What are Child and Adolescent Mental Health Services for?

There’s been a row brewing recently about the new set of psychiatric diagnoses in the draft DSM 5.

Millions of healthy people – including shy or defiant children, grieving relatives and people with fetishes – may be wrongly labeled mentally ill by a new international diagnostic manual, specialists said on Thursday.

In a damning analysis of an upcoming revision of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other experts said new categories of mental illness identified in the book were at best “silly” and at worst “worrying and dangerous.”

I’ve occasionally been asked what all this will mean for Child and Adolescent Mental Health Services (CAMHS) in the UK. To be honest, I don’t think this is going to be the real issue for us. I think other issues are going to define what we do and how we do it.

Some people have suggested to me that the draft DSM means that CAMHS are going to wind up diagnosing the entire world. Every child will have its own medicalised label – be it oppositional defiant disorder for naughty behaviour, or social anxiety disorder for shyness. We’re going to be out there gleefully sorting and categorising the nation’s kids into little boxes.

The first response to that is that in the UK we mostly use the ICD-10 rather than the DSM for diagnostic categories – though I wouldn’t be surprised if the next revision of ICD (due in 2015) winds up being influenced by the DSM.

But I suspect that in the months and years to come the defining issue for us isn’t going to be diagnostic criteria but referral criteria. The reason for this is – surprise, surprise – a need to conserve resources during a period of austerity.

I’ve been hearing a lot of talk from our higher-ups about the need to focus on our core client base. Historically, CAMHS emerged out of what used to be called “child guidance clinics” (interestingly, I recently discovered that they still call them that in the Republic of Ireland) and have tended to have a broader outlook than adult mental health services, dealing with a lot of social and family problems. Increasingly, the party line is likely to be that we are a mental health service and it’s only our job to deal with mental health problems.

In the four years I’ve worked in CAMHS, I’ve noticed the referral criteria getting stricter, and that’s accelerated recently due to the cuts. In particular, I’ve noticed us getting more strict on not accepting two particular types of referral:

Behavioural/Conduct Problems

We still regularly get letters from GPs along the lines of, “This child is displaying angry and defiant behaviour, parents are at their wits end, please assess with a view to anger management.” CAMHS used to run anger management classes for these kids, and parenting classes for the parents. Anger management, as I’ve said before is a type of therapy that I regard with a scepticism bordering on contempt. I’ve seen lots of kids being sent for anger management, and virtually none of them come back any less angry or better-behaved. It’s a vapid, crass, sticking-plaster non-solution of a therapy that doesn’t address the rather obvious question, “Why is this child angry?” (Clue: an angry child is a distressed child.) It’s also often started for the wrong reasons. “He needs anger management to control his anger management” is often a euphemism for, “Please get him to behave for me.” Under such circumstances, it’s easy for CAMHS to fall into the trap of having a parent handing them responsibility for parenting their child. That sets everyone up to fail – CAMHS, the parents and most importantly the child him or herself.

School refusal

This is another thing we still get referrals for. Despite everybody’s best efforts, a child,for whatever reason, isn’t going to school. So, a letter goes to CAMHS asking us to see them for “school phobia”.

As with behavioural problems, school refusal is something that CAMHS simply isn’t successful at “treating” anyway. The longer a child stays out of school, then the more difficult it can be to get them back in, until it starts to feel like an exercise in pulling teeth. Either way, the effort needs to come from schools rather than a mental health service. Apart from the general lack of success, involving CAMHS can be interpreted as a medical reason not to go to school, because the child is “mentally ill”.

So, regardless of whether there’s a psychiatric diagnosis that can be used to label such problems – be it “oppositional defiant disorder”, “conduct disorder” or “school phobia” – we’re increasingly unlikely to accept referrals simply because a child won’t behave themselves or go to school. Our role is to work with conditions such as depression, anxiety, self-harm, eating disorders, ADHD, ASD, psychosis and so on. Personally, I think that’s as it should be.

One other effect of the cuts is a narrowing of disciplines as well as referral criteria. In some places, social workers in CAMHS have been provided by social services rather than the NHS, so it makes them vulnerable to being pulled out by social services departments who’ve been told they have to lose staff. Why lose social workers in your own office when you can get rid of or redeploy the ones who are over at CAMHS?

Also vulnerable for the chop are the psychotherapists – they’re more likely to get culled, and less likely for new posts to be advertised. We’re seeing a bonfire of the family therapists, psychodynamic therapists, art therapists, play therapists…retreating onto the core disciplines of doctors, nurses and clinical psychologists. You wouldn’t think it from some of my views on psychotherapy regulation, but I find this deeply depressing and worrying. The chance to work alongside family therapists has been genuinely transformative on my clinical practice, and I’ve had some fascinating case discussions with our psychoanalytic therapist. I worry that new staff coming into CAMHS won’t get those experiences that I’ve had, and that the service will be poorer for it.

So, that’s what I think the future of CAMHS is likely to look like. Slimmed down to its core client base, and with a less eclectic mix of disciplines. It won’t be about us expanding out to medicalise the nation’s children.

3 thoughts on “What are Child and Adolescent Mental Health Services for?

  1. While I certainly agree with most of your analysis of the potential future for a worrying reduction of range of services and multi-disciplinary support, as someone who has a lot of experience working with young people who have refused school, I feel I should challenge your suggestion that ‘school phobia’ is never a mental health issue. It is certainly true that refusing pupils are often labelled as ‘school phobic’ when the reality is that they are simply reacting to a situational problem, whether that be at school (and where schools should be doing more) or at home (where schools often have very little influence). Nonetheless there are some pupils who are displaying the signs and symptoms of latent mental health problems, where early CAMHS intervention may (and does in my experience, if not yours) have a life-changing outcome. It would be of great concern if the opportunity for enlisting CAMHS help in supporting such pupils were no longer available to education professionals and would definitely result in some young people suffering even further disadvantage.

    • Perhaps I should clarify what I mean in the original post.

      If a child has a mental health problem and this was contributing to their not going to school, then it would still be the role of CAMHS to get involved and treat the mental health problem.

      CAMHS might turn down a referral (or get the primary mental health workers to signpost) if a child was refusing school but showing no other signs of a mental health problem. However, if the child was, say, depressed or anxious, and that was contributing to their school non-attendance, then a referral to us would still be appropriate.

  2. I notice our local Priory Hospital offers a plethora of dodgy diagnoses, including “oppositional defiant disorder”, with all manner of resources covering most if not all schools of thought, together with the interesting claim (pre recent cuts) that 80% of their adolescent patients are NHS funded. So, on the one hand, over-diagnosis (and parent collusion?) with all the resources anyone could wish for. On the other, rigorous diagnosis without proper resources. Sigh, we’ve been here before, haven’t we Charles? I hear Mr Bumble the Beadle has re-applied for his old job and Fagin is seeking CQC sanction to open a CAMHS residential facility. Why do politicians, and indeed electors, never learn from experience?

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