Factors that determine the level of care children and adolescents experiencing mental disorders receive
Abstract
RESUMO: Resumo Uma prestação de serviços de saúde mental para crianças e adolescentes (CAMHS) oportuna, eficaz e baseada na evidência pode evitar incapacidade a longo prazo. No entanto, estes serviços são criticamente sub-financiados em todo o mundo. É um imperativo garantir que este precioso recurso não seja desperdiçado. Os governos e outras partes interessadas relevantes na área da saúde mental precisam de conhecer o estado de saúde mental da população, quais os recursos disponíveis e como melhor utilizar os recursos disponíveis para orientar uma política e decisões efectivas sobre os níveis de serviços. Objetivo: O objetivo deste artigo é explorar o papel da acuidade, gravidade e complexidade na determinação dos cuidados em saúde mental especializados recebidos por crianças e adolescentes que sofrem perturbações mentais. Métodos: Este estudo é exploratório envolvendo uma revisão sistemática da literatura. Foi realizada uma pesquisa com palavras-chave utilizando bases de dados PsychINFO, EMBASE, PubMed e MEDLINE. A literatura cinzenta também foi investigada com um enfoque nas abordagens sistémicas, organizacionais e políticas para a organização e comissionamento de CAMHS. Foram selecionados apenas documentos escritos em Inglês. Três países, Bélgica, Reino Unido e Estados Unidos, todos eles com modelos muito diferentes de organização de CAMHS, foram revistos para investigar de que forma os conceitos de acuidade, gravidade e complexidade foram utilizados na sua concepção de serviços para determinar o nível da assistência prestada. Resultados: Nem a Bélgica, nem o modelo norte-americano de CAMHS organização de serviço parecem estar alinhados com os principais conceitos na determinação do nível de prestação de serviços. O sistema de serviços do Reino Unido de CAMHS está mais estreitamente alinhado com esses conceitos e tem uma alocação de recursos mais equilibrada entre o hospital e a comunidade. O seu ponto fraco está na falta de flexibilidade entre os níveis de serviço e na falta de apoio para com o sector dos cuidados de saúde primários. Conclusões: A variabilidade na alocação de recursos a diferentes níveis especializados de CAMHS (em regime de internamento, ambulatório, e na comunidade) e o modelo diferente de estrutura de serviços entre os países estudados indica uma inconsistência na forma como as crianças e adolescentes que apresentam aos CAMHS são referenciados para os cuidados que recebem. Isto põe em questão se as crianças e adolescentes com perturbações mentais estão a receber o nível e tipo de cuidados concordantes com as suas necessidades. A concepção e o comissionamento de sistemas de CAMHS levam-nos à discussão de uma série de princípios fundamentais que devem ser considerados. O sistema perfeito no entanto, ainda está para ser encontrado. -------------------------------- ABSTRACT: Provision of timely, effective, evidence based mental health services to children and adolescents can prevent long term impairment, but they are critically underfunded across the globe. There is an imperative to ensure this precious resource is not wasted. Governments and other relevant mental health stakeholders need to know the mental health status of the population, what resources are available and how best to use the resources available to guide effective policy and decisions about service levels. Aim: The aim of this paper is to explore the role of acuity, severity and complexity in determining the specialist mental health care that children and adolescents experiencing mental disorders receive. Methods: This study is exploratory involving a systematic scan of the literature. A key word search was conducted using databases PSYCHINFO, EMBASE, PUBMED and MEDLINE. Grey literature was also searched to focus on systemic, organisational and policy approaches to the organisation and commissioning of CAMHS. Only documents written in English were selected. Three countries Belgium, UK and the US all with very different models of service organisation for CAMHS were reviewed to investigate how well the concepts of acuity, severity and complexity were used to determine the level of care delivered in their service design. Findings: Neither the Belgium nor the US model of CAMHS service organisation appear to align with the key concepts driving intensity of level of service provision. The UK CAMHS service system most closely aligns with the concepts. It has a more balanced resource allocation between hospital and community. Its downfall is in its lack of flexibility between service levels and its lack of support for the primary care sector. Conclusions: The variability in resource allocation to different service levels (inpatient, outpatient, community) within specialist CAMHS and the differing model of service structure across countries indicates an inconsistency in how children and adolescents presenting to CAMHS are allocated to the care they receive. This puts into question whether children and adolescent with mental disorders are receiving a level and type of care commensurate with their needs. In commissioning and designing CAMHS systems a number of key principles that should be considered are discussed. The perfect system however, is yet to be found.
Full text
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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