Low Intensity in Sefton CAMHS

CYP IAPT (2011)

CYP IAPT

• Leading on from the highly successful implementation of the IAPT programme for adults started in the NHS in 2008
• Designed as a service transformation programme to improve existing CAMHS services
• Based upon five core principles of participation, evidenced-based practice, awareness, accountability, and access
• A collaborative working between CAMHS providers from across both statutory and voluntary sectors
• Includes training a low intensity workforce to provide early intervention

Five Year Forward View (2014)

Five Year Forward View

• Relates to NHS services as a whole
• "The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health" (pg 10)
• Important with regards to the strong link between physical and mental health
• The promise to invest in evidence-based approaches to encourage independent health management

Future in Mind (2015)

Future in Mind

• Mental health conditions are common, however, “it is often the case that children and young people don’t get the help they need as quickly as they should” (pg. 7)
• Advocates the vital importance of early intervention in preventing crisis and the need for adult services in the future
• Promotes stepping away from 'tiered' services in favour of what best supports the child, young person and their family
• Champions increasing use of evidence based treatment building upon the CYP IAPT programme
• Proposes the development of a local Transformation Plan

Mental Health Task Force (2016)

Mental Health Task Force (FYFV)

• A report from the Independent Mental Health Taskforce to the NHS
• Calls for the Future in Mind recommendations to be implemented in full
• “Early intervention and quick access to good quality care is vital – especially for children and young people”
• Discusses the importance of waiting times being substantially reduced and inequalities in access being addressed
• Highlights support being offered whilst people are waiting for care
• Requirement for fundamental change, placing emphasis on prevention, early identification, and evidence-based care
• Need to ensure that good quality transformation plans are put into action, that the CYP IAPT programme is rolled out completely and that an access standard for CAMHS is developed

Implementing the Five Year Forward View (2016)

Implementing the FYFV

• Highlights the importance of implementing sustainable local transformation plans

• Based on key principals such as co-production with people with lived experience, voluntary sector partnerships, early intervention, delivering evidenced-based person-centred care and progression using outcome focussed data

• By 2020/2021 a significant expansion equalling 70,000 additional children and young people accessing evidence based treatment

• All local transformation plans to be refreshed to reflect the spending of extra funds available

• By 2018, all services should be working within the CYP IAPT programme, adding to a highly skilled workforce and leading organisational change

Next Steps on the FYFV (2017)

Next Steps: FYFV

• Following on from the Five Year Forward View and what needs to happen next
• Highlights the importance of addressing the gap between physical health support and mental health support, particularly for children and young people
• Reiterates the importance of early intervention
• Public survey’s reveal the demand for mental health services to be prioritised within the NHS

THRIVE: Framework for Change (Updated 2019)

THRIVE: Framework for Change

• Collaboratively developed by NHS and Anna Freud colleagues in 2014
• Recommended framework in the NHS Long Term Plan (2019)
• The framework is an integrated, person centred, needs-led approach
• Needs are NOT based on severity, diagnosis, or health care pathways
• Needs conceptualised into five categories: Thriving, Getting Advice, Getting Help, Getting More Help, Getting Risk Support
• Important in supporting early intervention, reducing waiting times, improving access and reducing inter-agency referrals; 'passing the buck'

Early Intervention: Latest

Early Intervention: Latest

• A rise in CAMHS workforce numbers to increase early access and reduce waiting times; 39.6% of children and young people treated in 2020/21 (NHS England, 2021)
• Increased need for continued offering of specialised low intensity treatments when appropriate; one in six 6-19 year olds were identified as having a probable mental health condition (NHS Digital, 2021)
• Calls from key bodies to ensure the government's 'levelling up' programme champions early intervention across all societal facets including mental health (EIF, 2021)
• An increase in the promotion of positive mental health and access to services (THRIVE model; Colizzi., Lasalva., & Ruggeri., 2020)
• “If I’d had the help in my teens that I finally got in my thirties, I wouldn’t have lost my twenties.” (Mental Health Task Force, 2016)

Worry Management

Worry Management

• Psychoeducation about anxiety, the vicious cycle of anxiety and worry and the role of reassurance seeking.

• Teaches techniques to help improve levels of anxiety, including worry diaries, spotting hypothetical worries, worry trees, worry time and problem solving.

• Tolerating uncertainty is also addressed

• Worry management lasts for 7 sessions and involves parental involvement at key stages.

Parenting - Conduct Problems

• A brief guided self-help intervention for parents of children between 2-9 years, with subthreshold mild behavioural problems with their child.

• This does not include children diagnosed with ADHD/ASC.

• It covers learning about why children may misbehave and works to enhance the relationship between the parent and child.

• Communication, self-esteem, emotional regulation, boundaries and routines are all covered as topics in this

intervention

Behavioural

Activation

Behavioural Activation

• The young person and practitioner work together to identify how the young person is spending their time (activity monitoring) and what matters to them most (values).

• Aim to make small behavioural changes that will increase their experience of reward from everyday life.

• 8 weekly sessions with structured parental involvement at key stages.

Parenting for anxiety

Parenting - Cathy Creswell

• For parents of children aged 6 to 12 years, who are struggling with a range of anxiety disorders: separation anxiety disorder; social phobia; specific phobia; generalised anxiety disorder; and agoraphobia/panic.
• This is a parent only intervention and involves teaching parents cognitive and behavioural strategies to help their child overcome their anxiety.
• Based around the book, ‘Helping your child with fears and worries’ - a self- help guide using Cognitive Behavioural Techniques’ (Creswell and Willetts, 2019).

Exposure Therapy

• For young people with phobias that interfere with their everyday functioning,

• This works by gradually exposing the young person to the feared situation, allowing the process of habituation to occur.

Exposure Therapy

Self Soothing

1. Relaxation & Guided Visualisation

2. The Body, Health & Exercise

3. Breathing

4. Smell

5. Touch

6. Sound

7. Final session Sleep and recap of course.

Self Soothing

• For carers of LAC (foster, adoptive, special guardians, kinship carers) <13yrs, (others on a needs basis)

• Holistic intervention, founded on attachment theory, neuropsychology, systemic psychotherapy and spirituality

• 7 x 1 hour sessions on MST (all must be attended)

• Each session involves basic theory and practical strategies to aid soothing and relaxation

• Encourage carers to practice themselves, then teach/guide CYP to use them. Idea is to build up a 'box' of useful strategies and underpinning theory

• Rolling programme, every quarter. Next intake Sept

• Contact Claire Barrie

Calm & Connected

- Calm & Connected is a virtual group which focuses on anxiety using a low intensity CBT approach and psycho-education.

- The group runs for 7 weeks.

- For ages 11-17, the course will consist of:

• Weekly group sessions (1hr)
• Weekly buddy sessions with other YP and me (2:1 for 30 mins) (This will give opportunity for more personalised goal setting and to explore any individual worries they may be experiencing.)
• Parent session (in week 3) and a parent drop in.
• Final 1:1 session in the final week (to discuss possible discharge/relapse prevention/next steps).

- Please refer to the Calm and Connected Information document in the Low Intensity Pathway folder for inclusion and exclusion criteria.

Overcoming your child's fears and worries

Overcoming your child's fears and worries

• Cathy Cresswell intervention

• Delivered in a group setting

• Jack Wolstenholme

Referrals

From Referrals

Most CYP will be picked up at the referral meetings

Previously they may have been sent to a Tier 2 service

These are added to the routine wait list with a note stating refer to CYWP

If a trainee is not present at referrals, then suitable cases (including AH numbers) are to be emailed to Julia Dunn

Case Managers

A request for specific work can be put in via MDT

This still needs to meet the criteria for a CYWP trainee but it is a bit more flexible as the case manager is holding responsibility

From Case Managers

Post-Choice

Post Choice

As with referrals, any suitable cases are to be emailed to Julia Dunn

They can then be pended for routine partnership with a note for CYWPs.

What if LII don't work?

What if LII doesn't work?

- The evidence shows that LII will work for a significant number of CYP, but nonetheless, they will not be a success for everyone

- By embedding CYWPs into CAMHS services, a more effective stepped approach model is created

-Any CYP will enter the waiting list at the point at which they were referred in date order to be allocated a case manager

Low Intensity = Tier 2

"Services need to be outcomes focused, simple and easy to access, based on best evidence, and built around the needs of children, young people and their families rather than defined in terms of organisational boundaries" (Future in Mind, 2015)

THRIVE Framework made it clear: Not based on severity, diagnosis or health care pathways

Traditional pathways are failing to meet the demands placed on the NHS (Green Paper, 2017)

Tier 2 Service

What about MHST in schools?

MHST

-Play a vital role in a school environment but for some children school is the source of stress/anxiety, so appointments here would be difficult

-School Refusers, home-schooled children etc. IAPT is about accessibility

-Ability to deliver LII remotely is a bonus

Increased Access to Services

Increased Access to Services

- One of the key principles of the CYWP programme is accessibility

- Many CAMHS services across England prioritize severe and complex cases, which means children with mild-to-moderate problems often experience significant wait times. (Green Paper, 2017)

- As such, timely treatment delivered to all cases across the severity spectrum could be conceptualized as preventative

Reduced Waiting Lists

- Initial plans would allow a CYWP to have 1000 clinical contacts per year (South West CYP-IAPT Collabortative)

- "By embracing the LI practitioner roles, services stand to gain in the amount of CYP they can effectively treat and free up space for the HI practitioners to see those

CYP who need more intensive work." (Wood, 2020)

Stepped Care Approach

- Low Intensity Interventions should be offered as step one, even in moderate cases (Bower et al, 2013)

- Allows "right care at the right time"

- CYWP would have the benefit of knowing services and staff at CAMHS well in order to step up appropriately when necessary

Cost Effective

- Richards et al (2016)

- BA in adult patients to be much more cost effective but equally as effective as CBT (>400pps)

- Due to lower salaries of MHW

- Stepped care models demonstrate economic benefits in CAMHS settings (Yeguez et al, 2019)

Cost Effective

Early Intervention is Key

- Psychiatric symptoms tend to persist or escalate with time for a significant minority of children (Weems et al 2002)

Early Intervention is key

Below threshold provision

- The LI Pathway including 1:1 intervention and groups, allow for gaps in treatment to be bridged due to not meeting current thresholds

Below threshold provision