National Assembly for Wales
Children, Young People and Education Committee
CAM 10
Inquiry into
Child and
Adolescent Mental Health Services (CAMHS)
Evidence from : Dr Maddie McCulloch – Principal Clinical Psychologist
There seems to be a growing consensus that early intervention is a better use of resources than waiting until more serious difficulties emerge. Both the WAVE Trust document ‘Tackling the Roots of Disadvantage’[1] and ‘Early Intervention: Smart Investment, Massive Savings’[2] both promote the financial, moral and effectiveness implications of preventative and early intervention models. The latter states that; ‘The traditional model – waiting until problems become apparent…is no longer enough.’. In addition, the 2009 document from the Centre for Mental Health (Childhood Mental Health and Life Chances in Post-War Britain)[3] also recommends early intervention given that difficulties in early life can have ‘profound’ long term consequences. There is indeed a great deal of research linking a variety of difficulties in later childhood and adulthood with early attachment relationships in infanthood (e.g. Fernivall, 2011)[4].
My understanding of current service provision within the area I work is that there is very little in the way of early intervention services. Whilst there are some initiatives both the Primary Care Mental Health Support Services and the Specialist CAMHS provide a service to only the children whose difficulties have reached a certain level of severity or endurance. I work with Looked After Children and the experience of my Social Work colleagues is that there is very little provision early on in a child’s life span.
Those services that are able to identify and support families where there are emerging difficulties are unlikely to have the necessary therapeutic skills to provide input to families where change is more difficult due to the complexity. Transgenerational difficulties in parenting, attachment and family relationships is a complex area often requiring highly skilled therapists and most services offer a medically trained primary care practitioner. For some families with emerging difficulties this will be enough but there is little access to more specialised therapeutic intervention. I am aware that Flying Start in Torfaen employ a part time Clinical Psychologist to support the staff in providing a more psychologically/therapeutically informed service and possibly to offer more specialist therapeutic interventions where necessary but this is the only service focusing on this age group that I am aware of that has this provision. For difficulties emerging later on then there are some other examples, however, again this is very patchy provision and not in all boroughs (e.g. FIT in Caerphilly).
In order to provide an early intervention service that is equitable and non-stigmatising then the over-reliance on diagnostic criteria in terms of service delivery may well need to change. By understanding infant and childhood mental health through a developmental and normalising lens (i.e. understanding that difficulties in childhood more often than not can be understood in the context of their history and environment) may lead to services that are better able to identify and work with emerging difficulties in order to prevent more serious difficulties emerging later on.
Working very closely with Social Workers I have heard much anecdotal evidence that getting a referral accepted by CAMHS in Newport is so difficult that they sometimes don’t even try despite working with children with very complex emotional issues. Some of the difficulty may stem from an overreliance on a more medical perspective of mental health issues in childhood to organise service criteria. One more recent example brought to a consultation is that of a teenage girl with a very difficult family history who had been rejected by her mother and had come into care. She had an assessment by an on-call mental-health practitioner following being admitted to A&E. The conclusion of the assessment was that her difficulties were ‘behavioural’ rather than indicative of a mental health issue. From providing a consultation I was aware that her behaviour was likely to be an expression of high levels of emotional distress and complex loss and this was manifesting in very challenging and sometimes risky behaviour. Unfortunately she did not get a referral to CAMHS and was not able to access psychological therapy which could, in my opinion, have been helpful to her. Through a medical lens she did not fit the criteria for any particular diagnosis but through a psychological lens she was experiencing very significant emotional difficulties and consequently had been putting herself at risk. These issues could have been addressed through psychological therapy if that had been available and accessible. This is just one example of many similar stories I hear from Social Workers regularly. Access to psychological therapy via CAMHS is seen as almost impossible unless difficulties have escalated to the point where the young person is suicidal or self-harming significantly.
There is an ever growing debate regarding the validity, reliability and usefulness of a medical understanding of mental health[5] not to mention the debate around the ethics of viewing childhood difficulties through this lens. A recent example of the pitfall of this approach came up in a recent consultation where the third generation of a family characterised by neglect and abuse had come into care and one of the children had been scapegoated and blamed for the breakdown of the family because of his diagnosis of ADHD.
Regardless of whether CAMHS services are structured around diagnostic criteria or a more normative/developmental lens, the current demand seems to outstrip the current supply considerably and most the children that I work with that have had a referral accepted are facing waits of several months. In terms of working with children with attachment difficulties and emotional issues stemming from early histories of trauma, abuse and neglect I am aware that the Clinical Psychologists working within CAMHS have the necessary specialist skills to provide psychological therapy for these kinds of issues but I am not aware of any other parts of the service that can provide this form of specialist psychological therapy so for Looked After Children the access to the most helpful form of therapy is extremely poor.
As a Clinical Psychologist based in Psychological Services for Children and Families within Gwent, my post is paid for by Newport Local Authority. I am providing a clinical lead role and shaping the therapeutic approach of a multi-disciplinary team providing a service for Looked After Children. I am aware that there is a similar post in Monmouth. This is very much an embedded service of over 9 years. This, again, however is an inequitable service provision and whilst very successful where it is in place, other boroughs in Gwent/ areas in Wales do not have this provision.
I don’t feel sufficiently informed to comment on this.
I don’t feel sufficiently informed to comment on this, however, Newport borders Cardiff and the Local Authority and Health Board do not have co-terminosity and therefore there are some Looked After Children that are registered with Newport Local Authority but served by Cardiff and Vale NHS Trust. In the cases I have been aware of that have sought CAMHS involvement my understanding is that provision there is equally difficult to access if not worse.
I don’t have enough experience of working with young people who have received emergency services to be very sure of how effective these arrangements are, however the handful of young people who have accessed emergency services that I have been aware of have received an assessment by someone who clearly did not have a good and thorough understanding of the consequences of a history of abuse/trauma/neglect on childhood development and the emotional/mental health consequences and merely. This is however only a handful of young people so may not be representative.
I do not feel well enough informed to comment on this.
The key themes that tend to emerge in consultation with Social Workers are that they can not get referrals accepted by CAMHS and that when they do they often feel that the practitioners do not fully understand the needs of the child or have the skills to provide the most helpful interventions for children and young people who have an early history of neglect/trauma/abuse. Generally, access to relevant specialist psychological therapies is seen to be very poor.
[1] WAVE Trust: Tackling the Roots of Disadvantage. Conception to age 2 – the Age of Opportunity. In collaboration with Department for Education. 2013
[2] Early Intervention: Smart Investment, Massive Savings: The Second Independent Report to Her Majesty’s Government, July 2011, HM Government
[3] Childhood Mental Health and Life Chances in Post-War Britain; Insights from three national birth cohort studies. (2009) Centre for Mental Health.
[4] Fernivall, J. (2011). Attachment-informed practice with looked after children and young people. IRISS Insight no, 10. Scottish Attachment in Action.
[5] E.g.: Johnstone, L (2000), Users and abusers of psychiatry: A critical look at psychiatric practice.
Bentall, R. P. (2003) Madness Explained. Penguin.