le el demand d i e
Ma ke d i en s alues d i en sys ems d i ing le el o ca e
The ma ke iza ion and p i a isa ion o se ices means ha he sys em can become inancially d i en
a he han alues d i en43 o based on p o essional p inciples44. The US Su geon Gene al poin ed
ou ha ea men decisions a e no based on model p ac ice o on need d i en by he young
pe son’s men al s a us when se ices a e p o i abili y d i en11.
Many young people needing less es ic i e ca e may ind hemsel es in hospi al se ings wi h a
mo e es ic i e en i onmen han equi ed due o he lack o a ailabili y o se ices in he
communi y. Equally young people equi ing a mo e in ensi e le el o ca e may no be able o access
he le el equi ed due o una ailabili y o se ices a ha le el. In some coun ies, wi h a ma ke
d i en sys em a he han uni e sal medical heal h ca e, he lack o accessibili y o he le el o ca e
equi ed is due o a lack o medical insu ance by la ge sec o s o he popula ion esul ing in only
ce ain sec o s o he popula ion able o access ce ain ca e le els. The MAMHS s udy in Mexico 14
iden i ied ha 40 pe cen o he popula ion we e uninsu ed. They we e se iced by publicly unded
heal h acili ies whe e he e was a use ee o each episode o illness making i p ohibi i e o la ge
po ions o he popula ion. T ea men s we e also ound o be una ailable in he p ima y and
seconda y sec o s. Only wo pe cen o he popula ion we e ound o ha e access o he mos
expensi e se ices.
Clinical skills o he wo k o ce d i ing se ice le el o ca e
Lack o esou ces also includes lack o ained skilled clinicians. The e is a wo ldwide sho age o
psychia is s and psychologis s ained in child and adolescen men al heal h23. This means ha
many child en and adolescen ’s men al heal h needs a e ea ed by clinicians who may be deli e ing
se ices po en ially de elopmen ally inapp op ia e o hem, o who a e un ained o add ess he
De e io a ing men al
heal h o he young pe son
Inc easing
in ensi y o ea men
Imp o ed men al
heal h o he young pe son
Dec easing in ensi y o
ea men
Time 1
Time 2
13 | P a g e
complex ca e needs equi ed. I may also esul in inapp op ia e e e al o a le el o ca e due o lack
o con idence in assessing he needs o he young pe son.
Psychosocial ac o s a ec ing se ice le el o ca e
Child en and adolescen s a ely p esen wi h a single diso de . They a e mo e likely o ha e a ange
o di icul ies. Psychological diso de s as a esul o ad e se li e expe iences a e common, pu e
psychia ic diso de s a e a e in his popula ion45. S udies in he UK ha e iden i ied ha some young
people ha e been unable o access se ices a all because hey a e ei he oo young o oo old, oo ill
o no ill enough, o can end up in hospi al because o unme social ca e needs46.
Whe e do coun ies p io i ise hei CAMHS esou ces?
In NSW, Aus alia and New Zealand se ice le el planning is based on an indica i e numbe o ca e
packages being equi ed a each le el o ca e pe 100,000 popula ion29. The “ca e packages” in he
NSW model a e ca ego ised acco ding o se e i y o p oblems, coded as “mild”, “mode a e” o
“se e e”47. This model is designed o in o m esou ce alloca ion o each le el a he han dic a e
clinical p ac ice. The ca ego y o se e e includes complex psychosocial si ua ions o ac o s, which
gi es some indica ion o con ex bu a e no clea ly de ined.
I child en a ound he globe ha e simila men al heal h needs, allowing o some a iabili y in clinical
p esen a ion,23 hen i would be an icipa ed ha he esou ces a each le el would be simila
p opo ionally be ween coun ies. Table 1 below is based on he A las 2011 s udy48 and compa es
he men al heal h acili ies o child en and adolescen s in a ious coun ies. No all coun ies we e
included as many we e lacking da a on CAMHS speci ic se ices. Low income coun ies we e
excluded o he pu poses o his analysis.
14 | P a g e
Table 1. A ailabili y o men al heal h acili ies o unde 18 yea olds by coun y
Numbe o acili ies/beds ese ed o child en and adolescen s only
Coun y
Demog aphics
Facili y Type
To al
Numbe
Ra e
Popula ion
(2011)
Popula ion
unde 18
Men al
heal h
ou pa ien
acili ies
Day
ea men
acili ies
Psychia ic
beds in
gene al
hospi als
Beds/places
in
communi y
esiden ial
acili ies
Beds in
men al
hospi als
To al
psychia ic
beds
a ailable
Psychia ic
Beds pe
100,000
popula ion
unde 18
Aus alia
21,211,888
4,666,615
215
UN
269
31
0
269
5.76
Aus ia
8,387,491
1,509,748
UN
UN
262
UN
135
397
26.30
Belgium
10,697,588
2,139,518
11
7
228
UN
620
848
39.64
B azil
195,423,252
60,581,208
86
122
120
24
350
470
0.78
Chile
17,134,708
4,797,718
Un
2
88
UN
36
124
2.58
England
52,234,000
11,491,480
UN
UN
560
UN
UN
560
4.87
Finland
5,345,826
1,069,165
UN
UN
250
UN
12
262
24.51
F ance
62,636,580
13,780,048
1,500
862
880
UN
1,542
2,422
17.58
Ge many
82,056,775
13,949,652
3,151
131
UN
NA
UN
-
-
G eece
11,183,393
1,901,177
34
13
UN
UN
10
10
0.53
Hunga y
9,973,141
1,795,165
68
2
UN
UN
40
40
2.23
I eland
4,589,002
1,147,251
UN
UN
40
UN
42
82
7.15
Is ael
7,285,033
2,258,360
35
3
63
UN
229
292
12.93
I aly
60,097,564
10,216,586
150
50
380
764
0
380
3.72
Japan
126,995,411
20,319,266
0
0
0
0
788
788
3.88
Luxembou g
491,772
103,272
2
2
31
0
12
43
41.64
Mexico
110,645,154
36,512,901
0
0
0
UN
120
120
0.33
Ne he lands
16,653,346
3,497,203
10
980
UN
0
1,700
1,700
48.61
No way
4,855,315
1,116,722
100
UN
UN
UN
326
326
29.19
Poland
38,038,094
7,227,238
173
26
464
0
638
1,102
15.25
Po ugal
10,732,357
1,931,824
25
3
24
0
0
24
1.24
Spain
45,316,586
7,703,820
146
55
UN
UN
0
-
-
Sweden
9,293,026
1,858,605
UN
UN
157
UN
N/A
157
8.45
Tu key
75,705,147
24,982,699
UN
UN
UN
0
97
97
0.39
US
317,641,087
79,410,272
UN
UN
UN
50,420
UN
-
-
UN – In o ma ion una ailable, N/A – I em no applicable
The calcula ed a e o beds pe 100,000 popula ion o unde 18 yea olds in he able abo e
excluded he beds in esiden ial acili ies. I hese we e o be included hen he a e o B azil would
change o 0.82, Aus alia o 6.43, I aly o 11.2 and he US o 63.
Table 1. clea ly demons a es a signi ican a ia ion be ween coun ies in hei in es men in CAMHS
speci ic inpa ien acili ies. The a e anges om 0.33 pe 100,000 in Mexico o 48.61 pe 100,000 in
he Ne he lands (o o 63 pe 100,000 in he US using he esiden ial se ing igu es).

15 | P a g e
Coun ies ha ha e a a e less han 10 pe 100,000 include Mexico, Tu key, B azil, G eece, Po ugal,
Hunga y, Chile, I aly (no included i using esiden ial se ings), Japan, England, Aus alia, I eland and
Sweden.
The coun ies ha ha e a a e highe han 20 pe 100,000 include Finland, Aus ia, No way, Belgium,
Luxembou g and he Ne he lands (including he US i using esiden ial se ings). The US clea ly
s ands ou wi h a a e o esiden ial placemen a 63 pe 100,000 popula ion. The e appea s o be an
o e eliance on hospi alisa ion o child en and adolescen s wi h men al diso de s in hese coun ies,
pa icula ly he US. I is no su p ising ha p e ious US s udies es ima ed 40 pe cen o he hospi al
placemen o child en we e inapp op ia e34. Apa om he US all he coun ies wi h high CAMHS
speci ic hospi al bed a es a e Eu opean. The CAMHEE epo on CAMHS in Eu ope ad ised ha
he e was s ill an o e use o ins i u ionalisa ion o child en in men al hospi als in some coun ies in
Eu ope7.
CAMHS inpa ien acili ies a e conside ed low olume and high cos , simila o o he highly
specialised o in ensi e acili ies elsewhe e in medical planning49. The e o e he high a e o CAMHS
speci ic hospi al beds in some coun ies is puzzling. Budge holde s a e gene ally looking o mo e
e icien ea men and se ice a angemen s50, pa icula ly in he cu en global economic clima e.
Conside ing he men al heal h budge s in CAMHS a e pa icula ly low, i is su p ising o ind high
le els o in es men in mo e expensi e and exclusi e ea men le els o ca e. The cos howe e
canno be looked a in isola ion om he e ec s.
Apa om he high cos o hospi alisa ion compa ed o in ensi e communi y ca e, inpa ien
in e en ions may be auma ic, dis up i e o he child and hei amily and ine ec i e in add essing
co e amily issues ha unde lie emo ional dys egula ion which a e a common ea u e o hospi al
p esen a ions51. Fi s do no ha m should be a cen al p inciple in deli e ing any heal h se ice o any
age g oup, howe e , he long e m impac pa icula ly o child en can esul in mo e equen
hospi alisa ions o e he li e ime.
A ecen e iew o he e idence looking a al e na i es o inpa ien ca e o child en and adolescen s
looked a bo h Eu opean and US s udies52. The Eu opean s udies epo ed app oxima ely 15 pe cen
o he po en ial inpa ien clien s we e sui able o be managed by home ea men p og ams. The US
s udies epo ed majo educ ions in hospi alisa ions when in ensi e home based ea men s we e
used. The Eu opean e idence also sugges s ha asse i e communi y ea men canno eplace he
need o inpa ien ca e bu i has he po en ial o educe i . Fu he e idence is equi ed o
de e mine which model is bes o which g oup o young people.
The da a p esen ed in Table 1. a e based on unded beds howe e admission a es would gi e a
mo e accu a e pic u e o who is accessing inpa ien ca e. The US is epo ed o ha e much highe
admission a es compa ed o he UK. One s udy sugges ed he di e ence was i e imes highe 53.
The da a on bed numbe s sugges i may be much highe .
Wi hou u he da a on he p o ile o he inpa ien popula ions o each coun y i is di icul o
explain he wide a ia ion in he a e o psychia ic hospi al beds o child en and adolescen s. One
ac o could be he a ailabili y o ou pa ien o communi y based ca e. Among he coun ies wi h
high a es o CAMHS beds, Belgium, Luxembou g and he Ne he lands all epo low numbe s o
ou pa ien acili ies. The esou ce alloca ion o CAMHS i appea s is hea ily skewed owa ds
hospi al based ca e in hese coun ies.
A s udy in Belgium e iewed he o ganisa ion o men al heal h se ices o child en and adolescen s
in Belgium. Two issues eme ged which could shed ligh on he si ua ion. Fi s he lack o ou pa ien
16 | P a g e
se ices led o c isis p esen a ions which ended up inapp op ia ely in esiden ial acili ies. They also
iden i ied a lack o adequa e il e ing sys ems in o le els o ca e54. This is in s a k con as o I eland
which has e y es ic i e c i e ia il e ing access o mo e in ensi e and cos ly le els o ca e36.
I is ha d o gauge he need o CAMHS inpa ien beds wi hou aking in o accoun he en i e ange
o CAMHS se ices a ailable. The Royal College o Psychia is s (2006) benchma k, based on
epidemiological e idence, es ima es 20-40 CAMHS beds pe million popula ion o young people up
o hei 16 h bi hday a e equi ed53. This benchma k canno be ex apola ed o he da a p esen ed
in Table 1. as he popula ion da a a e up o he age o 18 and i is likely ha he 16 and 17 yea old
age g oup may ex end he benchma k igu e conside ably as he age o onse o some diso de s
peaks in his age g oup.
O he possibili ies o he wide a ia ion include di e ing diagnoses ha child en and adolescen s
p esen wi h ha a e hospi alised in he di e en coun ies; a ia ion in h eshold o admission o
highe in ensi y ea men and di e ing models o ca e impac ing on he leng h o s ay. I child en
and adolescen s a e being hospi alised o longe pe iods due o hei model o ca e hen hey
unde s andably would need mo e beds as he beds a ailable would be occupied o longe . The
leng h o s ay in hospi al howe e , has been shown o be an inconsis en p edic o o ou come41.
In I aly communica ion diso de s and lea ning disabili ies make up app oxima ely hal o he casemix
o CAMHS18. Some coun ies may s ill be hospi alising child en wi h conduc diso de s despi e he
lack o e idence o e ec i eness. Hospi al da a on p esen ing diso de s and leng h o s ay would gi e
a clea e pic u e o which child en and adolescen s a e accessing his high in ensi y le el o ca e and
may go some way o explaining he a ia ion.
I may also be possible ha child and adolescen hospi alisa ions o men al heal h p oblems occu
in paedia ic beds and adul men al heal h beds a highe numbe s in he coun ies wi h less CAMHS
speci ic beds han in coun ies wi h high numbe s. This can esul in hiding he ue numbe o
hospi alisa ions o child en and adolescen s wi h men al heal h p oblems in coun ies wi h epo ed
lowe bed a es.
CAMHS se ice p essu e poin s
In e na ionally CAMHS a e dange ously o e s e ched wi h inc easing e e als, g ea e complexi y
in p esen a ions o he se ice and highe expec a ions om hei agency pa ne s as hey become
mo e bu dened hemsel es46. A B i ish consul an child and adolescen psychia is gi ing e idence
o pa liamen epo ed ha o e he las i e o six yea s he local se ice e e al a e had inc eased
app oxima ely 20 pe cen e e y yea 55. The se ice was commissioned o see 2,000 clien s bu hey
we e now ecei ing 4,000 e e als a yea . This kind o p essu e on he sys em means he e is li le
o no capaci y o ea ly in e en ion. The se ice hen becomes mo e c isis d i en which in u n pu s
p essu e on demand o hospi al beds as young people become mo e unwell wi hou app op ia e
ca e in he communi y.
Recen audi s o CAMHS in he UK epo an inc ease in wai ing imes which could be d i en by he
inc easing e e al a es as well as by he epo ed inc ease in complexi y and se e i y o p esen ing
p oblems56. I eland in 2013 also epo ed a 24 pe cen inc ease in wai ing lis s36. Men al heal h
se ice p o ision has always balanced he ension be ween ea ing illness and managing isk.
17 | P a g e
Figu e 4. Se ice spec um ension
The balance howe e , wi h he ising complexi y and se e i y epo ed shi s se ices mo e owa ds
he igh o he diag am, owa ds managing isk. CAMHS s uggles o con ibu e o p omo ion and
p e en ion and e en ea ly in e en ion in he ace o inc eased se e i y and complexi y o
p esen a ions. In some cases se ices a e so s e ched managing he isk ha hey a e unable o
o e e ec i e ea men s, le alone suppo o p ima y ca e. Ye all he e idence poin s o he ac
ha deli e ing ea men a an ea lie s age o illness is likely o be mo e e ec i e and less cos ly
han he esou ces ha will be equi ed o e a li e ime i ea ly in e en ion is missed46.
Almos 40 pe cen o he admissions o CAMHS inpa ien uni s in he UK acco ding o a 2012 epo
we e o sel -ha m o suicide53. This indica es ha beha iou s, no diagnosis could be d i ing
admissions. Many o hese young people admi ed display ea u es o bo de line pe sonali y
unc ioning and ha e su e ed abuse and neglec . A CAMHS mapping exe cise in he UK in 2002
iden i ied ha 65 pe cen o he child en seen in CAMHS had mul iple p oblems. A p e ious audi in
1999 epo ed he mos equen numbe o p oblems o be 5 wi h ewe han 5 pe cen ha ing only
one p oblem26. The e emains howe e , a lack o cla i y in he UK abou who is e e ed o CAMHS
and why. I is no clea i he numbe o p oblems o ype o p oblems o a combina ion o he wo
a e d i ing e e als, bu mo e impo an ly d i ing who is accep ed in o CAMHS.
These esul s a e no unique o he UK. A ecen s udy in I eland o 12 o 15 yea olds ha had
ecen ly been e e ed o CAMHS epo ed ha he majo i y had one o mo e diso de s, wi h almos
a qua e ha ing ou o mo e diso de s57. They also ound ha beha iou al diso de s we e he mos
common p esen a ion.
The si ua ion does no appea o be any be e in he US. The US Su geon Gene al’s Repo in 2000
e lec ed i was no easie o ge help in 1990’s han in he 1960’s and i “cos s mo e now o ge a
wo se ou come”11. The epo also iden i ied ha he US lacks a uni ied in as uc u e o s op
child en alling h ough he gaps esul ing in long wai ing lis s o se ices. Among he many ba ie s
epo ed o accessing ca e, he managed ca e sys em in he US se s a bi a y eligibili y c i e ia. The
bene i limi s a e no only inadequa e o mee he men al heal h needs o he mo e ch onically ill
child en and adolescen s bu hey a e based on a middle class popula ion, essen ially denying access
o he poo 44. The ca e needs o he amily a e also missed in his sys em which is no amily ocused.
The e a e p essu es acing CAMHS. The inc easing complexi y and se e i y o cases p esen ing o
CAMHS a e s e ching an al eady o e bu dened sys em. The e a e also a lack o se ices su icien o
mee he demand. The long wai ing lis s a e a e lec ion o he inc easing demand om complex and
se e e p esen a ions combined wi h a lack o esou ces. They also e lec a lack o comp ehensi e
se ice sys em o ganised in a way ha can bes mee he need. The balance in he p o ision o
specialis men al heal h ca e o child en and adolescen s appea s o be cu en ly ipped owa ds
managing isk and less owa ds clinical ea men .
Managing Risk
(Social ca e)
T ea ing Illness
(Heal h ca e)
18 | P a g e
When a e CAMHS specialis se ices equi ed?
Assessing he need o CAMHS speci ic se ices is a complex ask. Eligibili y c i e ia a y widely.
A emp s ha e been made o s anda dise he way heal h ca e wo ke s make decisions abou ca e
howe e , he e is s ill much wo k o be done in his a ea58. Gi en he cons ain s on esou ces and
he a bi a y eligibili y c i e ia he bes clinical decision may be a om he eali y o p ac ice.
Figu e 5. Use s’ low
Le el o se e i y and le el o complexi y expe ienced by he child o adolescen a e c ude indica o s
o whe he he need can bes be me by he p ima y ca e sec o o whe he hey need specialis
CAMHS expe ise o bes add ess he need. The le el o acui y o how unwell he young pe son
p esen s a a speci ic poin in ime is likely o de e mine wha ype o se ing he ca e will be
deli e ed in.
Al hough he e ms se e i y and complexi y a e widely used o desc ibe c i e ia o en y in o
se ices, hey lack cla i y o de ini ion26. I CAMHS i sel is no clea on he en y c i e ia, hen how
can e e e s know when o e e and wha o expec when hey do e e . A s udy in Sydney,
Aus alia ound a di e ence be ween he schools a ing o u gency o a young pe son’s need o
men al heal h in e en ion and he a ing o u gency gi en by he local CAMHS se ice59. This
di e ence can lead o se ice ension be ween he CAMHS se ice and p ima y ca e p o ide s. To
a oid wai ing lis s, educe ension be ween se ice pa ne s and p o ide an e icien se ice CAMHS
mus become clea in i s e e al c i e ia60.
Se e i y
Men al heal h diso de s p esen a ions a e o en ca ego ised as “mild”, “mode a e” o “se e e”. This
ca ego isa ion is used in commissioning men al heal h se ices and is one o he ac o s used o
de e mine wha le el o ca e is app op ia e. Iden i ying a clea de ini ion o each o hese le els in
he men al heal h con ex can be di icul . The e is e y li le in he li e a u e which ga e any clue o
de ining se e i y in he CAMHS con ex , despi e he ac ha i is so widely e e ed o.
The Aus alian Na ional Se ice Planning F amewo k ca ego ises men al heal h unde hese h ee
le els o de e mine se ice commissioning based on popula ion planning. Specialised men al heal h
se ices a e desc ibed as deli e ing ca e o he mode a e o se e e end o he spec um. They
iden i y he mode a e ca ego y as “ha ing signi ican o pe sis en symp oms wi h low o mode a e
le els o como bidi y, disabili y o isk”. The se e e ca ego y is de ined as “ha ing se e e, pe sis en
o mul iple symp oms wi h signi ican como bidi y, disabili y o isk”61. The use o he e ms
High P e alence Diso de s, Low Se e i y
High P e alence Diso de s, High Se e i y
Low P e alence Diso de s, High Se e i y
Can la gely be seen by P ima y Ca e
Can la gely be seen by CAMHS
May need o be seen by specialis eams wi hin
CAMHS
Inc easing Complexi y
25 | P a g e
O ganiza ion policy p ac ice guidelines76 and he Quali y Ne wo k o Communi y CAMHS S anda ds
om he UK36 which ecommend e e als come om a ange o p o ide s such as local eme gency
depa men s, schools, social se ices, paedia ic se ices, you h o ending eams and d ug and
alcohol se ices.
Bypassing p ima y ca e wi h di ec access o specialis CAMHS is p ominen in many coun ies. The
in e ace be ween p ima y ca e and CAMHS a ies be ween coun ies72. The Ne he lands, I eland
and he UK o example ha e he gene al p ac i ione in he ga e-keeping ole. In I eland e e als o
CAMHS a e only accep ed om gene al p ac i ione s. I he only e e al sou ce o CAMHS is h ough
gene al p ac i ione s hen he impac on gene al p ac ice mus also be aken in o accoun . While
o he p ima y ca e wo ke s such as p ima y ca e nu ses, school counsello s and you h se ices may
p o ide he p ima y le el o men al heal h ca e, he gene al p ac i ione does no ha e su icien
ime gene ally o ea men al diso de s. Thei ole is mo e o ini ial assessmen , guidance and
suppo , e e al and possibly medica ion managemen . By making he gene al p ac i ione he only
sou ce o e e al hen many child en and adolescen s who a e in need o men al heal h ca e ha e
an added ba ie o accessing ca e because as he e idence indica es gene al p ac i ione s a e poo
a de ec ion.
Using he gene al p ac i ione as he ga eway in o he sys em needs is no cos neu al. The isi o
he gene al p ac i ione o make he e e al is an ex a cos in he sys em o he go e nmen in
coun ies wi h public heal hca e such as he UK, Canada, Aus alia and New Zealand. In coun ies
wi hou publicly unded heal h ca e his cos is bo ne by he pa en o ca e . While he cos o his
isi is no seen in he men al heal h budge i will con ibu e o he heal h cos s o e all. The e a e
some hidden cos s in his model as well which include he ime ha he gene al p ac i ione
spending seeing he pa ien , possibly o he de imen o seeing o he pa ien s wi h se ious physical
heal h issues and a cos in delaying ea men o he child, adolescen and hei amily as hey mus
wai o see he gene al p ac i ione be o e accessing he men al heal h ca e ha is equi ed.
Some sys ems expec he gene al p ac i ione o se ice he p ima y men al heal h ca e needs o he
bulk o he child and adolescen popula ion wi h men al diso de s. Is his jus shi ing he bu den o
men al heal h ca e on o an al eady o e bu dened and ime poo wo k o ce? Al hough ou o scope
o his pape a cos bene i analysis would be use ul in compa ing he gene al p ac i ione as he
ga ekeepe o CAMHS o o he pa hway models o de e mine he bes way o manage e e al in o
CAMHS.
Paedia icians
Paedia icians in some coun ies a e p ima y ca e p ac i ione s and in o he s a e specialis heal h
p o ide s, equi ing e e al om a gene al p ac i ione . The paedia ician in he men al heal h
sys em howe e is conside ed a p ima y ca e p o ide , being a key e e e o specialis CAMHS.
Paedia ic p o ide s ha e epo ed a lack o skills and knowledge o manage mos men al heal h
p oblems36.
An Aus alian s udy demons a ed ha Aus alian paedia icians we e being e e ed la ge numbe s
o child en wi h se e e and complex beha iou al p esen a ions77. The esea che s demons a ed a
clea o e lap in he clinical cha ac e is ics o p esen a ions o CAMHS and paedia icians. The main
di e ence hey ound is ha adolescen s in he paedia ic clinics we e mo e hype ac i e and he
adolescen s ound in a ypical CAMHS had highe emo ional symp om sco es. Using he S eng hs

26 | P a g e
and Di icul ies Ques ionnai e (SDQ), he bu den o dis ess and social impai men was signi ican ly
highe in he CAMHS clinic compa ed o he paedia ic clinic (p< 0.001).
When he e a e como bid men al diso de s and de elopmen al diso de s i can become e y unclea
as o which se ice i s he need o he pa ien bes . The au ho s o he s udy ques ioned whe he
iage is andom o based on he model o ca e in he se ice se ing and wha he apies can be
o e ed in he di e en se ings. The g ey a ea o o e lap in clien base can c ea e con usion o
e e s and amilies as hey a e no clea which se ice o app oach o ca e. The ole di e en ia ion
be ween paedia icians and CAMHS can lead o child en and adolescen s alling h ough he gaps as
bo h may ejec pa ien s belie ing he o he should be ea ing hem.
Pa en s and Ca e s
The o he and mos impo an ac o ha de e mines se ice usage is pa en s and ca e s. Gene al
p ac i ione s la gely ely on pa en s o b ing he p oblem o hei a en ion. Despi e he sys em o
se ice s uc u e adop ed by a coun y, he pa en uni e sally plays a key ole in de e mining se ice
use72. The pa en has o i s ecognise a p oblem and hen pe cei e ha he e is a need o se ices
o add ess he p oblem. A US s udy epo ed ha iden i ica ion o beha iou al o emo ional
p oblems by gene al p ac i ione s o e lapped by only se en pe cen wi h pa en s iden i ica ion o
p oblems11.
The pa en ’s con i ma ion ha he e is a signi ican p oblem is no ela ed o wha ype o diso de
bu a he o he social compe ence o hei child5. A e iew o s udies ound ha he p edic o s o
pa en al pe cep ion o a p oblem included symp om se e i y, le el o impai men , p esence o
ex e nalising diso de and men al heal h p oblems in he pa en hemsel es72. The e iew also
iden i ied he ac o s de e mining he pa en ’s pe cep ion o he need o se ices o add ess he
p oblem. These included pe cei ed impac on he amily o bu den and whe he he pa en
es ima ed he child’s p oblem o be g ea e han o he child en. The esul s o he e iew indica ed
ha he majo i y o pa en s o child en wi h a men al diso de did no pe cei e a p oblem and hey
did no end o aise a p oblem when hey did iden i y i wi h hei gene al p ac i ione . When
pa en s did pe cei e a p oblem hei eques o e e al played a g ea e ole han how se e e he
diso de was in de e mining whe he a e e al was made. Adul s who b ing child en and
adolescen s in o se ices a e a ec ed by he bu den78 o hei child’s illness as well as he gene al
bu den he amily aces and i appea s ha his bu den is wha d i es hem o seek ca e.
The BELLA s udy in Ge many also examined pa en al pe cep ion o need o ea men . They ound
ha be ween 26-37 pe cen o he child en in hei s udy wi h speci ic men al heal h p oblems we e
conside ed o be in need o ea men as epo ed by hei pa en s9.
I is clea ha child en, adolescen s and hei ca e s need clea e awa eness o how o ecognise
when hey migh ha e a men al heal h p oblem, bu mo e impo an ly cla i y abou when, whe e
and how o ge help79.
O he P ima y Ca e P o ide s
I he majo i y o child en and adolescen s wi h men al heal h p oblems ecei e ca e om he
p ima y heal h sec o and do no mo e on o specialis CAMHS, hen who is p o iding he ca e? The
p ima y ca e sec o can include a ange o o he p o essionals apa om gene al p ac i ione s and
27 | P a g e
paedia icians including eache s, school counsello s, p ima y heal h o communi y heal h nu ses
and p o essionals in social ca e and ju enile jus ice se ices o name a ew.
In B azil he Psychosocial Communi y Ca e Cen es o Child en and Adolescen s (CAPSi) we e
es ablished in 2002 as p ima y ca e uni s. These we e s a egically placed in he se ice spec um o
coo dina e and deli e men al heal h se ices. They a e s a ed by mul idisciplina y eams. They
we e no necessa ily se up o ea he se e e end o he spec um bu ecen da a om Sâo Paulo
indica ed ha he majo i y o pa ien s seen a e se e e13. This lea es a gap o child en and
adolescen s wi h less se e e and mo e common men al diso de s. The ecommenda ion was o one
uni pe 200,000 inhabi an s. The eali y in 2011 was he e we e only 136 acc edi ed CASPi uni s
wi h some egions ha ing none, lea ing only one uni pe 1.3 million popula ion in he Sou heas and
one uni pe i e million popula ion in he no h. I is no su p ising hen ha he majo i y o cases
seen a e a he se e e end o he spec um.
The example o B azil is no an uncommon one. I he e a e no enough esou ces a he specialis
end o he spec um as desc ibed in B azil, combined wi h a lack o esou ces a he p ima y ca e
le el, hen he p ima y ca e le el is le o deal wi h mo e se e e cases o which hey lack skill and
esou ces. The esul is ha child en and adolescen s wi h less se e e p esen a ions, in his case
es ima ed o be 90 pe cen , can be le wi hou a se ice in he se ing which is supposed o ca e o
hei needs. Wi h he oppo uni y o ea men a an ea lie s age being la gely missed i is likely o
lead o mo e in ensi e cos ly in e en ions equi ed o e he li e ime. The lack o specialis CAMHS
and he lack o p ima y ca e se ices deli e ing men al heal h ca e is a double blow o he child en,
adolescen s and hei amilies in his esou ce poo scena io.
An audi in he UK iden i ied ha people wo king in he p ima y ca e sec o we e gene ally
dissa is ied wi h CAMHS. They saw CAMHS as no mee ing he legi ima e needs o hei clien s74. The
p ima y ca e sec o a e mean o see he mild end o he spec um, howe e , he audi ound ha
90 pe cen o he young people wi h ecognisable men al heal h p oblems a e ne e seen by
CAMHS. In he UK, CAMHS epo seeing less o he child and adolescen popula ion (10%) han he
es ima ed p e alence o clinically signi ican cases5 (12-15%). The audi also ound ha CAMHS only
spend one pe cen o hei ime suppo ing p ima y ca e. The si ua ion hen a ises whe e an
o e s e ched CAMHS se ice pushes back o a p ima y ca e se ice which is anxious abou he
child en and adolescen s in hei ca e and eels unsuppo ed in managing hem.
S a egies o expand he expe ise o he p ima y heal h p o essionals and inc ease hei con idence
in managing men al heal h p oblems encoun e ed in he child en and adolescen s in hei ca e
would imp o e he accessibili y and esponsi eness o men al heal h ca e o child en, adolescen s
and hei amilies who do no mee “caseness” o eligibili y c i e ia o CAMHS bu a e in need o a
se ice. A common complain by schools when e e als o CAMHS a e ejec ed by CAMHS is ha
hey s ill ha e o deal wi h he p oblems on a day o day basis. Due o manda o y educa ion
equi emen s in mos coun ies, hey canno op ou o ha ing hese child en in hei ca e.
An example o a CAMHS deli e ed p og am o suppo he educa ion sec o is he School-Link
ini ia i e o New Sou h Wales, Aus alia which began in 1999 and is s ill unning80. The p og am was
s uc u ed wi h a School-Link Coo dina o employed by he Local A ea Heal h Se ice CAMHS o
suppo schools in men al heal h p omo ion, p e en ion and ea ly in e en ion. An ex ensi e
aining p og am o school counsello s o imp o e hei de ec ion and con idence in dealing wi h
high p e alence, low se e i y diso de s was a key ea u e o he p og am, esul ing in 98 pe cen o
he school counsello s who pa icipa ed in he e iew o he p og am epo ing ha hei counselling
p ac ice had imp o ed because o i 81. P esen a ions and men o ing o o he school s a such as
28 | P a g e
wel a e o pas o al ca e coo dina o s and p incipals and execu i e s a assis ed in cla i ying he ole
o he school, key g oups wi hin he school s uc u e and CAMHS when dealing wi h he men al
heal h o hei school popula ion. The e iew o School-Link in i s ini ial phase indica ed ha i had
es ablished a s ong pa ne ship be ween heal h and educa ion, aised he awa eness o child and
adolescen men al heal h p oblems and con ibu ed o he a eas o p e en ion and ea ly
in e en ion81. The e iew also epo ed ha 70 pe cen o schools and 66 pe cen o school
counsello s who ook pa in he su ey indica ed an imp o emen in hei capaci y o suppo
adolescen s uden s wi h, o a high isk o de eloping men al heal h p oblems h ough p o ision o
a ge ed o ea ly in e en ion p og ams. Al hough accessing CAMHS had imp o ed o some, he
majo i y (66%) epo ed con inuing di icul y in accessing se ices o hei s uden s. The skills and
compe ence o he CAMHS s a o suppo schools in his ype o ole is c i ical o he success o
imp o ing access o men al heal h ca e o child en, adolescen s and hei amilies.
Wi hou assis ance he p ima y ca e sec o canno p o ide subs an ial o e ec i e in e en ions26.
P o essionals wi hin he CAMHS sec o a e expec ed o ecei e clinical supe ision, so why does
CAMHS expec he p ima y ca e sec o o p o ide men al heal h ca e o child en and adolescen s
wi hou suppo om men al heal h ained p o essionals? CAMHS mus ha e buil in o i s sys em
s uc u es ha gi e i he capaci y o suppo he p ima y ca e le el h ough s a egies such as
consul a ion, co-loca ion and aining o p ima y p o ide s36. This would a oid an o e low o
e e als o CAMHS which could be managed a a lowe le el o in ensi y wi h some suppo .
The igu e below demons a es wha can happen o ela ionships wi h p ima y ca e when he
CAMHS sys em does no wo k well82.
Figu e 6. CAMHS e e al esponse ailu e
Poo ly managed CAMHS
Lack o clea e e al c i e ia
Lack o suppo o p ima y ca e
O e whelmed by demand
Demo alised s a
Resul o poo ly managed CAMHS esponse o e e als
Long wai ing lis s
Complex, con using e e al pa hways
Demo alised s a in p ima y ca e
Lack o con idence in CAMHS
Communi y aliena ed
29 | P a g e
CAMHS Se ice Sys ems
The e a e e y ew coun ies which ha e clea ly de ined CAMHS se ice sys em desc ip ions. While
sys ems a y g ea ly mos de eloped coun ies ha e se ices a each o he se ice le els iden i ied
ea lie . I is how hese se ices a he di e en le els ela e o each o he ha de e mine he se ice
sys em as a whole. Is i o ganised as a cohesi e comp ehensi e sys em o is i made up o a dispa a e
se o se ices wi h li le connec ion? A e he e clea e e al c i e ia be ween he le els using clea
de ini ions o acui y, se e i y and complexi y o ensu e he sys em wo ks e icien ly and e ec i ely?
Examples om h ee di e en coun ies wi h e y di e en sys ems o CAMHS se ice s uc u e will
be examined o illus a e how he design o he sys em can in luence wha ype o ca e will be
p o ided o whom. The h ee coun ies selec ed we e Belgium, England and he US. They we e
selec ed as hey we e all de eloped coun ies, hey had widely a ying models o ca e and he e was
in o ma ion in he li e a u e which ou lined some o he key issues and s uc u es.
Table 2. Compa ison o CAMHS beds a ailable, se ice models and e e al c i e ia be ween Belgium,
England and he US
Coun y
Popula ion
unde 18
CAHMS beds
in Gene al
Hospi al
CAMHS beds
in Men al
Hospi al
To al bed pe
100,000
unde 18
CAMHS Se ice
s uc u e desc ip ion
Clea e e al c i e ia
and pa hways in o
CAMHS
Belgium
2,139,518
262
620
39.64
Unclea
Unclea e e al
c i e ia and pa hways
England
11,491,480
560
UN
4.87
4 Tie ed Model o
Ca e
Clea c i e ia and
pa hways
US*
79,410,272
UN
UN
63 (using
esiden ial
bed da a)
Managed Ca e and
Sys ems o Ca e
Clea e e al c i e ia
in o Sys ems o Ca e
*Based on ede al da a
Belgium model o CAMHS ca e
A e iew o he CAMHS o ganisa ion was conduc ed in 201254. The ocus o he e iew is on he
commissioning o se ices and he se ice s uc u e ega ding le els o ca e in CAMHS. The
conclusion was ha Belgium did no ha e a clea cu CAMHS s a egy and he e was an absence o
an o e a ching ision and e alua ion amewo k. While ha ing a lowe bed base han some o he
Eu opean coun ies, Belgium s ill appea s o ely hea ily on hospi alisa ion o ea men o child en
and adolescen s wi h men al diso de s. Much o his hospi al based ca e is in he p i a e hospi al
sec o . This is no a e lec ion on he quali y o he hospi al ca e.
The e iew iden i ied a lack o sys em in place o il e whe e ca e is o be deli e ed. The cu en
e e al pa hway om assessmen does no speci y whe e he ca e is o be p o ided based on he
in ensi y o ca e needed. This di use and uns uc u ed access o CAMHS due o an ex eme
agmen a ion be ween o ganisa ions and sec o s esul s in p ima y ca e p o ide s and amilies and
ca e s ying mul iple en y poin s, esul ing in in la ed wai ing lis s.
In Belgium he e is a high a e pe popula ion o CAMHS beds compa ed o o he coun ies. The beds
a e mos ly ound in p i a e men al hospi als. The e iew iden i ied a ew a eas o de ici including a
lack o di e si y o supply. Compa ed o o he coun ies (see Table 1) Belgium appea s o ha e a lack
o ou pa ien se ices o CAMHS. The o he iden i ied a eas o de ici include a lack o eme gency
se ices and a lack o home and communi y based ea men models, especially wi h su icien
in ensi y o p o ide an al e na i e o inpa ien ca e. The pa e ns o admission o hospi al a e
30 | P a g e
s ongly in luenced by wha is a ailable. Un o una ely ha ing a high bed a e o he popula ion
does no gua an ee a hospi al bed when equi ed as hey could be illed wi h child en and
adolescen s who ha e no al e na i e ca e.
In his sys em he he apis o se ice d i es he in e en ion and se ing o ca e wi h limi ed
op ions o ca e a ailable. This is in con as o o he models such as he UK ie ed model whe e he
in e en ion and se ing i is deli e ed in is ailo ed o he need o he child o adolescen . The e is
li le lexibili y in he sys em.
I is clea ha jus add essing he c i e ia o en y in o inpa ien ca e will no add ess he p oblem
o o e u iliza ion o hospi al based ca e. Resou ces need o be placed in communi y ca e o he wise
he e is no al e na i e o placing a child o adolescen in es ic i e ca e which is cos ly, is conside ed
inapp op ia e and ine ec i e in he ea men o some diso de s and can be ha m ul o he young
pe son.
Changing a his o ically based model o ca e is no an easy ask o any go e nmen . The e iew
iden i ied ha he agmen a ion and he ela ionships be ween he sec o s needs o be
s eng hened o mo e o wa d owa ds designing a sys em ha be e sui s he needs o he
popula ion.
The e is no e idence in he cu en CAMHS sys ems s uc u e in Belgium ha acui y, se e i y o
complexi y d i es in ensi y o se ice deli e y o wha se ing ca e is p o ided in. His o y and ma ke
o ces appea o play a majo ole in how he se ice sys em ope a es a he han e idence based
models o ca e.
US model o CAMHS ca e
The a e o esiden ial ca e a exceeds any o he coun y. CAMHS speci ic hospi al bed da a we e
una ailable in he A las da a epo o 201148. E en wi hou he hospi al bed da a he esiden ial bed
base alone indica es a high a e o dependence on es ic i e ca e in he US. Again his is no a
e lec ion on he quali y o ca e in esiden ial se ings bu a e lec ion on how ca e is s uc u ed and
managed and o whom i is designed. This high a e o ins i u ional ca e may be a e lec ion o he
lack o communi y base ca e.
The US sys em is no a homogenous sys em and is dependen on he esou ces in indi idual s a es.
The e does appea o be wo simul aneously o e a ching ypes o ope a ing sys ems44. The i s is
he Managed Ca e sys em which se es he en i e eligible popula ion. Managed Ca e is a sys em o
inancing and deli e ing heal h ca e ha is ied o ei he heal h insu ance o Medicaid wi h
p ede e mined schedules o ea men based on diagnoses. This is a sys em d i en model o ca e.
The second is he Sys ems o Ca e which is ede ally unded o speci ic subg oups o child en and
adolescen s wi h se ious o se e e emo ional dis u bance and s uc u ed o w ap he se ices
a ound he young pe son and hei amily and is amily and needs d i en.
Managed Ca e
En y in o CAMHS h ough he managed ca e sys em is based on a bi a y u iliza ion p o ocols44. The
heal h insu e o Medicaid se s he bene i limi which is based on a model sui ed o a middle class
popula ion. Se ices bid o managed ca e con ac s o deli e public managed beha iou al heal h
plans. The ma ke o ces a he han p o essional p inciples o ca e d i e p o ision o se ice in his

31 | P a g e
model. The limi ed bene i s o e ed unde his sys em a e inadequa e o mee he men al heal h
needs o he mo e ch onically men ally ill child en and adolescen s. As he bene i s a e a bi a ily se
he sys em is minimally d i en by se e i y (de e mines which ca e package is a ailable o a limi ed
amoun ) bu no by acui y o complexi y.
Sys ems o Ca e
The Sys ems o Ca e model, unded by Cong ess began in he 1980’s wi h he Child and Adolescen
Se ice Sys em P og am (CASSP) o deal wi h he child en and adolescen s who we e deemed o be
mos in need4,83. The basis o his de elopmen was ha you h wi h he mos se e e men al heal h
p oblems couldn’ access communi y men al heal h as hey we e p i a ely un p ac ices which
a ou ed seeing he mild o mode a e end o he spec um. The CASSP sys em was he s a o he
concep o w ap a ound se ices which now all unde he heading o Sys ems o Ca e.
The h ee co e alues o he Sys em o Ca e a e ha i is child and amily ocussed, communi y
based, and cul u ally compe en 84. The clien is iden i ied h ough he social ca e sys em as ha ing
signi ican impai men . The sys em, made up o a numbe o o ganisa ions deli e ing di e en
componen s o ca e w aps i sel me apho ically a ound he needs o he p esen ing child and hei
amily. Each o he pa icipa ing o ganisa ions mus con ibu e o he pool o esou ces o p o ide
he se ices. The g oup o pa icipa ing o ganisa ions can look e y di e en inn di e en locali ies
based on he a ailable se ices.
Inpa ien ca e can be pa o he mix o se ices o e ed bu is no cen al o he model. Pa ien need
a he han ma ke o ces d i es he ypes and mix o se ices p o ided84. En y in o he Sys ems o
Ca e p og am is based on signi ican impai ed unc ioning in mul iple domains o unc ioning ha
ha e pe sis ed o a leas a yea . I is a biopsychosocial model and no jus a medically d i en
model. The quali y o he i s i a ed access in o his sys em plays an impo an pa in e ms o
access o ca e. The ca e is impai men -based no diagnosis based and seems o be di ec ed a he
g oup o child en and adolescen s wi h high social ca e needs a he han high men al heal h needs.
A ew downsides o his sys em include: he lack o men al heal h se ices a ailable in some s a es o
pa icipa e in a sys em o ca e model; access is only a ailable o a e y na owly de ined g oup o
child en and adolescen s based on hei psychosocial needs; he ocus on impai men c i e ia only
excluding men al illness c i e ia could mean ha child en and adolescen s wi h se e e men al illness
bu no necessa ily high psychosocial complexi y migh miss ou on ca e. The wo g oups a e no
mu ually exclusi e bu hey a e no comple ely he same g oup. Some young people wi h se e e
men al illness could ha e complex ca e needs bu no necessa ily complex psychosocial needs. The
e iew did no include da a on he s a es wi h his sys em in place bu a he ocused on he model
o se ice deli e y and again who i was designed o ea . The Sys em o Ca e model is unded o
se ice a e y small mino i y o he child and adolescen popula ion a he e y poin y end o he
social ca e spec um.
The main ad an age is in wo king wi h o he sec o s o gi e comp ehensi e ca e ac oss mul iple
domains, unlike o he models in less comp ehensi e sys ems whe e ensu ing mul iple need a e me
can be di icul and complica ed. While he p inciples o deli e ing ca e in his sys em a e clea ly
a icula ed, he e is su icien lexibili y in he sys em o deli e ca e based on needs. The e o s o
build he sys ems and o ganise he p ocess o se ice deli e y a ound his pa icula clien g oup
appea e ec i e demons a ing p omising esul s o he young people hey se e based on na ional
e alua ion85.
32 | P a g e
In ensi y o se ice in his sys em does no necessa ily equa e o di e ing le els o men al heal h
ca e bu appea s o be cen ed on mul iple se ice p o ide s in ol ed in ca e and numbe o
con ac s wi h he se ice p o ide s (in ensi y o case managemen ). Complexi y in e ms o social
ca e needs, se e i y in e ms o impai men , and ch onici y o he condi ion appea s o d i e his
sys em.
UK model o CAMHS ca e
The UK CAMHS sys em is based on a ie ed model o ca e which i s appea ed in 1995. The ie ed
model nea ly equa es wi h he le els o inc easing in ensi y o ca e equi ed and emains he
p e e ed amewo k o o ganise he commissioning o CAHMS86. The ie ed model was de eloped
o o m a s a egy o add ess he di e si y o unc ions in he CAMHS sys em and o mee he eal
p o iles o he needs o he popula ion26. Fo his eason he model, unlike he US Sys ems o Ca e
model, is no based on speci ic g oups o child en o adolescen s, no is i based on diso de s bu
ins ead a emp s o add ess he sys em o men al heal h ca e in a popula ion based amewo k.
The ie ed model is a amewo k buil a ound il e s and ie s wi h he in ensi y o inpu gea ed o
he complexi y o need68,71. The main me hod p io o he in oduc ion o he ie ed model was o
espond o e e als which was inadequa e wi h only app oxima ely 10 pe cen o child en and
adolescen s wi h men al diso de s being e e ed. This ie ed sys em akes in o accoun he ca e
needs in he p ima y ca e sec o known as ie one and no jus he mode a e o se e e end o he
spec um ha is se iced adi ionally by CAMHS.
The main concep behind he ie ed model is ha di e en clinical needs can be managed by
di e en le els wi hin he ie ed sys em68. The e ec i e managemen and unc ioning o he ie ed
sys em is dependen on he in e ace be ween he ie s as each one ac s as a il e o he nex le el.
The p og ession o a child o adolescen h ough he ie s is no linea , bu dependen on he ca e
needs o he child o adolescen a a pa icula poin in ime depending on he se e i y o acui y o
hei illness. As young people can mo e backwa ds and o wa ds h ough he ie s he in e ace
be ween hem becomes a c i ical ea u e o he model.
The il e ing sys ems be ween ie s is designed o allow child en and adolescen s wi h mo e complex
p oblems o each he highe ie le els and o il e ou mo e ou ine p oblems which do no
equi e he highe le el o esou ces a he highe ie le el, dec easing was age o expensi e
esou ces a he highe end o he spec um71. The assump ion is ha he needs o he child en and
adolescen s as hey p og ess h ough he ie s, canno be me by he p e ious ie .
The ollowing igu e is an adap a ion o he Na ional Heal h Se ice ie ed model o se ice
deli e y86.
33 | P a g e
Figu e 7. UK Na ional Heal h Se ice ie ed CAMHS model o se ice deli e y
The ad an age o his model is ha i a emp s o clea ly de ine he ole o he p o essionals in each
ie 71. The esou ces a each ie is ela ed o complexi y o need82. The model i s well wi h he
di e en elemen s deli e ed in di e en se ings ha a e equi ed in child and adolescen men al
heal h se ice deli e y. The e is consis ency in he model ac oss he coun y which means ha
child en, adolescen s and hei amilies should expec a simila se ice whe e e hey a e. Ano he
ad an age is ha se ice de ici s can be easily iden i ied p o ided you ha e no ms o ca e ha a e
moni o ed.
The in ensi y o he se ice is d i en by se e i y and complexi y. The Na ional In-pa ien Child and
Adolescen Psychia y S udy (NICAPS) in he UK in 2005 demons a ed ha while he p esen ing
p oblems be ween ou pa ien and inpa ien coho s we e simila , he le el o se e i y o diso de
based on HoNOSCA sco es we e g ea e in he inpa ien coho 87. They also ound ha he numbe
o p esen ing p oblems was highe in he inpa ien coho (a e age numbe o p oblems was 7)
compa ed o he ou pa ien coho (a e age numbe o p oblems was 5). Complexi y in his model
does no jus e e o psychosocial complexi y as in he Sys ems o Ca e model om he US.
Complexi y in his model also e e s o clinical complexi y. Clinical se ices o speci ic diso de s ha
equi e mo e complex clinical in e en ions, o example ea ing diso de s, a e de ined a he highe
ie ed le el.
The ole o he p ima y heal h p o essional is o e e o ie wo o h ee only when absolu ely
necessa y. The ole o he ie wo o h ee p o essional is o e e o ie ou only when necessa y.
This places he ole o he ga ekeepe on he se ices in he p eceding ie . The NICAPS s udy
epo ed ha 67 pe cen o he pa ien s e e ed by communi y based child and adolescen
psychia is s we e g an ed admission87. The ga ekeepe s in his example a e no always able o
access he se ice hey pe cei e is equi ed.
One o he main c i icisms o he ie ed model in he UK is ha h ough i s clea ly de ined in lexible
bounda ies be ween he ie s, i has unin en ionally c ea ed ba ie s be ween he se ices, causing
se ices o be p o ided in a agmen ed manne a he han as a comp ehensi e whole88. Each ie
ope a es sepa a ely wi h a lack o in eg a ion be ween he ie s. Child en and adolescen s needs can
change o e ime equi ing a low be ween he se ice le els. I each ie is pushing back o he nex
his can c ea e ension and us a ion be ween he di e en se ice p o ide s esul ing in child en
and adolescen s alling h ough he gaps.
Tie 1
P ima y Ca e P o ide s who
p o ide men al heal h
p omo ion, ea ly iden i ica ion
Tie 2
Independen p o essionals
who p o ide consul a ion o
ie 1 and ou each o iden i y
mo e complex, se e e o
pe sis en p oblems
Tie 3
Communi y based specialis
mul idiscplina y CAMHS Teams
who assess and ea child en
and young people wi h
complex, pe sis en o se e e
men al diso de s
Tie 4
Highly specialised Te ia y
CAMHS including inpa ien , day
p og ams, and in ensi e home
based se ices, specialis
ou pa ien p og ams o highly
complex p oblems
Inc easing se e i y and complexi y
34 | P a g e
This agmen a ion in he model is demons a ed by he lack o cla i y in he delinea ion be ween
ie wo and h ee. I is no as clea as say he delinea ion be ween ie h ee and ie ou . The
p o essionals in ie wo and h ee a e bo h specialis men al heal h p o essionals wi h sligh ly
di e ing oles. This could c ea e con usion among p ima y ca e e e e s as o whe he he child o
adolescen hey ha e in on o hem is a ie wo o ie h ee case. Unless e e e s we e e y
clea , and his is known no o be he case, his can c ea e an ex a laye o con usion and o
di icul y in accessing ca e. Also ie wo and h ee can be pa o he same CAMHS eam.
I may be be e o ha e he ie wo and h ee de ined oge he hen wi hin he s uc u e o he
se ice ha e a i a ed esponse based on he p esen ing need o he child o adolescen . Fo
example a b ie in e en ion may be all ha is equi ed o a longe e m he apy o in ensi e
communi y based he apy may be e sui he need o he p esen ing child o adolescen .
In con as , CAHMS in I eland is s uc u ed on a h ee ie ed model. Tie s wo and h ee a e
combined in he I ish model. This would go some way owa ds add essing agmen a ion o se ices
by c ea ing a single poin o en y in o CAMHS as he uppe ie is only accessed h ough he
communi y based ie wo in he I ish model and no wo le els as in he UK model.
The Choice and Pa ne ship App oach (CAPA)89, de eloped in he UK by Ann Yo k and S e e
Kingsbu y om he communi y CAMHS pe spec i e o add ess he long wai ing lis s and se ice
s uc u e o Tie 3. The app oach assis s in he o ganisa ion o communi y CAMHS o de e mine oles
and unc ions and skill se s equi ed o o m a ully complimen a y CAMHS communi y eam ha is
clien ocussed. I is based on demand and capaci y heo y. The bene i o his app oach means ha
in e en ions mus be ailo ed o need a he han he adi ional me hod o he apis o eams
d i ing he in e en ion. The commissioning o CAMHS s ill equi es su icien se ices o mee he
demand.
The o he downside o he ie ed model is ha i elies hea ily on suppo om CAMHS o ie one,
he p ima y ca e p o essional. As p e iously epo ed his is known o be se e ely lacking in he UK74.
When esou ces a e in limi ed supply and canno mee demand his kind o sys em is mo e likely o
use i s il e s be ween he igid ie s o “gua d” en y o ha ie , wi h de ini ions and bounda ies
becoming igh e and mo e es ic i e, lea ing many child en and adolescen s o all h ough he gap
o wha is o e ed a he p ima y ca e le el and he specialis CAMHS se ices.
On he o he hand, o open he doo s so o speak wi hou he esou ces a ailable lea es se ices
open o comp omising he in eg i y o he ca e hey p o ide. They can easily ind hemsel es
deli e ing ca e o a g ea e numbe o child en and adolescen s, bu a a sub-op imal le el o ca e. I
each clinician ca ies oo g ea a case load he ocus o ca e shi s he balance o managing isk
a he han deli e ing e ec i e e idence based clinical in e en ions ha can make a eal di e ence
o he ajec o y o he young pe son in hei ca e. This is a e y eal ension o many se ice
commissione s ying o balance who ecei es ca e and wha ype o ca e hey ecei e. I is e y easy
o all in o he ap o deli e ing a c isis d i en sys em o ca e a he han a quali y d i en sys em o
ca e wi hou some balance in he caseload held by each clinician. Commissione s mus make
decisions abou whe he o deli e minimum ca e o all o maximum ca e o a ew o somewhe e in
be ween.
Wi h he capaci y and capabili y o ie h ee de ining ie ou , i is impo an in his model ha ie
h ee is su icien ly esou ced o p e en he need o ie ou in ensi e se ices. The e is an
ongoing ension be ween each o he ie s o ca e ha a e no easily esol ed especially wi h
inc easing demand and dec easing esou ces ac oss he se ice spec um. The sys em howe e does
41 | P a g e
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