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					  A needs assessment of Enfield
Child and Adolescent Mental Health
        Services (CAMHS)




             2005/2006




                 1
                                                  Contents
Executive Summary ............................................................................................ 3
Key recommendations ........................................................................................ 4
Aim of the needs assessment ............................................................................ 5
Objectives ........................................................................................................... 5
Introduction ......................................................................................................... 6
Background ......................................................................................................... 7
Efficacy and effectiveness of interventions and service models ....................... 9
Local need for CAMHS ..................................................................................... 15
CAMHS provision for Enfield residents ............................................................ 28
Local use of CAMHS ........................................................................................ 33
Summary of met and unmet need .................................................................... 43
Conclusions....................................................................................................... 49
Recommendations ............................................................................................ 50
Appendix 1 : Definitions and examples of Tiers .............................................. 51
Appendix 2: Prevalence of specific child and adolescent mental health
conditions .......................................................................................................... 54
Appendix 3 : Team type definitions .................................................................. 55
Appendix 4 : ENFIELD CYPSPB FLOW CHART ............................................ 56
Appendix 5 : ENFIELD CAMHS - Linked Projects and Teams ....................... 56
Appendix 5 : ENFIELD CAMHS - Linked Projects and Teams ....................... 57
Appendix 6: Staffing levels ............................................................................... 58
Appendix 7 : Markers of Good Practice (Children’s NSF) ............................... 61




                                                           2
Executive Summary
Mental health issues are estimated to affect 13,745 children in Enfield (Table
2). The Child Guidance Service (Tier 3) sees over 1200 cases per year.
Unless there are many children seen by Tier 1 and Tier 2 professionals there
is potentially a huge amount of unmet need within the borough. The
consequences of this shortfall are enormous: many children and adolescents
with mental health problems go on to be disturbed adults who will use the
adult psychiatric and medical services as well as social services and the legal
system.

Considering several of the risk factors for mental illness suggests areas of
greatest needs are in the Eastern part of the Borough with particular
emphasis on the South Eastern corner. Use of the local CAMHS team reflects
predictions by epidemiological data; i.e. that need increases by age and boys
outnumber girls. Potential gaps identified by the CAMHS mapping exercise
are amongst provision for young offenders, children with learning difficulties
and within Black and minority ethnic groups; these groups may be currently
underrepresented in the local caseload. (However this exercise is based on a
snapshot of one month’s data and may not be representative of the annual
caseload).

Other gaps identified through comparative analysis and stakeholder review
include both generic and specific areas of provision, for example, increasing
the mental health promotion work carried out in pre-school years and within
the school setting.

It is often easy to dwell on the gaps in provision but it should also be
remembered that there are many areas where Enfield CAMHS performs
particularly well, for example setting up the new SCAN service (Service for
Children with Neuro-developmental disorders) in response to an assessment
of local need, providing an on call service etc.

Some of the following recommendations have been highlighted by other local
work, for example, an action plan exists to promote mental health awareness
within BME communities.




                                      3
Key recommendations

Development of existing services

      Transparent planning is necessary for the re-accommodation of
       existing services. It is vital that this takes into account the geographical
       spread of mental health needs and risk factors. The possibility of
       providing regular outreach services in the community should also be
       considered.
      Reduce the use of out-borough placements
      Continue and extend the work in local schools to include all schools
       and early year’s settings. (For example, initiatives such as Healthy
       schools, drop in centres, Place 2 Be and the Behaviour Improvement
       Programme).
      Regular evaluation of services is necessary.
      Carry out a training needs analysis of all those providing mental health
       services
      Identify and provide suitable services for children who may currently
       under-use CAMHS.
      Improve the collection of data on ethnicity.
      Look at children and young people in the context of the family.
       Enhance services for parents with mental health problems, those
       facing domestic violence or who have substance dependencies.

New services

      Develop borough wide services for 0-2 year olds and their
       parents/carers; for example, extend the Edmonton Sure Start scheme.
      Develop specialist foster care and/or specialist accommodation to
       provide a secure base for those requiring medium term care. Ensure
       that respite care is available.
      Provide intensive community based tier 3 services locally (Tier 3 ½
       services) so that Tier 4 services can be reduced.
      Establish a network for supporting local counselling services.
      Provide transitional services for those moving from child to adult care
      Develop early intervention teams for young people with first episode
       psychosis
      Clarify arrangements for those leaving Tier 4 provision and make
       available suitable supported accommodation




                                        4
Aim of the needs assessment
To review the child and adolescent mental health services available to Enfield
residents.

The Children’s NSF states that the commissioning and delivery of services
should be informed by a multi agency assessment of need that is updated on
an annual basis. 1


Objectives
      To assess and document current provision of CAMHS for Enfield
       residents
      To compare the existing service provision to estimated needs and
       models of care identified from the literature
      To identify any gaps in service provision
      To make recommendations about how those gaps may be addressed




                                      5
Introduction
Mental health is increasingly recognised as being central to the psychological,
physical, emotional and social well being of people. Mental health in young
people is indicated by 2:

      A capacity to enter and sustain mutually satisfying personal
       relationships.
      Continuing progression of psychological development.
      An ability to play and to learn so that attainments are appropriate for
       age and intellectual level.
      A developing moral sense of right and wrong.
      The degree of psychosocial distress and maladaptive behaviour being
       within normal limits for the child’s age and context.

There is evidence that childhood difficulties can lead to mental and social
problems in later life3. Emotional and behavioural disorders may affect
childhood development, a young person’s future capacity to make long-term
relationships and the adequacy of parenting their own children. It may also
affect their capacity to enter employment. Mental health problems can
interfere with education. This may lead to poor attainment, low self-esteem
and increase the risk of psychological problems 4. Mental health promotion
with children and families is therefore a key priority.

Children and young people who cause concern to themselves, parents, carers
or teachers may be referred to child and adolescent mental health services
(CAMHS), other health services or other agencies.    Some mental health
problems among young people can be relatively mild and self-limiting whilst
others are more serious. Some conditions, such as self-harm or eating
disorders, can be life threatening.

CAMHS in Enfield are provided for children and young people aged 0-18
years. CAMHS aim to prevent, investigate, assess and treat child and
adolescent mental health problems. They deal with a wide range of problems
and disorders from minor self-limiting difficulties through to conditions that
result in major disability. Adequate management requires a network of multi-
disciplinary, multi-agency flexible services.




                                      6
Background
National Context

In 1995, the NHS Health Advisory Service published a review of child and
adolescent mental health services (Together We Stand), which proposed a
four-tier model for commissioning and delivering comprehensive services.
Four years later, in the report “Children in Mind”, the Audit Commission took
this four-tier approach as its baseline and confirmed its applicability to the
future planning of mental health services for children.

In September 2002, “Improvement, Expansion and Reform” (the Priorities &
Planning Framework 2003-06) set the expectation that comprehensive mental
health services for children and young people would be available in all areas
by 2006. This should include early intervention and mental health promotion.
It also states that CAMHS is to be increased by at least 10 per cent each year
(in staffing, patient contacts and/or investment) according to local agreed
priorities.

In 2003, the Government published a green paper entitled “Every Child
Matters”. Following a wide consultation “Every Child Matters: Change for
Children” was published in November 2004 and the website was launched
soon afterwards.

The Children Act 2004, providing the legislative spine for developing more
effective and accessible services focused around the needs of children, young
people and families. This Act requires co-ordination of a wide range of
national initiatives to be delivered through Extended Schools, Children’s
Centres, Sure Start and Connexions. Mental health promotion is an integral
component of the delivery of these services.

In September 2004, the Children's National Service Framework (NSF)
included the mental health and psychological wellbeing of children and young
people as one of its 11 standards (standard 9). The Children’s NSF states that
the commissioning and delivery of services should be informed by a multi
agency assessment of need that is updated on an annual basis.

Local Context
The Comprehensive Performance Assessment (CPA) Improvement Plan and
Putting Enfield First Action Plan (Delivering Excellence) will both impact on
the CAMHS over the next few years. These include aims such as reducing
youth offending and improving services for vulnerable children.

The Children and Young People’s Strategic Plan 2004- “Promoting Positive
Futures” was produced by Enfield’s Children and Young people’s Strategic
partnership. It includes the principles & values underpinning Enfield’s vision
for the future of the borough’s children and young people. It also includes a




                                      7
local preventative strategy which looks at early intervention and realigning
resources.

Young Minds produced a report for the Enfield Children’s Fund proposing a
plan for preventative services locally. In the production of this report current
services were mapped and users and other stakeholders were consulted.

National Child and Adolescent Mental Health Services (CAMHS) mapping has
been developed for the Department of Health to contribute to the monitoring
of the expansion and development of mental health service provision for
children and young people. It was set up in 2002 and has become an annual
exercise.

In 2005 a Joint Area Review (JAR) was carried out in Enfield. The review
provided a comprehensive report on the outcomes for children and young
people in the local area. It incorporates the inspection of youth services and
replaces the separate inspections of local education authorities, local
authorities' social services, Connexions services, and the provision for
students aged 14–19.




                                       8
Efficacy and effectiveness of interventions and
service models

Interventions
Prevention
Prevention of mental health problems in young people is important as there is
a risk of problems continuing into adult life. For example, conduct disorder
ignored in childhood may lead to delinquency in adolescence. This in turn
may lead to antisocial personality disorder or an increased risk of offending in
adulthood. On the other hand, the promotion of resilience skills can raise self -
esteem and mental well-being.

An Effectiveness Bulletin (1997) reviewed mental health promotion for high
risk groups 5. For disadvantaged children e.g. those living in poverty:

             Interventions including high quality pre-school and nursery
              interventions have produced improvements in self-esteem,
              motivation, social behaviour and other educational and social
              outcomes.
             Social support visits to provide new parents with child-rearing
              skills are effective.
             Parent training is less likely to be effective where there are
              health and socio-economic problems.

School-based interventions and parent training programmes for children
showing behavioural problems can improve conduct and mental well-being.
Well planned joint working between CAMHS and school has been shown to
result in6:
    An increase in children’s happiness and well being
    An improvement in children’s behaviour
    An improvement in attendance

The local Behaviour Improvement Programme (BIP) has shown a reduction of
80% in permanent exclusions and a reduction of 50% in fixed term exclusions.
Overall attendance has also increased by more than 50%. 31 Whole school
approaches have been found to be vital in effectively promoting emotional
competence and well being in children 7.

The Enfield Mental Health Promotion Strategy (February 2002) contains more
detailed information on the evidence of effectiveness.

Treatment
Mental health services for children and young people provide a variety of
assessments, treatments and other interventions for individuals, families and
groups. Research on effectiveness of interventions is complex; it is difficult to
determine how much of the outcome is due to the intervention and how much
to the individual therapist or child. This may make findings difficult to replicate


                                        9
in other settings, with other children and other therapists 8. An overview of the
studies available suggests that:

              Psychotherapy is better than no treatment.
              The magnitude of improvement parallels that of adults.
              Differences between treatments tend to favour behaviour
               therapy, including cognitive treatments 3.

Fonagy et al published a book in 2002 which critically reviewed the mental
health treatments available for Children and Adolescents 13. There are also
specific NICE guidance available for some disorders.

CAMHS Outcomes Research Consortium (CORC) is a collaboration between
child and adolescent mental health services across the UK. CORC has
initiated a programme of outcome evaluation 9. The following 3 measures have
been agreed as the core measures to be used by all member services:
      Strengths and difficulties questionnaire (SDQ)
        This is the agreed key measure to capture child and parent views of
        change in difficulties. The SDQ is a 25 item questionnaire completed
        by referred children aged 11-18 and parents of children aged 3-16
        before first meeting and at 6 months after first appointment.
      Commission for health Improvement (CHI) Experience of Service
        Questionnaire (ESQ)
        This is the agreed key measure to capture parent and child views
        related to their experience of service. The CHI-ESQ is completed by all
        users aged 9 and over, at 6 months after their first appointment.
      The Children’s Global Assessment Scale (CGAS)
        This is the agreed key measure to capture practitioner views of change
        in difficulties. The CGAS is completed by practitioners for all age
        groups after first meeting and 6 months later.

Affective disorders
Specific guidance for the management and treatment of depression in
children and young people was published by NICE in September 2005
(CG28). The guideline recommends that:
     Children and young people with moderated to severe depression
       should be offered, as a first line treatment, a specific psychological
       therapy (such as cognitive behavioural therapy, interpersonal therapy
       or family therapy for at least 3 months)
     Antidepressant medication should not be offered to children or young
       people with moderate to severe depression except in combination with
       a concurrent psychological therapy and should not be offered at all to
       children with mild depression.
     Healthcare professionals in primary care, schools and other relevant
       community settings should be trained to detect symptoms of
       depression, and to assess children and young people who may be at
       risk of depression




                                       10
      Attention should be paid to the possible need for parent’s own
       psychiatric problems (particularly depression) to be treated in parallel, if
       the child or young person’s mental health is to improve.

Anxiety disorders
In some cases anxiety may be managed by parental reassurance;
encouraging the parents to help the child to experience whatever it is he is
avoiding14. In some circumstances anxiety may benefit from medication. 14
Guidance for adults can be found in the NICE guidance CG22, published
December 2004.

Attention deficit and hyperactivity
The most effective symptomatic treatment is stimulant medication, though the
benefits are lost on cessation of treatment.            Medication should be
accompanied by treatment of other difficulties such as self-esteem.
Combined use of behavioural and pharmacological therapies may provide
added benefits to some children. Dietary manipulation through a paediatric
dietician may also be helpful. Some children with attention deficit hyperactivity
disorder have low blood zinc levels 10. There is also evidence of essential fatty
acid deficiency in children with attention deficit hyperactivity disorder, and
supplementation may be helpful 11.

Autism, learning difficulties and related developmental disorders
Programmes that deal with secondary behavioural or emotional disorders and
training in social skills are important. The overall management programme for
young people with autism involves provision of medical care, appropriate
education, family support, focused treatment with speech and language,
social skills or other therapies.

Bed wetting and soiling
Cure rates using alarms have been on average 80% successful, but this can
be a difficult procedure to maintain. Medication has short-term benefits for
enuresis. Faecal soiling requires both medical and psychological
management.

Conduct disorders
E.g. Stealing, fire setting and anti social behaviour. Conduct disorders are
among the most resistant to intervention. Research is beginning to identify
successful treatment approaches. Community based approaches, social
problem solving skills and parenting programmes 12 have been shown to be
beneficial. There is growing evidence of the effectiveness of CBT in
combination with parent training amongst children with conduct disorder aged
8-12.13

Eating disorders
NICE guideline CG9 was published in January 2004. This guideline makes
recommendations for the identification, treatment and management of
anorexia nervosa, bulimia nervosa and atypical eating disorders (including
binge eating disorder) in primary, secondary and tertiary care. The guideline
applies to adults, adolescents and children aged 8 years and older.


                                        11
Feeding and sleeping disorders
The main evidence for effectiveness of procedures comes from successfully
treated single cases. Difficulties getting to sleep and night waking tend to
respond to behavioural management.

Obsessive compulsive disorders
Behavioural treatments are effective, particularly if combined with family
therapy.14 A NICE guideline is currently in development and is expected
November 2005.

Physical and sexual abuse
The treatment of individuals who have been abused is complex. Removal of
a child to a hospital, residential unit or other place of safety may be required.
There are indications that behaviour modification such as anger management
in the abusers can benefit some children.                    Individual dynamic
psychotherapeutic approaches are also used.

Post traumatic stress disorder and attempted suicide
Guidance for adults and children was published by NICE in March 05, CG26

Schizophrenia
There is little evidence on the outcome of treatment for children and young
people, although it has been assumed that it is the same as for adults. A
NICE guideline was published December 2002, CG1.

Self Harm
NICE guideline CG16 published July 2004 provides guidance on the short-
term physical and psychological management and secondary prevention of
self-harm in primary and secondary care.

Tic disorders
Psychological interventions involving education about the disorder and
support are the core treatments. Pharmacological treatment is used in more
severe cases. Cognitive, behavioural and other psychotherapeutic treatments
show some evidence of effectiveness, but further evidence is required.




                                       12
Service models
The Health Advisory Service (HAS)2 has described a model of services for
child and adolescent mental health problems in four tiers. Wallace et al 3
describe a similar approach based on the size of a population. The tiered
framework is a useful way of describing what kinds of services are provided.
However, services that have developed in response to local need may not
always neatly fit into the tier structure.

HAS2 identified a number of principles of providing CAMHS as follows:

             Accessibility
             Multi-disciplinary approaches
             Comprehensiveness
             Integration
             Accountability
             Development and change.


Wallace et al have also identified several principles in developing models of
care in child and adolescent mental health3:

            The majority of problems can be dealt with in primary care.
            Specialists should provide support to other groups.
            Services should be patient centred.
            There should be patient choice.
            Specialist services should accommodate the spectrum of need.
            Services should be concentrated in areas of greatest need.
            Professional isolation should be avoided.
            Service isolation should be avoided.
            Good communication and collaboration are essential.

The Children’s NSF set out 10 markers of good practice for CAMHS; these
are listed in Appendix 7.

As a requirement of the bidding process for the CAMHS grant local
interagency groups should have been set up in 1999 15. In Enfield this group is
the CAMHS Joint Services Planning Team (JSPT) which includes
representation from local agencies (e.g. Local CAMHS, Social Services,
Education, PCT, Acute Trust).




                                      13
                                  Summary

Mental health promotion should be a balance of whole population initiatives
and programmes targeted towards at risk populations

School and pre-school interventions produce improvements in self-esteem,
happiness and behaviour.

Psychological therapies (e.g. Cognitive behavioural therapies) work well for a
number of disorders

Parents’ mental health should be assessed and treated at the same time as
offering therapy to the child or young person.

CAMHS in Enfield is provided by multi disciplinary teams; direction is provided
by the Joint Services Planning Team (JSPT).




                                      14
Local need for CAMHS
To estimate local need for CAMHS consideration is given to national
prevalence studies and local risk factors.

Nationally derived figures
Recent epidemiological studies from several countries suggest that at any one
time approximately 20% of all children have diagnosable disorders 4. The
mental health spectrum is vast and there has been some estimation of the
prevalence in more specific disorders. For example, diagnosable anxiety
disorders affect around 12% of those aged 4-20, disruptive disorders around
10%, attention deficit disorder 5%, specific developmental disorders, enuresis
and substance abuse up to 6% depending on age group. 16 However, it is
important to bear in mind that prevalence figures are based on disorders
studied in strictly defined research terms. Results may not translate readily
into case load or case-mix as they present in real life.

The prevalence of particular disorders varies according to age and to some
extent gender. For example, the Health Survey for England 17 found that the
proportion of young people aged 13-24 with high scores on the General
Health Questionnaire 12, indicating possible mental ill-health, increased with
age. The proportion was higher among males than females. Males aged 4-
15 scored higher on the Strengths and Difficulties Questionnaire (SDQ) than
females. This was designed to detect behavioural, emotional or relationship
difficulties. Overall 12% of boys and 8% of girls had scores indicating
difficulties. In a national study in 1999 18, 10% of boys aged 5-10 years, and
6% of girls in the same age group were found to have a mental disorder. In
the 11-15 year olds the proportions were 13% for boys and 10% for girls.

Prevalence will reflect differences among the population, for example social
class distribution and levels of deprivation. The Health Survey also showed
that the proportions of boys and girls with high SDQ scores increased as
household income decreased. In a national study children from families in
social class V were three times more likely to have a mental health problem
than those from social class 1. 18 This study also found that prevalence rates
of mental disorders are greater among children:
    In lone parent families compared with two parent families (16%
       compared with 8%)
    In families with five or more children compared with two children (18%
       compared with 8%)
    If the interviewed parent had no educational qualifications compared
       with a degree level or equivalent qualification (15% compared with 6%)
    In families where neither parent worked compared with both parents in
       employment (20% compared with 8%)
    In families with a gross weekly household income of less than £200
       compared with £500 or more (16% compared with 6%)




                                     15
Other groups at high risk of mental health issues include looked after children.
Research carried out in Oxfordshire found that 67% of looked after children
had some type of mental disorder, the rate was even higher for those in
residential units at 96%. 19 Young people who are in the Justice system also
show a high incidence of mental health problems e.g. 90% of re-offending
juvenile delinquents have had a conduct disorder at age seven. 20

There is evidence to suggest that many forms of mental health problems in
young people are becoming more frequent 2. There has been an increased
demand for CAMHS over recent years, due to growth in incidence of mental
health problems such as depression, self-harm, delinquency and substance
misuse. Other factors contributing to the increased demand are greater
parental expectations, heightened demands on social services resources and
increasing recognition of certain disorders such as hyperkinetic disorders.
Certain risk factors, such as parental separation have also increased. Divorce
rates increased steadily from the 1960s until the 1990s, reaching a peak of 14
per 1,000 married people during 1993 21. The latest figures from ONS are for
1999 and give a rate of 13 divorces per 1,000 married population.


Local data
There are around 69,000 young people aged 0-18 in Enfield. Numbers of
under 18s are projected to rise by 3% by 2011. Numbers aged 0-4 are set to
increase by 1,804 (9.9%) by the year 2011. Numbers of young people aged
5-18 are likely to stay relatively stable.
Table 2 shows the estimated prevalence of mental health problems for
children and young people in Enfield. However, it is unlikely that the
population will grow uniformly across the Borough. Currently the locality of
Edmonton has the largest proportion of young people (24% of its population
are aged 0-14), it is also the area where population is predicted to increase
the most. Both the wards of Edmonton and Lower Edmonton are predicted to
grow by 24% in the period 2001-2021.22 It is therefore likely that the number
of children and young people with mental health problems will be higher in this
area than the rest of the borough.


Table 1 : Population estimates, Enfield 2003 & 2011

                                        0-4         5-15        16-18          0-18
         2003 Male                    9,243       20,180        5,425        34,848
              Female                  8,986       19,639        5,248        33,873
              Total                  18,229       39,819       10,673        68,721

         2011 Male                   10,133       20,078        5,559        35,770
              Female                  9,900       19,462        5,365        34,727
              Total                  20,033       39,540       10,924        70,497
Source: Greater London Authority (GLA), Data Management and Analysis Group


Table 2 : Prevalence estimates, Enfield 2003 & 2011




                                          16
                                     0-4        5-15       16-18         0-18
        2003 Male                  1,849       4,036       1,085        6,970
             Female                1,797       3,928       1,050        6,775
             Total                 3,646       7,964       2,135       13,745

        2011 Male                  2,027       4,016       1,112        7,154
             Female                1,980       3,892       1,073        6,945
             Total                 4,007       7,908       2,185       14,099
                     2
Source: GLA, Bates

Appendix 2 shows the estimated levels of certain mental health issues within
Enfield. Depending on the disorder, it may be brought to the attention of the
health visitor, teacher, GP or CAMHS. As children may be seen by many
different professionals there is a difficulty finding comprehensive data on the
incidence of local mental ill health. It tends to be the more serious disorders
which form part of the health activity data, for example, referral to CAMHS.




                                      17
There have been no recent local surveys on the prevalence of mental health
issues amongst Enfield children and young people. Local need therefore must
be predicted from both national figures (above) and risk factors. The
University of Durham developed a mental illness needs index (MINI) to
estimate the relative need for specialist mental health services for severe
mental illness23. A score of 1 is the average for England, Enfield scores 0.93
showing a lower than average need for mental health servic es (London
scored 1.5). However, there is considerable variation within the borough; from
a score of 0.47 in Trent ward to 1.39 in Latymer. The Mini model was
developed in 2000 and is therefore based on old ward boundaries, the map
below clarifies the geographical pattern of need; the greatest need for
specialist mental health services is in the Southern and Eastern parts of the
borough. The map also shows the position of local CAMHS teams.




         Hospital Paediatrics
         Hospital Paediatrics
                                                                                 Chase
                                                                                 Chase
                                                                                                                                 Turkey Street
                                                                                                                                 Turkey Street


                                                                                                                                                 Enfield Lock
                                                                                                                                                 Enfield Lock




                                            Cockfosters
                                            Cockfosters
                                                                                                                                          Enfield Highway
                                                                                                                                          Enfield Highway
                                                                              Highlands
                                                                              Highlands                  Town
                                                                                                         Town
Child Development Team, SCAN
Child Development Team, SCAN

                                                                                                                    Southbury
                                                                                                                    Southbury


                                                                                             Grange                                      Ponders End
                                                                                                                                         Ponders End
                                                                                             Grange


Behaviour Improvement Project, Enfield CAMHS (Avenue House), HEART
Behaviour Improvement Project, Enfield CAMHS (Avenue House), HEART
                                                                  Southgate
                                                                  Southgate                                                           Jubilee
                                                                                                                                      Jubilee
                                                                                                  Bush Hill Park
                                                                                                  Bush Hill Park
      mini 2000                                                                  Winchmore Hill
Behaviour Support Service, Enfield CAMHS (Dryden Road), SAFE
Behaviour Support Service, Enfield CAMHS (Dryden Road), SAFE                     Winchmore Hill
                                                                                                                                 Lower Edmonton
                                                                                                                                 Lower Edmonton
                                                                                                           Haselbury
                                                                                                           Haselbury                                               Sure Start (Edmonton)
                                                                                                                                                                   Sure Start (Edmonton)
     1.13to 1.39 (6)
                                                                                         Palmers Green
                                                                                         Palmers Green                     Edmonton Green
                                                                                                                           Edmonton Green                         Youth Offending Team
                                                                                                                                                                  Youth Offending Team
     0.97to 1.13 (6)                                           Southgate Green
                                                               Southgate Green

     0.84to 0.97 (7)                                                                                                                                            Teenage Parents Project
                                                                                                                                                                Teenage Parents Project
                                                                                 Bowes
                                                                                 Bowes                          Upper Edmonton
                                                                                                                Upper Edmonton
     0.64to 0.84 (7)
     0 to 0.64 (7)




There is no way of predicting whether a child is going to f ace mental health
problems. However, research has identified two main dimensions termed
resilience and risk factors.
     Resilience refers to protective factors enabling some children to cope
     Risk factors increase the probability of a child developing a mental
        health problem.

Both factors may be found within the child themselves, within the family or
within the broader environment.




                                                                                          18
Resilience factors
There are some children who are more resilient than others in the face of
certain life events. An important key to promoting children’s mental health is to
build on the protective factors which enable children to become more resilient.

                              Resilience factors16
In the Child                 In the Family               In the Environment
Being female                 At least one good           Wider supportive
                             parent-child relationship   network
More intelligent             Affection                   Good housing
Easy temperament             Supervision,                High standard of living
when an infant               authoritative discipline
Secure attachment            Support for education       High school morale and
                                                         positive attitudes
Positive attitude,           Supportive marriage         Schools with strong
problem solving                                          academic and non-
approach                                                 academic opportunities
Good communication                                       Range of sport and
skills                                                   leisure opportunities
Planner, belief in control
Humour/religious faith
Capacity to reflect

The following outline of the risk factors for mental ill-health locally
demonstrates high levels of variability of risks across the borough. For
example, to the North West of the borough there are wards which fall into the
20% most affluent in England, whereas in the south and east, there are wards
that are amongst the 20% most deprived.




                                        19
Risk factors
Certain factors may predispose the development of emotional and
behavioural disorders in young people or may act to perpetuate existing
problems. The risk factors fall into four main groups as shown in Table 3
below.

Risk     factors      in    the     child      (estimated Impact on rate of disorder
population prevalence)
                                                             3 times increased rate
Physical illness - chronic health problems (5%)              4-8 times increased rate
                  - brain damage                             2.5-3 times more disorder
Sensory impairments - hearing (4/1,000)                      No figures
                        - visual (0.6/1000)                  2-3 times increased rate
Learning difficulties (3-4/1,000)                            4 times rate of disorder
Language & related problems (2%)

Figure 2 shows % of Enfield children with special education needs
0.15% of the Enfield school population were permanently excluded in 2001/02
36% of Enfield pupils had English as an additional language (2005)
Risk factors in the family                                   Impact on rate of disorder
Family breakdown (1in 4 under 16s affected)                  Significant increase in disorders
Family size & overcrowding                                   Large family size associated with
                                                             increased conduct disorders in
                                                             boys.
Parental mental illness - schizophrenia                      8-10 times rate of schizophrenia
                        - maternal psychiatric disorder      1.2-4 times rate of disorder
Parental criminality                                         2-3 times rate of delinquency
Physical & emotional abuse                                   Twice rate of disorder if physically
                                                             abused, 3 times if neglected
Sexual abuse                                                 Twice rate of disorder
Information on looked after children and children on child protection registers follows
this table
Environmental risk factors                                   Impact on rate of disorder
Socio-economic circumstances                       Relationship not quantified
Unemployment (4.9% in Enfield March 2005)          Relationship not quantified
Housing & homelessness (930 households were High rates developmental delay,
accepted as homeless in 2004/05, 2535 were in temp emotional & behavioural problems
accomodation)
School environment                                 E.g. bullying
Life events                                                  Impact on rate of disorder
Traumatic events, e.g. disaster, bereavement                 3-5 times rate of disorder. Rises
                                                             with recurrent adversities.
Asylum seekers: 104 families and 59 unaccompanied children were supported by the
council March 2005
Table 3 : risk factors for mental health problems in children and young people;
numbers affected/at risk in Enfield 3




                                          20
Risk Factors in the Child
Enfield currently has 65 primary 17 secondary,6 special schools and 3 Pupil
referral units. Figure 1 shows the percentage of all Enfield state school pupils
within each ward who have special educational needs. There has been an
increase in the number of children with special educational needs from 2003-
05. 15 of the 22 Enfield wards have seen an increase; the largest being in
Bowes and Turkey Street (both increased by 5.1%). 24 At least 20% of children
with special education needs have behavioural and emotional difficulties.
Brent tPCT undertook a mental health risk assessment which showed that
children with special educational needs were 3.6 times more likely to be in
touch with the CAMH services 25.




       %




Figure 1 : Percentage of pupils in state schools with special educational needs 2005
(Source: Enfield Council, Pupil Level Annual School Census)
Other factors identified in the Brent report estimated that truanting children
were 9.6 times more likely to be in touch with CAMHS than children regularly
attending school. Children known to social services were 3.2 times more likely
to be using mental health services. 25
Information from the health care commission on substance misuse related
admissions to hospital, in the under 20s, showed that Enfield had a lower
value than expected 26. The rate of admissions for drug-related disorders and
poisoning by drugs was significantly lower than the England average. The
health care commissions interpretation is that a low value indicates that drug
misuse in the area is not leading to a high level of admissions to hospital.
Either due to there not being a major drug problem amongst children and


                                          21
young people in the area, and/or having good access to treatment/services
that address problems short of hospital admissions.




                                   22
Risk factors in the family
In 2003, there were 11/10,000 children in Enfield on the child protection
register. This is the lowest in the North Central London sector (the highest
being Camden at 68/10,000). The commission for Social care inspection put
the rate in Enfield for 2003/04 at 13.2/10,000 population under 18 – this
compares to a rate of 13.5/10,000 in England. All Enfield children on the child
protection register are allocated a social worker. (In England, an average of
1.1% of children on the register are not allocated to a social worker).

There were 310 Looked after Children (LAC) in Enfield in 2003, the majority of
these (60%) had suffered abuse or neglect. The rate of LAC in Enfield was
48/10,000. Again this was the lowest in the sector. The borough of Islington
had the highest rate of looked after children in London at 135/100,000.
However numbers are increasing in Enfield. Between 1998 and 2002, Enfield
experienced a 42% increase in the number of looked after children. In March
2004 it was calculated that 6% of Enfield’s looked after children were
unaccompanied asylum seeking children. There is also a higher than average
level of minority ethnic children looked after, 44% in Enfield compared to 18%
nationally.

The Brent risk assessment identified the following family factors:   those living
at an address which had reported domestic violence were 1.6          times more
likely to be in touch with CAMHS, those in social housing 1.4        times, lone
parent households 1.6 times and those families in receipt of         council tax
benefit 1.3 times.25




                                      23
Environmental risk factors
Socio economic circumstances are believed to have an impact on mental
health issues. Variation occurs geographically. Twenty two per cent (22%) of
children are eligible for free school meals within the borough, but this ranges
from 4.3% in Grange ward to 36.7% in Edmonton Green. All wards, except
Southgate, have experienced a rise in the percentage of pupils eligible for free
school meals in the period 2003-0524.
A similar geographical distribution pattern is shown by unemployment rates
(Figure 2).




Figure 2 : unemployment by Ward, Enfield Observatory




                                        24
Figure 3 shows, in more detail, pockets of income deprivation affecting
children. The geographical pattern is broadly the same.




Figure 3 : income deprivation affecting children



Vulnerable groups
Refugees
Refugees are likely to experience some form of psychological disturbance as
a result of their experiences 27. The effects of displacement on the mental
health of refugees can be profound. This is likely to be particularly the case
for children and young people. Enfield has an expanding refugee and asylum
seeking population. Data from the London Asylum Seekers Consortium
(September, 2004) shows that Enfield Council are currently supporting 847
asylum seekers, which is the eighth largest number of all London boroughs.
One hundred and thirty three of these are Unaccompanied Children who are
supported by the Looked After Children’s Service and the Leaving Care
Team. The Social Services Asylum Team has reported receiving over 100
referrals a day over the year 2003/04.31 This includes an increasing number of
referrals involving child protection and mental health concerns. 428 children
between 5-13 are currently known to the team and this figure does not include
families who have voucher only status. 31


Black & minority ethnic communities
Enfield has a diverse ethnic mix including large Turkish, Turkish Cypriot,
Greek, Greek Cypriot, Asian and African populations. This has changed
rapidly over recent years, and continues to do so. It is estimated that over 100


                                          25
languages are spoken in the borough and this diversity is reflected in the
school population. Ethnic minorities form about 35% of the population and in
schools this rises to over 48% 28
Studies suggest that the prevalence and presentation of mental health
problem varies amongst children and young people from different ethnic
communities3. They can also disproportionately experience many of the
identified risk factors for mental health problems. The 1999 study found that
Black children were more likely to have a diagnosable mental disorder than
White children; Asian children had lower rates of mental ill heath. 18
Culture may effect the presentation of mental health problems and influence
the way that parents interpret their children’s behaviour and what action they
take when they consider it abnormal. Research has highlighted that young
people from minority ethnic groups can face particular problems accessing
statutory mental health services. 29


 Learning difficulties
The recent Committee of Inquiry (Count us in) 30 highlighted the considerable
gaps in appropriate services for young people with learning difficulties. The
committee found considerable variability in where and what services were
available cross the country. The need to look for ways of promoting resilience
was emphasised as well as the use of early intervention.
In 2001 there were 297 children in the borough with severe learning
disabilities, many with other complex needs.31




                                     26
                                  Summary

Approximately 13,800 Enfield children and young people could be
suffering from diagnosable mental disorders. This covers a wide spectrum
of disorders. Local prevalence data is not available but the following is
extrapolated from national surveys and local risk factors.

Males are more likely to be affected by a mental health disorder than
females. The prevalence of problems increases by age.

Mental Illness Needs Index (MINI) scores estimate that mental health
problems are highest in the South East corner of the borough, levels are
also high along most of the eastern border. There are pockets of need
throughout the borough.

The same geographical spread is seen for several risk factors: Haselbury,
Upper Edmonton and Edmonton Green have the highest concentration of
children eligible for free school meals, with English as an additional
language and with special educational needs. The converse pattern is
seen for resilience factors – higher standards of living are more prevalent
in the North West of the borough.

In comparison to the rest of the sector, Enfield has the lowest rate of
children on the child protection register and a relatively low rate of looked
after children.

There are a large number of refugees and asylum seekers in the borough;
unaccompanied children may require special support. The ethnic mix in
schools is high with 48% of the school population from a black or minority
ethnic group. Within Enfield there is a higher than average proportion of
pupils with English as an additional language.

It is important that children with special educational needs are identified
and supported.

Links between agencies should be checked to ensure that children and
young people have any mental health needs met. For example, links
between CAMHS and SENCOs, social services asylum teams and the
social workers supporting children on the child protection register.

Primordial prevention; for example reducing poverty and increasing life
chances will have a long term impact on the need for mental health
services




                                    27
CAMHS provision for Enfield residents
Early intervention
The national targets specifically relating to prevention and early intervention
are detailed in Enfield’s Preventative Strategy, Chapter 8 of “Promoting
Positive Futures: Children and Young People Strategic Plan”. The national
strategy “Skills for Life” highlights the effect of low literacy and numeracy on
children. Since 2000, the London Borough of Enfield has actively promoted a
range of activities, which come under the umbrella term “Family Learning”.
Family learning recognises that parents and carers are a child’s first educator
and involves families and carers in acquiring new knowledge, skills and
attitudes that are of mutual benefit. Enfield PCT has developed a suicide
prevention strategy and a mental health promotion strategy.

Service delivery
Enfield CAMHS is provided by organisations working in the health sector,
education and social services. It works towards the principles set out by
HAS.2

Accessibility        Enfield CAMHS is provided following the hub & spoke
                     model; with 3 or main “hubs” and some community
                     based “spokes”.
                     The area east of the A10 has been identified as a
                     particular area of need; space has been secured within
                     the Forest Road LIFT building to help meet this need.
Multi   disciplinary Enfield CAMHS has been externally commended for its
approaches           multi disciplinary approach; examples of multi
                     disciplinary teams includes SCAN and HEART
Comprehensive        The service looks at both the breadth of depth of
                     provision; it has identified the need to provide more tier
                     2 services and more community outreach.
Accountability       CAMHS employees are accountable to the head of the
                     service, who in turn, is accountable jointly to the
                     Barnet, Enfield & Haringey mental health trust and the
                     London Borough of Enfield. There is also a link through
                     the JSPT to Enfield PCT and accountability to the
                     Children’s and Young Person’s strategic partnership
Development     and The service has expanded and continues to do so.
change               There were 50 employees 8 years ago, and 95 now,
                     this is likely to increase to over 100 in the next 6
                     months.
                     Additional teams have been developed, for example,
                     HEART and SCAN. Joint appointments have been
                     made, for example, with local schools.




                                      28
The Child Guidance Service (CGS) has multidisciplinary teams operating from
4 sites – 2 generic teams, an adolescent team and a new service for children
and young people with neuro-developmental disorders. These centres provide
appropriate secure and confidential therapeutic settings.

   1. Avenue House
      Based in Bycullah Avenue EN2 (generic team)
      Clients come mainly from the north and west of the borough

   2. Dryden House
      Based at 8 Dryden Road EN1 (generic team)
      Clients come mainly from the south and east of the borough

   3. SAFE
      Based at 24 Dryden Road
      Specialist service seeing young people aged 13-18 from anywhere in
      the borough

   4. SCAN
      Based at Cedar House, St. Michael’s site
      Clients come from anywhere in the borough

For several years there have been plans to develop a third generic centre
east of the A10. 32 There is current discussion about re-accommodation of the
teams as the local authority wishes to sell the three properties it owns.
The CGS provides a variety of projects within the borough and Appendix 4
shows how the projects and teams link in together, while Appendix 5 shows
staffing levels.

The CGS has met with health visitors and school nurses to promote the
CAMHS agenda. Approximately 2/3 of health visitors see themselves as part
of the broader CAMHS.

Education
There are approximately 20 school nurses working in Enfield schools. Current
areas of work include developing school drop in centres and providing advice
on drugs and alcohol. Those nurses that wish may attend a 3 month course
looking at the mental health needs of children and young people.
The Behaviour Improvement Programme runs in 4 secondary and 21 primary
schools. The teams working in schools are multidisciplinary and may include
Educational Psychologists, Education Welfare Officers, Child Guidance Social
Workers, Counsellors, School nurses etc.

Social services
The Asylum Team is based at Southgate Town Hall. Although much of the
work has traditionally been focused on providing practical support, since 2003
there has been a shift towards more intensive support. It has become
apparent that there is a need to provide advice around child protection,
domestic violence and mental health needs 31.



                                     29
Cheviots children’s disability team works with children and young people up to
the age of 18. Cheviots also runs an independent counselling service.
There are 2 family support centres within the borough and a borough wide
family support team. Currently about 200 families receive services; the
support offered ranges from mother & toddler groups, through parenting skills
development to more intensive levels.

Voluntary sector
    AHEADS (Adolescents in Haringey and Enfield Alcohol and Drug
      Service). This service provides advice, information and treatment for
      10-17 year olds.
    ADHD support service provides support to parents of children with a
      range of learning disorders.
    Crossroads Care provides support and respite care for carers
    DAZU provide a range of counselling and arts based therapies in a
      variety of settings, including local schools. The project also provides
      work on anger management for the Youth Offending Team. The DAZU
      young carers project works with approximately 60 families to provide
      practical and emotional support.
    Ebony People’s Association provide information, advice services and
      advocacy to African and Caribbean families.
    Enfield Parents Centre provides advice, information and support
      covering topics such as special educational needs and school
      exclusions. They also run a 6 week positive parenting course.
    Place 2 Be Enfield (P2B) works in Enfield schools providing drop in
      sessions for children, teacher consultation sessions and advice for
      parents. Referral to the service is by teachers or Special Education
      Needs Co-ordinators.

There are other voluntary sector services provided outside the borough but
available to Enfield residents. For example the Refugee Therapy Centre in
Islington provides psychotherapy and counselling for young refugees and
asylum seekers.

Specialist services

New Beginning is a Tier 4, 12 bedded acute in-patient unit, based on the
Edgware Community Hospital site.
Medium term CAMHS is provided from Simmons House (Muswell Hill) and
Northgate clinic (Edgware). Both units accept young people aged 13-17.
They offer both inpatient and day patient treatment programmes; although
inpatient stays tend to be for 5 days only.
Enfield PCT also commissions a range of separate specialist provision, for
example, an eating disorders service from the Royal Free hospital. However,
increasingly the borough and PCT are seeking to develop specialist in
borough resources to avoid placement outside.




                                     30
Asylum seekers and Refugee children
Within the Child and Adolescent Mental Health Services provision in Enfield
there is a dedicated Refugee Education Team (RET) which includes
educational psychologists and bilingual mental health workers, One of these
speaks Kurdish-Turkish and the other is fluent in several African languages
and Arabic. 33

Services for young people using drugs in Enfield
Step-AHEAD is the only substance misuse specific service offering provision
to young people in Enfield. The service, which works with 10-18 year olds,
has been in operation since 2001. it is jointly commissioned with Haringey
Drug and Alcohol action team and is located in Tottenham. They have a team
of drug workers who provide harm reduction advice and information, needle
exchange,       health      assessments,       alternative      therapies,  home
detoxification/stabilisation prescribing, referrals to tier 4 CAMHS provision and
home visits.

The Drug Action Team (DAT) supports the School Improvement Service in
their work with schools to review their drugs policies, achieve the National
healthy Schools Standard and carry out targeted prevention activity. The DAT
also supports targeted prevention activity carried out by the council’s Youth
Service, the Police Youth & community Service and the Youth Offending
Service.

Views of local stakeholders
The Enfield Child guidance services aims to regularly consult with users,
partners and stakeholders. Key methods used are:
Questionnaires, cross agency meetings at all levels, seminars, discussion
groups, working parties and liaison meetings.
A new key tool which is still being explored for 2005/06 is a forum for parents
and for young people to give verbal feedback.
Listed below are examples of current and planned consultation activities being
undertaken in 2005/06:
     Feedback/satisfaction questionnaires to go to parents and young
       people (aged 11-18) when CFS/SAFE cases are closed. Currently
       response rates are low but a high level of satisfaction is reported
       amongst questionnaire returnees.
     Feedback questionnaires to parents of children with Educational
       Psychologists’ stage 3 reports. 94% of returns give ratings of
       satisfactory and above.
     Logging of complaints and near misses. The clinical governance sub
       group is to explore more effective methods of recording such
       information.
     Consultation with Children’s Social Care (Social Services). Liaison
       meetings with managers to be reviewed
     Consultation with GPs. A further seminar is being considered.
     Health visitors seminars
     Establishment of Parents and young people’s service user’s forum




                                       31
      Participation in Joint Area Review and Corporate Performance
       Assessments as relevant
      Completion of user consultation/needs assessment for providing
       service for children with parents who have mental health problems.
      Consultation to school nurses. Feedback on processes needs to be
       obtained
      Consider a review of non attendees
      Consultation of young people, parents and referrers about access to
       services (particularly around access to the proposed new site on
       Carterhatch lane).



                                 Summary

Services are provided by multi disciplinary teams, working in line with the
Health Advisory Service’s principles. A comprehensive range of services are
available, for example the generic and specialist teams provided by CGS as
well as the specific teams such as the Refugee Education team and the
Cheviot’s centre. Tier 1 services are largely uncoordinated although the CGS
works closely with health visitors and school nurses, however, further work
may be needed to include GPs. The voluntary sector also provides services
for a variety of groups. The Child Guidance Service regularly consults with
referrers and users to ensure the services meet their needs.




                                    32
Local use of CAMHS
Data from CAMHS mapping exercise34
This is now an annual exercise, unfortunately the format has changed each
year so comparisons between years are not always possible. Additionally,
local finance information has been input by different people over the time
period and so may vary due to different interpretation of definitions.
Information available from the CAMHS mapping exercise allows comparison
between the North Central London sector and nationally. However, the data is
a snapshot based on one month of the year and as such may not be
representative of the year as a whole. Definitions of data to be included are
strict but may be interpreted differently across the country, this may explain
some of the variations seen. Enfield PCT services within the mapping data
refers to activity within the London Borough of Enfield rather than all services
used by residents of Enfield. Data from the local CAMHS includes mainly
referrals to tier 2 and tier 3 services. It has not been possible to obtain data on
tier 1 provision within, for example, general practice. (Definitions and
examples of Tiers are given in Appendix 1).

Services
CAMHS provision should be comprehensive. Nationally specialist CAMHS
provision has grown to meet the diverse needs of children and young people.
The mapping exercise categorises teams into 5 types to capture the range of
work undertaken. Definitions are in Appendix 3.




Figure 4 : national trends in team type staffing.




                                            33
In Enfield there are 2 Generic teams, 6 Targeted and 4 Dedicated teams.

        Generic                       Targeted                 Dedicated
  (multidisciplinary)
Enfield CAMHS –              Child Development          Behaviour Improvement
Avenue House                 team                       Project (BIP)
Enfield CAMHS –              Health & Education         Behaviour Support
Dryden Road                  Access and Resources       Service
                             Team (HEART)
                             Service for Children &     Hospital Paediatrics
                             Families with
                             neurodevelopmental
                             disorders (SCAN)
                             Service for Adolescents    Teenage Parents
                             and Families in Enfield    Project (Listening 2 U),
                             (SAFE)                     Edmonton
                             Sure Start (Edmonton)
                             Youth Offending Team
                             (Edmonton)


The number of CAMH services with on-call provision increased from 2003 to
2004. Enfield has an on-call service.




Figure 5 : National trends in CAMHS on call provision


Provision for vulnerable groups.
Nationally, the number of services which reported specialist provision for
children and young people with both learning disabilities and mental health
problems rose from 2002-2004. Nationally the number of learning disabilities
cases represented 8% of the total caseload during the mapping period. Thirty
seven children (6% of local caseload) with moderate and severe learning
disability were seen by the following Enfield teams in 2004:
     Behaviour Improvement Project (BIP)
     Child Development Team
     CAMHS at Avenue House & Dryden Road
     Health & Education Access and Resources Team (HEART)


                                          34
    Service for Adolescents and Families in Enfield (SAFE)
    Youth Offending Team (Edmonton)
Enfield has now developed the SCAN service for children with neuro-
developmental disorders/learning difficulties. However this service was not
open to receive referrals at the time of the mapping and so activity in this area
may be under represented.

Nationally, the number of CAMHS teams providing a focus on looked after
children increased in 2004. The number of looked after children cared for by
CAMH services during the mapping data collection period represented about
8% of the total caseload. In Enfield 44 of the children (7.5% of local caseload)
accessing CAMHS were currently “looked after” by their local authority.
These children were seen by the following teams:
     Behaviour Improvement Project (BIP)
     Enfield CAMHS at Avenue House & Dryden Road
     Health & Education Access and Resources Team (HEART)
     Service for Adolescents and Families in Enfield (SAFE)
     Youth Offending Team (Edmonton)

Just over 5000 young offenders received care from CAMH services across
the country, this represents approximately 5% of the total caseload. In Enfield
15 of the children (2.6% of local caseload) seen by the Behaviour
Improvement Project (BIP) and the Youth Offending team had been in contact
with youth offending services in the last year. As part of the Joint Area
review, information from youth offending showed that Enfield performed well
as regards the timely referral of juveniles manifesting mental health
difficulties. According to figures from the Youth Justice Board, 100% of Enfield
juveniles manifesting acute mental health difficulties were referred to CAMHS
(well above the national average). From October 03-June 04 100% of Enfield
juveniles with non-acute mental health needs were also referred to CAMHS;
this dropped to 77.8% in the next quarter 35.

Investment




Figure 6 : National predicted and actual spend on CAMHS 2003-05




                                        35
Nationally spend on CAMHS increased by 23% between the financial years
2003/4 and 2004/5. In North Central London, budgets rose by 45% over the
same period. Enfield PCT increased annual expenditure by 12% from
2002/03-2003/04. The predicted budget for Enfield PCT in 04/05 would result
in an 82% increase in spending from 2003/04-2004/05. Nationally, spend per
child was £30.70 in 2003/4, rising to £37.60 in 2004/5. In 2003/4 the spend
per child was over £45 in the North Central London sector. For Enfield PCT
spend per child rose from £14.45 in 2003/04 to £26.30 in 2004/05.

Activity
Nationally total caseload of services increased by 21% from 2003 to 2004. In
Enfield the increase in total caseload referred into the service was 24%




Figure 7 : national trends in cases seen and waiting


Length of wait
Nationally the majority of new cases (51%) were reported as having waited
less than 4 weeks to be seen by a CAMHS team. This shows a continuation
of the improvement in waiting times detected in the 2003 & 2002 mappings.
In Enfield 41% of new cases waited less than 4 weeks. Only 3% of new
cases had to wait more than 26 weeks, better than the national average (all
cases waiting this length of time are investigated locally).




Figure 8 : National trends in cases and length of wait


                                           36
Age
The mapping exercise looked at the age profile of users of tier 2/3 teams and
showed that the North Central London sector had the highest percentage of
active case load in the 0-4 year age group. It had the third highest percentage
in the country of active case load in this age group accessing tier 4 teams.




Figure 9 : National trends in age of CAMHS caseload in tier 2/3 teams




Figure 10 : National trends in age of CAMHS caseload in tier 4 teams


Data for Enfield is available for 2004 (Figure 11). Although a similar pattern is
seen to national figures there are a couple of anomalies. Locally there seem
to be relatively more young boys (aged 5-9) accessing services and more
older females (16-18).




                                          37
                  Team caseload by age

  50%

  40%

  30%                                                         Male
  20%                                                         Female

  10%

   0%
          0-4      5-9    10-14    15     16-18   19-25


Figure 11 : Enfield teams caseload by age & sex, 2004 (CGS)

Ethnicity
Nationally 81% of the children and young people using CAMHS teams were of
white British origin. The proportions of cases from Black and minority ethnic
communities were 3% Asian, 3% Black African, Caribbean and Black British,
4% of mixed race and 1% other. In only 7% of cases no ethnicity was
recorded. In North Central London just over 55% of users of tier 2/3 services
were White. Approximately 75% of tier 4 users were White.
In Enfield, 34% of the caseload did not have a recorded ethnicity, which
makes comparison with national and sector figures problematic. According to
the service, families are not always happy to provide data on ethnicity. Where
ethnicity was recorded 70% were White, 10% were of mixed origin, 3% Asian,
10% Black and 7% “Other”. (Census figures for Enfield children were
respectively 70%, 6%, 8%, 14% and 2%) 36. There are fewer Asian and Black
service users than would be expected from the Census figures. According to
the ONS study, rates of mental ill health are higher than average in Black
children and lower in Asian18. Although difficult to draw conclusions due to the
high level of missing data, it is possible that Black children are under
represented amongst service users.

Primary presenting disorder
The most common primary presenting disorder was emotional disorder,
accounting for 28% of cases nationally. Conduct disorder and hyperkinetic
disorder were the next most common reasons for referral. Similar patterns
were seen across the North Central London sector. The most common
primary presenting disorder in Enfield was also for emotional disorders (36%
of caseload), though many children & young people present with multiple
problems (24%). For users of tier 4 services, the primary presenting disorder
in the sector was eating disorders

Workforce
The total number of staff employed in CAMHS teams increased by 14.6%
nationally. The largest reported growth was in the number of clinical
psychologists (32.4%). In Enfield staff levels grew by 2.2% from 2003-2004;
recruitment locally has been restricted by lack of accommodation space.



                                         38
Child Guidance Service
The Child Guidance Service is made up of CAMHS and the Education
Psychology service. The CAMHS part of the service is made up of the Child &
Family Service (CFS), Services for Adolescents and Families in Enfield
(SAFE) and Service for Children with Neuro-developmental disorders (SCAN);
most of this provision is tier 2 and 3.

Activity
In the financial year 2004/05 there were 1171 referrals of which 1126 were
accepted by CFS and SAFE. 37
     4.5% of the referrals were Looked After Children
     11.2% of all first appointments did not attend. This ranged from 8.5%
       for those due to attend generic services, to 22.2% for SAFE; this level
       of DNA for a Tier 3 ½ service is apparently not uncommon 38.
     1022 cases were closed during the year; almost 30% of these were
       because the client withdrew, DNA’d or failed all appointments.
       (However this ranged between 35% for Dryden Road generic service to
       21% at SAFE)

Referrals to the Child Guidance Service came from the following sources:
     GP                   43%
     Other Health         25%
     Education            22%
     Social Services      9%
     Self                 1%
A geographical mapping of referrals to SAFE was undertaken by the service;
this showed that the majority of young people using the service lived in the
East and South of the borough 39.

In 2004 there were 438 referrals to the Education Psychology Service (EPS).
The EPS allocated 1229 EP visits to Enfield Schools. 32 (there are 66 primary
schools, 17 secondary and 6 special schools within Enfield). Between 1997-
2000 there was a 93% increase in referrals to this service.

Ethnic Monitoring
The percentage of referrals from different ethnic groups are compared with
the percentage of that group in Enfield borough. Monitoring enabled the
service to identify that an Albanian speaking link worker would be helpful in
engaging the Albanian community (funded by a Children’s Fund grant). The
number of asylum seekers and refugees referred to the Service is also
monitored.


Place 2 Be
This service offers support within the school setting which engages with the
wider issues of mental health in the school community. Place2Be have a total
of 10 primary schools within the Enfield local authority, covering a school
population of 4,556 children.
Place 2 Be Enfield provided the following in 2003-04


                                      39
      4086 children self referred to the Place2Talk
      1767 individual sessions and 1680 group sessions were held with
       children during the year
     Work was also carried out with parents, teachers and SENCOs
Half of the children accessing services were of white ethnic origin and almost
a quarter were Black or Black British. 43% of the children accessing individual
or group interventions came from lone parent households. 6% of children
were looked after.
SDQ scores were compared before and after the interventions. Analysis of
these showed that both individual and group interventions were effective at
dealing with a broad range of difficulties experienced by primary school aged
children. The changes involved not only a reduction in unwanted behaviours
but also an increase in behaviours indicative of positive social and emotional
wellbeing in the children.

Evaluation data
CORC
Goodmans Strengths & Difficulties questionnaire should be completed before
and after therapy by the parent, and adolescent, if appropriate. This outcome
evaluation measures was introduced locally as part of the protocol agreed
with CORC. Other agreed measures are the Children’s Global Assessment
Scale (C-GAS) and the Association of Clinical Psychologists and Psychiatrists
(ACPP) clinical reasons for referral.
A draft CORC report was produced in July 2005 40 but this is for the local
mental health trust as a whole so includes Barnet, Enfield and Haringey.
Unfortunately although SDQ scores were recorded when children were first
seen, there is insufficient “after” data to evaluate the local services. Initial
data shows that local children, when assessed by their parent(s) or
themselves, have similar SDQ scores to those from other CORC collaborating
areas.
CGAS scores are also put on the patients’ notes, however, there also seems
to be a current lack of “after” data to evaluate interventions provided.
This is being addressed by the service. There are plans to recruit an assistant
psychologist/research psychologist and to bring the SDQ2 forward so that it’s
sent out 6 months after the initial questionnaire to improve response.

CFS Satisfaction Questionnaire Summary (September 2004)
217 questionnaires were sent out to parents & carers and also to children and
young people (aged 11-18). This revealed a high level of satisfaction with the
service. The response rate however was only 22%; it is unknown whether the
responders were representative of service users as a whole.


Health Activity data
Primary care data
Tier 1 services are provided by a variety of professionals and there is
currently no routine data available.




                                      40
Secondary care data
This would include young people with problems at the more serious end of the
spectrum. Some data is available from New Beginning and the private sector
for in patient stays. However data is not available from the local acute trusts.
Although children are admitted to the Kingfisher ward at Chase Farm hospital,
activity and payment of this forms part of the general service level agreement
(SLA) held with the hospital. (However, there is a specific mental health
nurse post funded through the SLA to support children on this ward, this post
is currently vacant).
No routine data is received from the local Accident and Emergency
departments. A psychiatric liaison service is currently provided at Chase Farm
but not at North Middlesex.

Suicides
Between January 2001 and December 2003 there were 76 suicides in Enfield,
53 (70%) in males and 23 (30% in females. This is comparable with national
rates. The age group at highest risk is 20-39 years for both genders. Only 3%
of suicides were under 20 years (2 deaths). Overall the highest rates of
suicide were in the Upper Edmonton ward.




                                      41
                                   Summary

Compared to national data Enfield CAMHS fares well in many areas, for
example, with an on call provision and specific services for young people with
neuro-developmental disorders and learning difficulties.

The national comparison highlights that although Enfield CAMHS staff
increased by 2.2% this was less than the 14.6% seen nationally. However the
existing size of team and staff profile within Barnet, Enfield & Haringey mental
health trust compares favourably with national data 40.

Expenditure nationally rose by 23%, 45% in the sector and 82% in Enfield
PCT (based on projected budgets for 2004/05). This increase in expenditure
will bring the local spend per child closer to the national figure.

Proportionately fewer children and young people were seen within 4 weeks
than nationally. However, locally there were only 3% that had to wait more
than 26 weeks (compared to approximately 8% nationally).

Compared with the national picture local children are presenting with similar
disorders and similar SDQ scores.

The mapping exercise showed that the Enfield caseload is similar to the
national picture as regards looked after children, but children with moderate
and severe learning difficulties and young offenders may currently be under
represented locally.

The mapping exercise also highlighted the limited recording of ethnicity
locally. From the partial data available it’s possible that Black children are
under represented amongst service users.

There also appeared to be a difference in the age distribution of children
accessing the service, with a higher than expected level of boys aged 5-9 &
higher than expected level of females aged 16-18.

Locally there appears to be a problem with children not turning up to the
service. There is also a need to evaluate the service, its effectiveness and
acceptability to users.

The geographical pattern of referrals echoes the pattern of risk factors.

The only tier 1 information available is from Place2Be. Interventions provided
are showing good results as measured by SDQ scores. They are seeing
relatively more children from Black, Black British and mixed ethnicity
backgrounds than would be expected from the census figures. The proportion
of children from lone parent households is unusually large, with nearly four
times the proportion observed in the general population.



                                       42
Summary of met and unmet need
The Children’s NSF states that many children who could benefit from mental
health services are not accessing services. There are a variety of reasons for
this, such as a lack of trust in statutory services, a wish to solve problems
themselves, a lack of recognition and agreement that a problem exists, a fear
of being teased and stigmatised, a fear of lack of confidentiality and a belief
that nothing can be done 41. Locally accessible services are thought to improve
attendance and engagement. The NSF therefore has recommended that
services are offered as close to home as possible.

Evidence
      Mental health promotion, both at the population level and targeted to
       specific at risk groups, is key for the future well being of Enfield’s
       children and young people
      Behavioural therapies work well for a number of disorders
      Assessment, treatment and support of parents is necessary for the
       treatment success of children and young people

Epidemiological and comparative
      Service location should reflect the geographical spread of mental
       health needs estimated by MINI scores and the prevalence of risk
       factors. Geographical location should also take into account ease of
       access by public transport. The Eastern border of the borough was
       highlighted with particular need for mental health services in the South
       Eastern corner.
      The size of the mental health burden estimated from national
       prevalence figures is not reflected in local use of CAMHS as measured
       by available data. However, the majority of those affected would
       require Tier 1 services which currently do not provide routine data. The
       number estimated to need Tier 3 services equates with the number of
       referrals to CGS.
      More male than female service users were predicted and this was
       borne out by figures from the CGS
      CGS figures mirror predictions that service use increases by age; the
       exception being the higher than expected use of service by males aged
       5-9
      Looked after children are likely to have high levels of mental disorders,
       one study predicted that 67% would have problems 19. Locally only 14%
       of LAC were seen by CAMHS teams. However, as a % of total
       caseload Enfield sees similar levels to that reported nationally (7.5% v
       8%)
      Children with moderate and severe learning disability make up 6% of
       caseload locally compared to 8% nationally; however this may change
       due to the recent introduction of the specialist SCAN service for
       children with neuro developmental disorders/learning difficulties.
      Young offenders may also be under represented locally (2.5% of
       caseload) compared to 5% nationally.



                                      43
      There was a low level of recording of ethnicity in the mapping exercise
       it is therefore difficult to tell if service users are representative of the
       local population. From comparisons with the census and predictions
       from national studies it is likely that Black children are under
       represented amongst service users.

Corporate – stakeholder views
This data collection was time limited and as such may not be reflective of all
stakeholders’ views within the area.

Young Minds report for Enfield Children’s Fund on preventative services
This report was produced in 2004 following consultation with 82 children, 20
parents and 55 providers of preventative mental health services. The report
sets out a plan for developing preventative mental health services in Enfield
borough for children aged 5-13. Young minds summarised the areas of unmet
need as:
     Counselling in the borough’s special schools for pupils with learning
       difficulties
     Support for young people experiencing divorce
     Support for young people who are bereaved, especially in-school
       support
     Provision for young carers (including those caring for a parent with
       mental health problems)
     Provision for young people whose parents do not speak English
     Home visiting support and anti-racism work to support young refugees
       and asylum seekers
     Sexual health services, including for young refugees and asylum
       seekers who are the victims of rape
     Informal in-school drop in support (4 drop in centres were proposed in
       the Health Improvement Action plan, but only the one at Albany is
       currently open)
     Mentor support in schools (and support/supervision of Tier 1
       professionals including mentors and learning support assistants)

The report highlighted that the lack of data about traveller children and
children with sensory impairments may mask unmet need amongst these
groups.

Enfield Child Guidance Service
From the Framework for 3 Year Plan April 2005-March 200832
This listed 9 key objectives that the service would focus on for 2005/06
    Enhance educational psychologists’ work with early year’s settings
    Review service delivery and assessment practice
    Contribute to whole school provision for vulnerable children
    Deliver high quality service during accommodation transition
    Promote emotional well being and prevention of mental health
        problems among young people by providing appropriate specialist
        services to children and their families
    Continue to improve access to CAMHS


                                        44
      Develop and implement training and support strategy for Tier 1
       professionals
      Continue to strengthen and improve multi disciplinary and interagency
       working
      Ensure responsiveness of services

Local Authority drivers
From the Corporate Performance Assessment (CPA) Improvement Plan,
“Promoting Positive Futures” Children and Young People’s Strategic Plan
2004-06 and Putting Enfield First Acton Plan (Delivering Excellence)
    Work in partnership with schools to support school improvement and
      raise inclusion of under achieving and challenging pupils
    Increasing the participation of pupils in Enfield schools by improving
      their attendance
    Improve services for vulnerable children
    Improve access to health and care with our partners
    Develop new ways of increasing participation, especially among
      younger residents. Involving children, young people and families in
      planning and monitoring services
    Improving and increasing access to CAMHS for LAC and children on
      the child protection register.

North Central London Tier 4 CAMHS Steering Group
Taken from the “Development plan for medium term tier 4 CAMHS services”
August 2005, suggestions for service development:
    More intensive treatment options in the community, for example, day
      services and residential support after discharge.
    Rehabilitation after psychotic illness including social, educational and
      therapeutic packages of care
    Specialist CAMHS for young people with learning disability and mental
      illness
    Accommodation on discharge to a specialist housing provider or
      specialist foster care
    Expand the range of interventions which can be delivered intensively in
      tier 3

Social Services Research and Development Unit/Institute of Public Care
Service Gap Analysis
This revealed gaps in the following:
    Support for lone parent families
    Housing for homeless people
    Low level of services for children with non-acute disabilities
    Low level of services for those with parenting difficulties arising due to
       mental health problems
    CAMHS services for those outside the 13-18 year range
    Services for unaccompanied minors




                                      45
Local use of the National Assessment Matrix
This assessment matrix was developed for use by local CAMHS partnerships
in self assessment of their capacity to deliver a comprehensive CAMH service
that is responsive to locally defined need, and to inform ongoing development
of their local multi agency strategy. The following gaps were identified through
the use of this matrix:
     Provision of services for those moving from child to adult care.
     Work needs to be developed with children whose parents are mentally
        ill, face domestic violence or who have drug dependencies. There is
        already an interface group in place.
     Early intervention teams for young people with first episode psychoses
        needs developing.
     Specific services for 0-2 year olds and their parents/carers are not
        currently available. Plans need to be developed with SCBU and Sure
        Start
     There are gaps in the current arrangements for discharge and aftercare
        of those leaving Tier 4 provision.
     A systematic training needs analysis of staff should be done to provide
        an overview of current training requirements. At the moment training
        needs are developed on an individual basis. Training is particularly
        lacking for Tier 1 professionals including primary mental health
        workers.
     There are currently no occupational therapists within the local CAMHS
        team.
     There are problems with the current infrastructure as regards the IT
        network and phone provision. There are space/capacity issues with the
        current offices. Additional equipment is also needed.
     User involvement and consultation has been addressed but could be
        developed further if sufficient resources/support are available.
     Currently insufficient resources to provide regular audit, outcome
        monitoring and evaluation of services.

Meeting with SAFE team
   Some 16 to 18 year olds are sent home from North Middlesex hospital
      without a psychiatric assessment. (Those aged up to 16 are seen on
      the paediatric ward, those aged over 18 are referred to adult mental
      health services).
   There is a need for tier 3 ½ services. Specialist adolescent services
      tend to be available either as acute inpatient episodes or as an out
      patient. Some young people would benefit from regular structured day
      services. Northgate and Simmons house provide 5 day a week care
      but this is not always suitable for those children without secure bases.
   Early intensive intervention is required for psychotic episodes. The use
      of an occupational therapist has also been suggested. The need for
      local rehab following the first psychotic episode has also been
      highlighted (currently this is contracted to a private provider).
   The provision of a secure home for some young people with emotional
      and behavioural disorders is needed. It is felt that there is little point in
      offering therapy to someone without a secure base. Some of these


                                        46
       young people are homeless or with very troubled home situations. A
       multi agency response is needed here. Accommodation should be
       supported by skilled staff.
      Availability of respite is lacking.
      Some 16-18 year olds are living on their own, trying to look after
       themselves and attending education. They currently have very minimal
       support. Some would benefit from more support, not necessarily
       placement in a unit but rather regular, skilled support from a
       parent/guardian figure.
      Access to counselling is also needed. Previously this could be
       accessed via “Open Door” but this is no longer available.

Meeting with Ebony People’s Association (Patricia Obichukwu)
This is the only charity in Enfield specifically dealing with the impact of mental
health problems amongst the Black community. Patricia felt that the following
were service gaps that need addressing:
    EPA have no access to interpretation services (they specifically need
       access to French and African languages such as Congolese and
       Somali). This may mean that they are better meeting the needs of their
       clients who speak English who tend to be more affluent
    Culturally sensitive psychology services provided as outreach at their
       centre; some families are wary of statutory services & their settings.
    Drop in centre for children so that parents get a break and children are
       able to talk
    Patricia felt that there is a lack of mental health support within schools
    Holistic approach looking at the needs of the family is important. Many
       parents have mental health problems and require support
    More emphasis needs to be placed on population based prevention
    A helpline or call centre (similar to Childline or NHS direct) dealing
       specifically with mental health issues
    Culturally sensitive respite services.




                                       47
                                   Summary

Epidemiological, comparative and corporate methods of needs assessment
identified the following similar themes;

Vulnerable groups may need particular support to ensure that they access
services, including looked after children, those on the child protection register,
young offenders, refugees, children with learning difficulties.

The mental health needs of the family should be considered alongside those
of children and parents. Special support may be needed for children with
caring responsibilities or from lone parent households.

It is possible that Black children are under represented in local services, but
data recording is poor locally. Acceptability and accessibility of services
should be evaluated especially in light of the re-provision of local services to
alternative sites.

School based services are necessary for mental health promotion and early
intervention. Drop in centres, counselling and support were all mentioned as
services to be developed.

Gaps in provision existed for younger children, specifically in those aged 0-2.




                                        48
Conclusions
National guidance recommends a needs led rather than service led approach
to CAMHS. This needs assessment considered the evidence for effective
provision of treatment and services. It then looked at describing the mental
health needs of the population by using epidemiological and comparative
data. Stakeholder views were also included to provide a corporate needs
assessment. By comparing these needs with the current service provision
certain gaps were highlighted. The following recommendations highlight ways
of developing or reconfiguring local CAMHS to meet these gaps.
This needs assessment should be updated regularly to ensure that services
keep in line with need.




                                    49
Recommendations
Service development or reconfiguration should also show commitment to the
national standards laid out by Every Child Matters, the Children’s NSF and
NICE. These recommendations are not in order of priority.

Development of existing services

      Transparent planning is necessary for the re-accommodation of
       existing services. It is vital that this takes into account the geographical
       spread of mental health needs and risk factors. The possibility of
       providing regular outreach services in the community should also be
       considered.
      Reduce the use of out-borough placements
      Continue and extend the work in local schools to include all schools
       and early year’s settings (for example, initiatives such as Healthy
       schools, drop in centres, Place 2 Be and the Behaviour Improvement
       Programme).
      Regular evaluation of services is necessary.
      Carry out a training needs analysis of all those providing mental health
       services.
      Identify and provide suitable services for children who may currently
       under use CAMHS.
      Improve the collection of data on ethnicity
      Look at children and young people in the context of the family.
       Enhance services for parents with mental health problems, those
       facing domestic violence or who have substance dependencies.

New services

      Develop borough wide services for 0-2 year olds and their
       parents/carers; for example, extend the Edmonton Sure Start scheme.
      Develop specialist foster care and/or specialist accommodation to
       provide a secure base for those requiring medium term care. Ensure
       that respite care is available.
      Provide intensive community based tier 3 services locally (Tier 3 ½
       services) so that Tier 4 services can be reduced.
      Establish a network for supporting local counselling services.
      Provide transitional services for those moving from child to adult care
      Develop early intervention teams for young people with first episode
       psychosis need developing.
      Clarify arrangements for those leaving Tier 4 provision and make
       available suitable supported accommodation.




                                        50
Appendix 1 : Definitions and examples of Tiers

Tier 1                                        Primary care services

Mild emotional and behavioural difficulties          GPs
or the early stages of disorders.                    health visitors
                                                     school nurses
Many conditions are self limiting, but may           social services
cause considerable distress in the child and         voluntary agencies
family, disruption in the classroom and              teachers
child’s learning. Specialist support is by           residential social workers
professionals such as school nurses or
                                                     juvenile justice workers.
consultant community paediatricians. Tier
1 services often undertake management
                                              Non-specialists provide CAMHS. They aim
problems in consultation with tiers 2&3.
                                              to:
Wallace8 describes this level of service as
being required for localities.
                                                    identify problems early in their
                                                      development.
15% of children and young people with
mild disturbances require Tier 1                    Offer general advice and in certain
services.      This would mean 10,308                 cases treatment for less severe
people aged 0-18 in Enfield                           problems.
                                                    Pursue opportunities for promoting
                                                      mental health and preventing
                                                      problems.
Tier 2                                        Individual specialist or uni-professional
                                              care
Common disorders with one or two risk
factors.                                            clinical child psychologists
                                                    paediatricians, especially
Services offer expert assessment of the               community
mental health aspects of child and family           educational psychologists
problems, treatment or referral. Problems           child psychiatrists
that require Tier 2 services are not usually        community child psychiatric
complicated by co-morbidity or serious risk           nurses/nurse specialists
factors and can be managed by mental                child psychotherapists.
health professionals with the relevant skills
and experience.                               CAMHS professionals would be able to:
                                                      offer training and consultation;
                                                      offer diagnosis and treatment;
7% of children and young people have
                                                      offer consultation for professionals
moderate or serious problems-4,810
                                                       and families;
aged 0-18 in Enfield.
                                                      enable young people to benefit
                                                       from their home, community and
                                                       education;
                                                      enable young people and their
                                                       families to cope with life
                                                       experiences;


                                    51
                                                    offer outreach to identify needs
                                                       which require more specialist
                                                       interventions;
                                                    offer assessment that may trigger
                                                       treatment at a different tier.
Tier 3.                                       Multi-disciplinary teams in a community
                                              child mental health clinic or child
Less common problems indicating a more psychiatry out-patient service.
severe, complex and persistent condition.
Specialists should work closely with general        child and adolescent psychiatrists
paediatric and adult psychiatry services,           social workers
local authority social services and                 clinical psychologists
education teams. Co-ordination of solo and          community psychiatric nurses
multi-disciplinary service can vary, two            child psychotherapists
main models exist:                                  occupational therapists
                                                    art, music and drama therapists
 professionals collaborating in a multi-           intensive psycho-analytic therapy
   disciplinary service that also provide a
                                                    family therapists.
   solo service.
 Multi-disciplinary and solo professional Service should be able to offer:
   services     that   are   organisationally
   distinct, but have a mechanism to
                                                   multi-professional assessment and
   collaborate effectively.
                                                     treatment of mental health disorders.
                                                   Assessment for referrals to Tier 4.
Both Tiers 2 and 3 should be available for
communities of up to 250,000.                      Contribution to services,
                                                     consultation and training at Tiers 1 &
1.85% severe disorders - 1,271 aged 0-18             2.
in Enfield.                                        Participation in R&D projects.




                                     52
Tier 4.                                         Tertiary level services such as day
                                                centres, highly specialised out-patient
Potentially severe disorders. Intensive and teams and in-patient units.
highly specialised care usually provided for
older children and adolescents who are Services include:
severely mentally ill or at suicidal risk.
                                                      adolescent in-patient units,
Services are provided on a supra-district             secure forensic adolescent units,
level (over 750,000) and not all districts can        eating disorder units,
expect to offer this level of expertise.              specialist teams for sexual abuse
                                                        and
0.075% have           the    most      serious,       teams for neuro-psychiatric
persistent & complex problems, 51 in                    problems.
Enfield.
                                                Tasks include:

0.02% may include a period as an in-                Assessment, treatment &
patient, 14 in Enfield.                              management.
                                                    Provision of interventions requiring
                                                     such a high level of skill
                                                    Provision of specialist
                                                     interventions.
                                                    Experience of working with rare
                                                     conditions.
                                                    Support to staff in other tiers.
Sources: HAS 2 ,Wallace3 & Kurtz4




                                     53
Appendix 2: Prevalence of specific child and adolescent mental health
             42
conditions
                                                                      Enfield

Nocturnal enuresis
8% of 7 year olds                                                         297
1% of 14 year olds                                                         36

Severe tantrums
5% of 3 year olds in urban settings                                       176

Simple phobias
2.3-9.2% of children                                            1,581-6,322

Educational difficulty
Reading problems in 10-19% of London 10 year olds                   371-704

Emotional disorders with onset in childhood
4.5-9.9% of 10 year olds                                            167-367

Conduct disorders
6.2-10.8% in 10 year olds                                           230-400

Tic disorders
1-13% of boys                                                     348-4,530
1-11% of girls                                                    339-3,726

Hyperkinetic disorders
1.7% in children aged 5-9 years                                           309

Anorexia nervosa
0.5-1% of 12-19 year olds                                           143-286

Suicide
7.6/100,000 in 15-19 year olds                                            1.4


Enfield figures are estimates based on GLA 2003 population projections.




                                      54
Appendix 3 : Team type definitions


Generic teams: Generic CAMHS teams meet a wide range of the mental
health and psychological needs of children and adolescents within a defined
geographical area

Generic (multi) teams: These are made up of CAMHS professionals from a
number of disciplines who work together to ensure integrated provision.

Generic (single) teams: These are single-disciplinary groups of staff who
provide a range of therapeutic interventions

Targeted teams: These teams provide for children with particular problems or
requiring particular types of therapeutic intervention

Dedicated worker teams: Dedicated workers are fully trained CAMHS
professionals who are out-posted in teams that are not specialist CAMHS
teams but have a wider function, such as a youth offending team or a generic
social work children’s team.

Tier 4 teams: These services provide longer term or more intensive provision.
This may take the form of whole or half day activities, inpatient care, or
outreach support (such as emergency or after care) which is considered an
alternative to in-patient care. Some may provide more than one of these types
of care.




                                     55
      Appendix 4 : ENFIELD CYPSPB FLOW CHART
                                              CHILDREN & YOUNG PEOPLES’ STRATEGIC PARTNERSHIP BOARD

                                             Oversees the Council’s Strategy and planning for vulnerable children
                                       Co-ordinates the work of other agencies, ie, PCT/Policy with Council Strategy

                                                                      Meets quarterly
                                                                  Chair: Rob Leak (CEO)




                             LAC CORPORATE PARENTING                                                      CAMHS JSPT                COMMUNITY DEVELOPMENT
AREA CHILD PROTECTION                 BOARD                       SERVICE DEVELOPMENT &                                                & PREVENTION SUB
      COMMITTEE                                                     MODERNISATION SUB                      Co-ordinates                   COMMITTEE
                                                                          GROUP                          commissioning of
 Oversees child protection                                                                                                          Co-ordinates the work of service
      arrangements                                               Ensures that the services of the
                                                                  Council and other agencies
                                                                                                            CAMHS      .            providers for vulnerable children
                                                                                                                                     within and without the Council.
 Stakeholder Group meets                                          respond appropriately to the           Meets Bimonthly
         quarterly                                                needs of vulnerable children.                                       Monitors Local Preventative
                              LEAVING CARE STEERING                                                                                             Strategy
Core Group meets monthly              GROUP                               Monitors FSR                                                     Meets quarterly

  Lead: Andrew Fraser                                                    Meets quarterly

                                                                  Lead: Karen Fletcher-Wright




 EDUCATION PROTECTS            TRAINING SUB              QUALITY                      HEALTH SUB
                                  GROUP               ASSURANCE SUB                     GROUP
                                                          GROUP



                                                                                                                                USER              IDENTIFICATION,
                                                                                                                            PARTICIPATION           REFERRAL &
                                                                                                                           WORKING GROUP             TRACKING
                                                                                                                                                     PROJECT
                                                                                                                                                 STEERING GROUP
                                                                                           56
Appendix 5 : ENFIELD CAMHS - Linked Projects and Teams
                                                          OUTREACH TO TIER 1

                         Schools                           Homes                                            Hospital Settings


                                                                                   'SCAN'
                        Child Guidance Sure          CDT                           Service for Children &
                        Start (under                 Child Development             Families with Neuro-
                        4s)Edmonton Local            Team                          developmental
                        Programme                                                  Disorders



BSS                                                                                                     Paediatric Liaison
(Behaviour Support                                                                                      Chase Farm Hospital
Service)
Primary Aged Children                         ENFIELD TIER 2/3 CAMHS
                                                      Child & Family Service
                                                      Service for Adolescents
                                                                                                        CAMHW
                                                       & Families in Enfield
                                                                                                        Liaison with Social
Children's Fund                                       Educational Psychology
                                                                                                        Services
Mental Health Project                                  Service
                                                       - and including CGS
                                                         Refugee Team
                                                                                                        YOT
                                                                                                        (Youth Offending Team)
 BIP
 (Behaviour Improvement
 Project)                                     HEART
 3 Secondary Schools                          (Health & Education Access to                             Listening 2 U
 and feeder primaries                         Resources Team for Looked                                 Teenage Parents Project
                                              After Children)


   Family Centres                                    Voluntary Sector                                       Community
   Groups

                                                OUTREACH TO TIER 1

                                                                              57
Appendix 6: Staffing levels

                                                                 Wte
Avenue House Team

Consultant Psychiatrist                                          1.0
SHO (starting February 05)                                       1.0
Clinical Psychologist Grade A                                    0.7
Trainee Clinical Psychologist                                    0.3
Child & Adolescent Psychotherapy Grade A                         0.9
Child & Adolescent Psychotherapy Grade B                         0.7
Trainee Child & Adolescent Psychotherapist                       0.4
Child Guidance Social Work Therapists                            3.93


Dryden Road Team

Consultant Psychiatrist                                           0.9
SpR                                                               0.4
Clinical Psychologist Grade A                                     1.2
Child & Adolescent Psychotherapy Grade A                          1.0
Child & Adolescent Psychotherapy Grade B                          0.5
Trainee Child & Adolescent Psychotherapist                        0.3
Child Guidance Social Work Therapists                             3.25
Mental Health Worker                                              1.0

SAFE Team (Adolescent Service)

Consultant Psychiatrist                                           1.0
Clinical Psychologist Grade A                                     0.6
Clinical Psychologist Grade B                                     0.65
Child & Adolescent Psychotherapy Grade A                          0.6
Child & Adolescent Psychotherapy Grade B                          0.6
Child Guidance Social Work Therapists                             1.5
Specialist Nurse                                                  1.0
Mental Health Worker                                              1.0




SCAN (Service for Children with Neuro-developmental Disorders)    Wte

Consultant Psychiatrist                                           1.0
Clinical Psychologist                                             0.8
Educational Psychology                                            0.1
Administrative Support                                            0.8



                                                                 58
Teenage Parents Project

Child & Adolescent Psychotherapist Grade A    0.1
Child Guidance Social Work Therapist          0.11
Administrative support                        0.05

Sure Start (Edmonton Local Programme)

Consultant Psychiatrist                       0.1
Social Work Therapist                         0.5
Educational Psychology                        0.4
Administrative Support                        0.4

Youth Offending Team

Clinical Psychologist Grade A                 0.4
Clinical Psychologist Grade B                 0.1

Child Development Team

Clinical Psychologist Grade A                 0.4

Hospital Paediatrics

Clinical Psychologist Grade B                 0.15

BIP/BSS

Child Guidance Social Work Therapists         2.8
Educational Psychologists                     1.8




                                             59
HEART (Health, Education, Access & Resources Team for LAC)                  Wte

Child & Adolescent Psychotherapist Grade A                                  0.3
Child & Adolescent Psychotherapist Grade B                                  0.4
Clinical Psychologist                                                       0.5
Family Therapist                                                            0.2
Educational Psychologist                                                    0.4
Education Welfare Officer                                                   0.4
Nurse                                                                       0.8
Senior Teacher                                                              0.8
PEP Project Manager                                                         1.0
Connexions Adviser                                                          0.4
Administrative Support                                                      0.7
Co-ordinator                                                                0.1
Clinical Psychology Grade B                                                 0.1
(Consultations to Adolescents and Leaving Care Team)

Notes

1.      There is a CAMHS Manager, who is also the Principal Officer and Principal
        Educational Psychologist for the Service.
2.      There is an Administrator who supports the Child Guidance Service as a whole.
3.      The teams of administrative staff support the Service as a whole but some
        projects have specific admin time allocated for them.
4.      Some of the posts are currently vacant.
5.      Each Educational Psychologist works approximately 0.1 in Tier 3 CAMHS.




                                                                           60
Appendix 7 : Markers of Good Practice (Children’s NSF)

  1. All staff working directly with children and young people have sufficient
     knowledge, training and support to promote the psychological well-being of
     children, young people and their families and to identify early indicators of
     difficulty.

  2. Protocols for referral, support and early intervention are agreed between all
     agencies.

  3. Child and adolescent mental health (CAMH) professionals provide a balance of
     direct and indirect services and a re flexible about where children, young people
     and families are seen in order to improve access to high levels of CAMH
     expertise.

  4. Children and young people are able to receive urgent mental health care when
     required, leading to a specialist mental health assessment where necessary
     within 24 hours or the next working day.

  5. Child and adolescent mental health services are able to meet the needs of all
     young people including those aged 16 and 17.

  6. All children and young people with both a learning disability and a mental health
     disorder have access to appropriate child and adolescent mental health
     services.

  7. The needs of children and young people with complex, severe and persistent
     behavioural and mental health needs are met through a multi-agency approach.
     Contingency arrangements a re agreed at senior officer levels between health,
     social services and education to meet the needs and manage the risks
     associated with this particular group.

  8. Arrangements are in place to ensure that specialist multi-disciplinary teams are
     of sufficient size and have an appropriate skill-mix, training and support to
     function effectively.

  9. Children and young people who require admission to hospital for mental health
     care have access to appropriate care in an environment suited to their age and
     development.

  10. When children and young people are discharged from in-patient services into
      the community and when young people are transferred from child to adult
      services, their continuity of care is ensured by use of the “care programme
      approach”.




                                                                            61
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                                                                                                   62
35
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Priscilla Ibekwe




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