Introduction to the executive committee of the

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					               Introduction to the executive committee of the
              Adolescent Forensic Special Interest Group


Dr Philip Collins, Chair
Adolescent Forensic Psychiatry in Youth Offending Services (YOS)
Consultant in Child and Adolescent Forensic Mental Health at Lewisham CAMHS,
London and at Lewisham YOS

Each local authority area across England is obliged by legislation to organise a multi-
agency team to manage the delivery of a range of assessments and youth justice
interventions to young people who have offended, or are at risk of offending (for
further details see www.yjb.gov.uk )

One aspect of the services provided by these teams is the commitment to detecting
and referring on significant mental health problems to the appropriate professionals
in the locality. This is appropriate given the very high rates of mental health difficulty
within the young offender population. This occurs when a basic mental health
screening tool is used by the YOS worker who assesses the young person to alert
the system to the possibility of disorders such as depression, hyperkinetic disorders
or psychosis. When this happens, a further assessment by the YOS mental health
worker is indicated.

The mental health worker, usually employed by the National Health Service and
seconded into YOS, will then decide on the basis of the mental health assessment
how to treat the problem. The local child and adolescent mental health service
(CAMHS) may need to become involved in order to provide the necessary psychiatric
expertise.

Each locality, in practice, organises itself differently on the basis of local inter-agency
agreements and protocols. The level of adolescent forensic psychiatry input can
differ greatly across localities depending on the availability of suitably trained
psychiatrists. Most areas will have arrangements with a local child and adolescent
psychiatrist to provide assessment of complex cases and to deliver the appropriate
package of treatment.

 A tension can arise when psychiatrists who are not specifically trained to deliver
adolescent forensic assessments or interventions are required to provide a service to
young offenders with complex risk and offending profiles linked to major mental
health problems. It is rare to have full time psychiatric input into a youth offending
service and many localities will have just one or two staff – often from a psychology
or nursing background- within the YOS delivering mental health working to the
young people. This can lead to very high levels of demand on the worker and can
make it very difficult to deliver a comprehensive package of assessment or treatment
to the young person and their families or carers.
YOS mental health workers can experience high stress levels given the enormity of
need for mental health intervention in the absence of adequate resources locally to
deal with the complex mental health problems presented by this high risk/high
unmet needs group of young people. In greater London, the YOT Mental Health
Worker Forum was established to provide a regular meeting point for those of us
who work in this area. The group meets regularly at a central London location to
discuss best practice, new developments within localities and to offer peer support
to offset the isolation which single-handed mental health workers can experience.

In contrast, within Lewisham YOS and within a small number of other YOS across
England, a full multidisciplinary specialist mental health team has been established
to provide young people who offend and their families with a comprehensive CAMHS
service. The team incorporates child and adolescent forensic psychiatry, psychology,
child mental health forensic nursing, substance misuse nursing, mental health triage
working and child mental health specialists and provides an enhanced range of
specialist assessment and treatment programmes. For example, robust specialist
outpatient based programmes for young people with sexually harmful behaviours
have been established to provide a wider range of sentencing options to the courts
in these cases. The team are also trained to provide specialist risk assessments to
YOS and other agencies.


Dr Richard Church, Finance Officer
Specialty Registrar in Forensic Psychiatry, West London Mental Health Trust

I was first exposed to this field during my days of general SHO training. The
opportunity arose to perform an assessment under the supervision of a local
consultant adolescent forensic psychiatrist…eh?? What on earth do they do?!

I entered a fascinating area of psychiatry. I was rapidly exposed to a huge range of
mental disorders including a range of neurodevelopmental disorders, psychoses,
OCD and consequences of head injuries. I saw young people and families from all
manner of ethnic and socioeconomic backgrounds, often faced with a form of
psychosocial adversity such as poverty, illness, migration, family breakdown or
abusive experiences. I conducted assessments at community CAMHS bases, on
home visits, in prisons, in youth offending teams and in schools, and I have
prepared assessment reports for GPs, CAMHS teams, youth court, criminal court and
family court.

Based on my experience so far, I can say that adolescent forensic psychiatry really
draws on my knowledge and skills as a general medical doctor, as well as a specialist
psychiatrist. The young people and parents who come into contact with forensic
CAMHS services often have (neglected) physical health problems, and general
medical training also helps when faced with forensic scientific evidence which often
features in court proceedings.

My route through psychiatric training has been unusual in that I embarked on
CAMHS SpR training on one scheme and then, in my final year, applied for Forensic
ST4-6 training on another scheme. During my CAMHS training I gained as much
forensic experience as possible through generic adolescent CAMHS/YOT work, a
specialist outpatient adolescent forensic service and a specialist adolescent forensic
inpatient unit, whilst maintaining the breadth of CAMHS experience required for a
CCT in child and adolescent psychiatry. In accordance with the subsequent letter
published by the Dean of the College, I:
    - justified the requirement for dual training in terms of career plans
    - informed the deanery of my interest in dual training early during higher
       training
    - applied for a second set of training within the same deanery

I persevered for several years in my quest to secure dual training and I am delighted
with where I am today, as ST4 in forensic psychiatry. Already I see more clearly
than ever how essential it is to be trained in both CAMHS and forensic psychiatry for
work in the challenging field of adolescent forensic psychiatry. Dual training is
supported by the overwhelming majority of consultants in the field and is something
this Special Interest Group aims to protect and promote.

I would like to thank Dr Ekkehart Staufenberg for all his hard work over the last few
years and I am honoured to take over from him as the new Financial Officer for the
SIG. I will also be updating this website on behalf of the Executive - we look forward
to keeping you informed!


Dr Ernest Gralton, Forensic Psychiatry of Developmental Disabilities

Adolescents with developmental disabilities who have forensic needs are a very
complex population and present unique challenges to those who care for them.
Those who are referred to secure psychiatric services often have a variety of co-
morbid disorders, some unrecognised for long periods due to difficulties in carrying
out comprehensive assessments (Barlow & Turk 2001) or because of the
phenomenon described in amongst the developmentally disabled as 'diagnostic
overshadowing' where abnormal behaviours are attributed to the presence of
intellectual disability alone (Mason et al 2004).

Psychiatric disorders are up to four times more prevalent in adolescents with
intellectual impairment than adolescents without impairment, however only a small
minority young people receive any form of specialist service (Emerson 2003, Tonge
et al 2001). Diagnoses amongst this population frequently include developmental
problems including Autism and Attention Deficit Hyperactivity Disorder,
Developmental Dyspraxia/Developmental Coordination Disorder, Tourettes and Tic
disorders.

In addition to this a number of environmental insults notably
developmental trauma (including neglect and physical and sexual abuse), head
injury and substance misuse are extremely common. Some have also gone on to
develop a variety of formal mental illness including atypical affective disorders,
anxiety disorders (including complex PTSD or Developmental Trauma Disorder) and
a range of psychoses, although these are not always easy to recognise.


Dr Ollie White, Higher Specialist Training
SpR in Child & Adolescent Forensic Psychiatry, Oxford

As adolescent forensic services continue to develop, their success will in part depend
on the expertise of consultant psychiatrists who have the necessary training to work
in this specialist area of psychiatry. As of 2007, only 17 members of the College
were registered as having dual CCT qualifications in Child & Adolescent Psychiatry
and Forensic Psychiatry. There is, therefore, an ongoing need to dual train
psychiatrists in order to meet service demand, albeit at relatively small numbers.

Despite this service need and the desire from some trainees to dual train in child &
adolescent and forensic psychiatry, training opportunities have become extremely
limited over the past 2 years. There are a number of reasons for this, the greatest
being the introduction of Modernising Medical Careers (MMC). Although there
continues to be the scope to provide dual training under the MMC framework, it is
unclear how this will be facilitated. Access to dual training will continue to be at the
deanery level but it seems likely that it will be increasingly linked to service provision.
The lead-time of 5 years for higher dual training means that trusts and deaneries will
require long-term vision. Alongside these changes, the College is continuing to
consider how best to accommodate the increasing specialisation within psychiatry
training. Options include increasing the number specific curricula (either via more
CCTs or more sub-speciality endorsements) and it is possible that adolescent
forensic psychiatry may become an individual speciality in the future. The move to
competency-based training may facilitate this development, as it is likely to become
easier for doctors to demonstrate achieved competencies across psychiatric
specialties.

It is at present unclear to what extent dual training opportunities will exist within the
new structure of MMC. Indeed, it appears that there are very few specific dual
training schemes being offered at ST4 level at present, and none to my knowledge in
child & adolescent and forensic psychiatry. It has been suggested that training in a
second psychiatric specialty may occur after the first CCT has been achieved and I
am aware of one trainee with a CCT in child and adolescent psychiatry who has been
appointed on a forensic psychiatry training scheme at ST4 level. It is unclear at
present whether this will be the solution to the lack of specific dual training
schemes, and raises a number of issues, most crucially surrounding the funding of
additional post-CCT training. Deaneries would have fulfilled their responsibility to
provide training to CCT and may be reluctant to fund training beyond this. An
alternative solution is that special interest sessions could be used to obtain
competencies in a specialty other than that in which the trainee will obtain their CCT.
This would require careful planning and cooperation between trusts and training
programme directors and it is unlikely to be a sufficient alternative to full dual
training.

It is clear that the combination of child & adolescent and forensic psychiatry remains
crucial to the provision of adolescent forensic services and appropriate training must
therefore exist to ensure that there are specialists in this area. However, traditional
dual training appears to be under threat and adaptations need to be made to the
new structure of postgraduate training to allow trainees to develop the necessary
competencies across specialties. The rhetoric surrounding MMC promised greater
flexibility of training and it is of paramount importance that this is developed in order
for trainees to achieve the broad and diverse range of competencies that are
required by these developing services. This will allow us to meet the needs of our
patients and deliver the best possible care.

The SIG are keen to hear from any trainee interested in training in Adolescent
Forensic Psychiatry – please feel free to contact us via these webpages.

For more information please see the following article published in the Psychiatric
Bulletin:

Oakley C, White OG & Bailey S (2009). Dual Training in Psychiatry: Which way now?
Psychiatric Bulletin 33: 231-234.
http://pb.rcpsych.org/cgi/content/full/33/6/231


Dr Nick Hindley, Community and Prisons

At present there is no clear countrywide network of community forensic CAMH
services. We (members of the Special Interest Group) are however aware that a
number of services across the UK do consider themselves to fulfil the functions of a
community forensic mental health service for young people.

The SIG would be interested in forming a directory of community forensic CAMH
services and we would be happy to coordinate this via this website.

As a first step towards this I am providing a link to an information document for
referrers which outlines the organisation and functions fulfilled by our team in
Oxford. Key issues relating to the service include:

      Regional specialist commissioning agreements and funding
      A dedicated service for a catchment population of 2.2million
      A strong emphasis on liaison work and support for other services working
       with young people
      Strong local, regional and national links within CAMHS, YOS and other
       agencies
Dr Heidi Hales, Independent Sector

The independent sector provision for adolescent forensic psychiatry continually has
to reinvent itself as the NHS provision catches up with the need which is being
provided by the independent sector. Prior to the NCA funded NHS medium secure
beds, much of the independent sector provision was for mentally disordered young
offenders who had major mental illnesses. There was also provision for adolescent
females (and less so males) who were self harming to such a degree that they
required the levels of nursing care that are provided in secure settings.

With the advent of the NCA NHS medium secure beds, the greater need now is for
provision of secure beds for mentally disordered offenders with emergent personality
disorders (male and female). There are ongoing ethical and moral debates with the
adolescent and child and adolescent fraternity about whether these young people
should receive care within the context of mental health provision and whether there
is evidence based effective care that can be offered.

Those of us working in these services believe that these young people do not receive
the appropriate care in the other statutory services and are seeking to offer care
that will improve their prognosis. Good research into this care is also essential for
the future provision of services for these young people.

Another level of service offered through the adolescent forensic independent sector
is for low secure adolescent beds. There are insufficient of these in the NHS
and by April 2010 it is a statutory duty through the amendments to the Mental
Health Act that age appropriate beds are made available where possible.


Dr Tina Irani, Scottish Services
Specialist Registrar, Forensic CAMHS, West of Scotland

Services
The only health board that has an established Community Adolescent Forensic
Mental Health Service in Scotland is NHS Greater Glasgow and Clyde and it only
available to patients within the Greater Glasgow area.

The Adolescent Forensic Team consist of:
Senior Clinical Specialist (Interim Clinical Lead)
Consultant Child & Adolescent Psychiatrist
Forensic Nurse Therapist
Nurse Therapist
Social Worker
Assistant Clinical Psychologist
Trainee Forensic Psychologist
Consultant Clinical/Forensic Psychologist
2x Secretary

Referrers
80% of referrals come from Social Work. Remaining (20%) of referrals come from
inpatient units, other health professionals, the secure estate and others.

Services the team offer include:
The team offers both Forensic and Clinical interventions.
Forensic Interventions include specialist risk assessments , formulations of risk and
evidence based individual, behavioural and prevention programmes to programmed
manualised approaches for risk reduction.
Clinical interventions involve comprehensive mental health care and treatment. This
includes medication and psychological approaches.
The team also offer in-reach services to inpatients and secure settings. They also
offer consultancy and advice to all stages of services both health and social work
who are working with high risk individuals.

FCAMHS services in Scotland
There are pockets of individuals but none that offer a stage 4 comprehensive
multidisciplinary integrated service. There are no secure Inpatient services in
Scotland for children and young people. The national commissioning group accepts
referrals for admission.

When enquiring about FCAMHS services around the country I got strong response
from my trainee colleagues both in Forensic Psychiatry and CAMHS. There is a keen
interest in the subject and disappointment in the lack of training opportunities.

Some of the quotes are as follows:

“I am interested in FCAMHS and would like to know more about the scope for
training in Scotland”. Aberdeen

“do think that a bit more FCAMHS training in the generic CAMHS training would be
good given the lack of FCAMHS in everywhere but Glasgow”. Glasgow

“I would be very interested in FCAMHS training. I thought it was one of the greatest
MMC failures that this opportunity had been removed”. Glasgow


Adolescent Forensic Psychiatry training in Scotland

The Forensic CAMHS training in available in the West of Scotland training scheme.
It’s a five year training programme, the first two years in CAMHS the next two in
Forensics, with the final year in Forensic CAMHS.

The core CAMHS training involved one year of generic community CAMHS and one
year at the regional adolescent inpatient unit.

Other Specialist CAMHS training available is at the national child in- patient unit,
paediatric liaison, Scottish Centre for Autism, Learning Disability CAMHS, Looked
after and Accommodated Child and Adolescent Mental Health Services, and
Addictions.

The core Forensic training involved one year at the regional medium secure unit, 6
months of Community Forensics and 6 months of Learning Disability Forensics.

Other Forensic experience available; High Secure placement at the state hospital,
low secure placement, Female offenders, prison Psychiatry (Adult males, young
offenders, and female offenders) and working with sex offenders.

The final year of training involves 3months in a FCAMHS in - patient unit in England,
6months with the community FCAMHS Team in Glasgow and 3 months to cover any
special interest including being attached to the mental welfare commission.

I would like to say thanks to the Community Forensic CAMHS team, Dr Aileen Blower
and all my SpR/ ST colleagues within Forensic Psychiatry and CAMHS in Scotland for
helping me collate this information.

                                                                            May 2010

				
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