CAMHS and gender identity

I work in Child and Adolescent Mental Health Services (CAMHS). One of the roles of CAMHS is to act as a gateway to the Gender Identity Development Service (GIDS) at the Tavistock and Portman in London. GIDS is the only service in the NHS that can prescribe hormone treatments to young people under 18 with gender identity issues. I’m something of a CAMHS jack-of-all-trades, and gender identity issues aren’t a large part of my role, but they’re a part of my role nonetheless.

The purpose of this blog post is to assemble some of my thoughts on the role of CAMHS with regard to gender identity. It’s a bit different to my usual blogging content in that it isn’t so much giving my own views as inviting others to give feedback. I think I should give the usual preface that any opinions I state here are personal ones and not necessarily those of my employer.

Just what do I do all day in CAMHS?

 

 

 

 

 

Last year there was a picture meme going around on the theme of What people think I do/What I actually do. After I made some sarcastic remarks about the meme on Facebook, I was challenged to come up with one for my own role as a nurse therapist in Child and Adolescent Mental Health Services (CAMHS). Being one never to ignore a thrown-down gauntlet, I went on a trawl through Google Images, and promptly knocked together the following illustration.

 

 

A few days ago, I noticed that this graphic (which I’d probably devoted an entire half-hour to creating) was being passed around on Twitter. Since that’s the case, perhaps I should elaborate on it a little, and explain the different images. that I selected

What adult mental health services think I do.

Okay, it’s probably an exaggeration to suggest they think I work with Teletubbies. Even so, there is something of a disconnect between adult services and CAMHS. Our core client groups are palpably different, and so too are our ways of working.

We don’t work a lot with people who have psychosis. Despite the American fad for diagnosing “pediatric bipolar disorder” (which even the Americans have been backtracking on in the last couple of years), conditions such as schizophrenia and bipolar disorder are rare in children. I see maybe one psychotic young person a year, usually in their mid-to-late teens. I do work with young people who hear voices, but it tends to be at the level of pseudohallucinations rather than outright hallucinations.

One unfortunate consequence of this is that on those odd occasions when a psychotic child comes to a CAMHS team, they may not be as geared up to supporting them as an adult service. Conversely, adult services often aren’t as geared up towards treatment of eating disorders as CAMHS.

Another difference is that people with depression and anxiety are more likely to be seen in primary care during adulthood, and in secondary care during childhood and adolescence.

These difference tend to result in all kinds of problems when a young person turns 18. They often discover that they’re either transitioning to a very different kind of service, or they simply aren’t being offered a service at all.

What Peter Breggin thinks I do.

It is true that use of psychiatric medication has risen in the UK in recent years, and I’d be lying if I said I’m entirely comfortable with all aspects of that. Despite this increase, it’s still fair to say that CAMHS are much more cautious in their use of medication than either their American counterparts or their colleagues in adult services.

I could count on one hand the number of medications I’m likely to come across in any given working day. If a young person is prescribed an antidepressant, 9 times out of 10 it’s likely to be fluoxetine, not least because it’s the only one licenced for under-18s. For ADHD there’s some relatively new drugs on the market, such as lisdexamfetamine aka Elvanse, but they’re not being prescribed much. The great bulk of young people with ADHD are still prescribed good old-fashioned methylphenidate (you know it as Ritalin, but it’s far more likely to be issued in various slow-release preparations such as Concerta XL, Medikinet XL or Equasym XL) with a smaller number taking atomoxetine aka Strattera. For sleep problems there’s melatonin. For highly agitated children there’s some use of low-dose antipsychotics (this has usually been risperidone, though there’s increasing use of aripiprazole instead) – and it’s this use of antipsychotics that I tend to feel uncomfortable about, even at low doses.

Outside of the higher-tier services dealing with deeply-unwell young people, that’s pretty much all the medication you’ll see. Despite the controversies about dubious use of psychiatric medications in childhood (by no means all of which are unjustified) a high proportion of the kids I work with are on no medication at all.

It’s also worth pointing out that I’ve worked with quite a few kids whose lives have been significantly improved through some judicious, well-monitored use of fluoxetine or methylphenidate.

What the Church of Scientology thinks I do.

All I have to say to this one is…If their argument is that psychiatry is superstition masquerading as therapy, and it’s all just a big scam to control people and take their money….Well, that’s a bit rich coming from the Church of Scientology.

What society thinks I do.

This image illustrates one of my major bugbears about what mental health services are perceived to be for. There’s a whole plethora of language devoted to it. “Oppositional defiant disorder.” “Conduct disorder.” “Behavioural problems.” “He has an anger problem.” “He needs anger management.” “She has difficulties with impulse control.”

All of which translates as, “Please make this child behave themselves.”

There seems to be an idea out there that all of society’s problems – unruly classrooms, chaotic family lifestyles, juvenile delinqency, crime – can be therapied away with six sessions of anger management. I can see why it would be an attractive idea to politicians, civil servants, parents, teachers, GPs, social workers – but it ain’t true. The psychiatric profession hasn’t helped itself in this regard by coming up with silly non-illnesses such as “oppositional defiant disorder”, but I don’t think mental health services should be there to get children to behave themselves, and I don’t think we generally do a good job when we try. If anything we can make the problem worse by trying to distil a wider systemic or social difficulty into a “condition” that the child has “got”. Hence why many CAMHS teams simply don’t accept referrals for ODD or conduct disorder.

What I think I do.

It would be fair to say I’ve put in quite a lot of training and studying into what I think I do. I’ve attended training on cognitive-behaviour therapy, as well as enhanced CBT for eating disorders. I’m currently paying out of my own pocket for some postgraduate study in systemic and family therapy. Over the years I’ve ploughed through a reading list of the great and the good. John Bowlby. Carl Rogers. RD Laing. Carl Jung. Paul Watzlawick.

What I actually do.

What do I do? Listen. Talk. Try to be a listener, an ally, a facilitator of reflection and problem-solving. Someone who works to build a relationship with young people and their families, and at times to help them build their relationship with each other.

When one puts it like that, perhaps what I do isn’t that complicated after all.

 

Diagnosis Shopping

The following story is fictional, but inspired by several real cases that I’ve been involved in.

A child is brought to Child and Adolescent Mental Health Services (CAMHS) by his parents. Mother is convinced he has aspergers. The child is clearly troubled, and shows signs of palpable distress. However, he shows no signs whatsoever of being on the autistic spectrum. On the contrary, he’s sociable, emotionally responsive, with no ritualistic behaviours and no sensory issues.

The school report he’s emotionally fragile, with low self-esteem. His teachers report that Mum seems very negative towards him.

The family spend some time with the family therapist. Themes emerge that Mum is strongly rejecting of the lad. She seems to be projecting something onto him, but we don’t get to find out what because Mum promptly sacks the family therapist as soon as he starts exploring that particular route.

Mum tells the consultant that he needs individual work on anger management and social skills, not this family therapy rubbish. The CPN gives him some individual sessions. For some unfathomable reason, the CPN has a habit of ensuring that Mum is in the room during the “individual therapy”. This is what is known as family therapy by stealth.

The boy is reviewed by the consultant. He’s now doing better, and there’s no evidence of mental illness or developmental disorder. Mum insists he has asperger’s, and demands a second opinion.

Another consultant provides a second opinion. No evidence of asperger’s or any other problems. Mum declares that she is outraged by this shabby treatment at the hands of the NHS.

The case is discussed in our team meeting. We feel we’ve done as much as we can. There’s nothing wrong with the boy, but Mum won’t take no for an answer. A team decision is made to discharge him from CAMHS.

As the discharge letter is being typed up, we get a phone call from the school. Mum has taken him to a child psychiatrist in private practice. After a single appointment, the private shrink has diagnosed him with asperger’s.

It seems that in a free market, even diagnoses are for sale.

What will the new DSM-5 mean for us Brits?

There was a slightly provocative headline to this Guardian article a couple of days ago. “Asperger’s syndrome dropped from psychiatrists’ handbook the DSM”. This refers to the DSM-5, the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which will be published by the American Psychiatric Association. Though actually Asperger’s isn’t so much being “dropped” as merged into one catch-all diagnosis of Autistic Spectrum Disorder.

This left me wondering about how the new DSM will affect mental health services over here.

I suspect it initially won’t affect us a great deal in Blighty. Psychiatrists in the UK usually base their diagnostic categories on the World Health Organisation’s ICD-10 rather than the American DSM. Also it’s important to note that diagnostic categories are not the only thing that affects what mental health services will or won’t do. There may be a diagnosis listed for, say, “oppositional defiant disorder” in the DSM and ICD-10, but my Child and Adolescent Mental Health Service doesn’t accept referrals for it. Such problems are considered the realm of school strategies, parent training and youth offending services, not child psychiatry. Those who say that psychiatry is out to medicalise all forms of human behaviour can take comfort that in our corner we wouldn’t be able to do that even if we wanted to. We don’t have the time or resources.

But it is true that what happens in America has a tendency to filter down to the rest of us, though not always. Pediatric bipolar disorder, for example, never really took off outside the United States.

I’m in two minds about the idea of merging Asperger’s into ASD. On one level I can see a rationale for it. It’s really not clear that Aspergers is a distinct condition from ASD. I also can’t think of anything that we do differently as a result of saying that a child has Asperger’s rather than ASD.

On another level, I wonder what effect this might have on the neurodiversity community and the sense of identity that some people have fostered. Also, I’m slightly concerned about the effect this might have, given that we’re referring to a condition that causes people to have difficulty coping with change.

This article on NHS Choices gives a few of the other changes. A new category coming in is “disruptive mood dysregulation disorder”; basically an angry child. The rationale given is an eyebrow-raising one, “to address concerns about potential over diagnoses and overtreatment of bipolar disorder in children”. In other words, the whole fad for pediatric bipolar disorder got so out of control Stateside that they had to create a diagnostic category to accept that some children get angry a lot. By comparison, I’ve been in CAMHS for five years and I’ve never met a pre-pubescent child with a diagnosis of bipolar disorder. Neuroskeptic has an excellent critique here, in which he points out that it basically describes the same thing as oppositional defiant disorder.

My guess is we won’t be accepting referrals for disruptive mood dysregulation disorder either.

There’s also some diagnoses going into the DSM-5 under the category of “conditions that require further research before their consideration as formal disorders.” Such as “internet use gaming disorder.” Here’s a musical number from some precontemplative addicts.

I doubt we’d be accepting referrals for that either, other than to write back suggesting the parents unplug the X-Box for a while.

There’s also some proposed categories that aren’t going to make it into the DSM-5, such as:

parental alienation syndrome – a term proposed to describe a child who ‘on an ongoing basis, belittles and insults one parent without justification’

Fair enough, because including that would be really silly.

There’s probably a lot more to be said about the DSM-5, particularly about the new dimensional approach to assessing personality disorders, but I’ve limited myself here to discussing it from a CAMHS perspective.

Not Working Together to Safeguard Children

One of the mantras that mental health services are supposed to live by is that there should be joined-up working between the NHS and social services. How’s that working out with children and adolescents?

In adult services, clinicians and social workers both work in Community Mental Health Teams (CMHTs). The CMHT will often have CPNs and social workers sharing offices, so that they can work closely together. In Child and Adolescent Mental Health Services (CAMHS) that’s not a given. Under the pressure of the cuts, quite a few areas have seen a loss of social workers. Social services departments who’ve been told they have to shed posts will often cut the staff over at CAMHS rather than the ones in their own office.

At the same time, both CAMHS and social services are under caseload pressures. Their resources are shrinking, but their caseloads aren’t. The talk in both camps is how to focus on their “core” clients, and who should be seen by other agencies.

Relations between CAMHS and social services have historically been fairly poor. As the gulf widens, this relationship can only get worse. The risk is that it can turn into a game of pass-the-parcel with children. As soon as one service accepts responsibility for a child, the other service steps back.

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.

Fostering Aspirations As The Downturn Bites Hard In Tyneside

Another day, another report on the parlous state of foster care. Media coverage, such as it is, homed in on the shortage of carers, variously estimated at between 8000 and 10,000, and on the poor outcomes for children in care in fundamental areas such as educational achievement, incidence of mental health problems and offending behaviour.

None of this is new – the Fostering Network has rendered impotent the word ‘crisis’, so often have they used it over the years – although there is no harm in it being said once again. However the report itself, Fostering Aspirations by the Policy Exchange  has a wider scope, incorporating the views of foster carers and children in care into their analysis of the quality of care and emerging with radical suggestions for tackling the problem, most notably a salary structure for a professional foster care service and an overhaul of commissioning arrangements that would see local authority fostering departments competing alongside the independent sector in a tendering process for placements or a total outsourcing of fostering.

Retreat into the Medical Model

Like just about everywhere else in the public sector, Child and Adolscent Mental Health Services (CAMHS) are feeling the effects of the cuts. As in so many other areas right now, jobs are having a nasty habit of not getting re-advertised when people leave. We haven’t yet had actual redundancies in our neck of the woods, but the whispers are in the wind.

Particularly vulnerable to the cuts are the psychotherapists – psychodynamic therapists, family therapists, art therapists, play therapists. There aren’t many of them employed in CAMHS, but their influence extends beyond their numbers. I’ve had some fascinating conversations with our psychodynamic therapist who keeps “accidentally” leaving papers on attachment theory on my desk. The opportunity to co-work with systemic and family therapists has genuinely transformed the way I conduct my clinical practice. They don’t just change kids and families. They change their colleagues too.

We get a complex mix of cases coming through our doors. Kids with neurological disorders such as ADHD and autism. Kids who have been abused, neglected or traumatised. Young carers to physically or mentally ill parents. Families under enormous strain, or with tortuous family dynamics. Educational issues. Child in need/child protection issues. It can be a bewildering variety of problems. To navigate it requires an eclectic mix of clinical models in your toolbox – medical, psychosocial, cognitive-behavioural, systemic, psychodynamic.

In hard times, it seems to be the psychotherapists – with their specialist outlooks and long, arduous training – who are most likely to be for the chop. My worry is that as we retreat to a core of doctors, nurses, psychologists and social workers, we’ll also retreat into a more narrow view of what CAMHS is for and what it does. Possibly diminishing into simply a medication and CBT service.

Don’t get me wrong, I’m not anti-medical model. I’ve worked with plenty of kids who’ve genuinely benefited from a bit of methylphenidate or fluoxetine. I’m not anti-CBT either, though I don’t think it’s the panacea cure-all it’s sometimes touted as. But one of the reasons I chose to work in CAMHS is because of its wide mix of models to suit the equally wide mix of problems that we deal with. Seeing our toolbox get smaller before my eyes is something that worries me.

Forgetting Young Carers

The constant stream of news coming out of the party conference hasn’t exactly left me impressed with the Tories this week, but here’ s at least one conservative that I can find some agreement with.

 

The children’s minister has warned colleagues that the government’s welfare changes “appear to undermine” ministerial commitments to support children of disabled lone parents by cutting as much as £3,500 a year from benefit payments.

In a letter seen by the Guardian, the education department minister, Tim Loughton, points out to Lord Freud at the Department for Work and Pensions (DWP) that the “planned changes in the welfare reform bill appear to undermine our efforts to ensure young carers are recognised and supported”.

The letter – between two Conservatives – exposes divisions over how heavy a burden the poor and vulnerable should bear from the budget cuts. Many argue that slashing welfare payments to disabled lone parents means their children will be forced to spend more time caring and less time growing up.

 

In Child and Adolescent Mental Health Services (CAMHS) we see a disproportionate number of young carers. They’re more likely to be depressed or anxious; they’re often more isolated than their peers; all too frequently they’re from low-income families. In some instances, they’ve dropped out of school to look after their physically or mentally ill parents.

In many cases they’re clearly dealing with far more responsibility than any child should. Some of them talk with the maturity you’d expect from somebody twice their age. More than a few of them look absolutely knackered as they do so. In short, they’re a very vulnerable group.

Fortunately, my local area has some very good young carer services. The support they provide can vary from counselling and therapy to simply taking them out with a bunch of other kids for some bowling or a KFC – basically a chance to act like a child rather than a carer. We’ve referred quite a few kids over to those services, and they do good work with them.

Increasingly, as CAMHS become more stretched due to cutbacks, the pressure on us is to do a referral to a young carer service and then discharge them. Which is fine until you remember that those services are also becoming more stretched, because they’re being hit by the cuts too.

I suspect that young carers, as with so many other vulnerable client groups, will be hit by a double whammy of a loss of income combined with support services drying up at the same time.