Underlying principles and concepts

Where are the young people that FCAMHS work with?

It is a frequent misconception that FCAMHS work only with young people in contact with the youth justice system. In reality, such services are predicated on the fact that they work with high-risk young people about whom there are mental health concerns; this means that they need to cater for young people both within and outside youth justice settings and processes.

The statistics that monitor young people's contact with the youth justice system in England and Wales are reviewed annually. The most recent statistics cover the year 2014–2015 (Ministry of Justice 2016) and are summarised in Table 1. It will be noted that numbers of formal community and custodial ‘disposals’ for young people have decreased dramatically since 2002. It is thus the case that, outside of formal youth justice provision, there are many young people involved in high-risk behaviours who are supported within a range of welfare secure and residential, specialist educational, voluntary sector and other provision (including their own families). There is a further group of young people who do not benefit from support of this kind and who, as a result, give particular cause for concern. These two groups and the professionals trying to work with them frequently require specialist input from FCAMHS with regard to the interplay between risk, mental health difficulties and the young person's developmental needs.

TABLE 1 Young people who offend: contact with the youth justice system in England and Wales (2014–2015)

High-risk young people may be found in a range of secure settings subject to welfare, mental health and youth justice statutory jurisdictions (Table 2). It will be noted that at any one time in 2015 there were about 1450 young people under 18 in secure settings in England.

TABLE 2 Numbers of young people in secure provision in England at any one time (2014–2015)^a

High-risk young people and mental health difficulties

The high rate of psychiatric and neurodevelopmental disorder in adolescent offender populations is well documented. Table 3 compares the prevalence of various mental disorders in adolescents in normal community samples with those involved in offending behaviour. Reference HagellHagell (2002) summarised the UK prevalence of diagnosed disorders among young people in custody (range: 46–81%) and young offenders in the community (range: 25–77%), and emphasised that conduct and oppositional diagnoses are the most frequent, often occurring in association with other diagnosable disorders such as those in Table 3. High rates of neurodevelopmental difficulties among adolescent offenders have been emphasised by Reference Hughes, Williams and ChitsabesanHughes et al (2012). Other studies have confirmed the high levels not only of diagnoses of emotional and behavioural disturbance, but of more general comorbid ‘complex needs’ (among which are ‘looked after’ status,Footnote c substance misuse, special educational needs, previous experience of abuse and family disruption) (Reference Lader, Singleton and MeltzerLader 2000; Reference Kroll, Rothwell and BradleyKroll 2002; Reference Harrington, Bailey and ChitsabesanHarrington 2005; Reference Chitsabesan, Kroll and BaileyChitsabesan 2006; Health in Justice LLP 2010; Reference Daniells, Speed and ScaresDaniells 2011).

TABLE 3 Mental disorder in adolescents in the general population and in criminal justice settings

Scope and organisation of existing provision

Dedicated FCAMHS are specialist services that should be regarded as complementary to core service provision for all young people. In this way, young people can receive services as close to their homes as possible and in contexts with which they are familiar. In principle, concerns about risk or about emotional or mental health should initially be considered by ‘universal’ services (e.g. within education, children's social care or primary healthcare). However, in some cases more specialist services will be required to meet emotional or mental health needs and risk of harm to others (e.g. residential and specialist educational placements, youth offending services and custodial settings, local CAMHS teams, ‘open’ CAMHS in-patient units). Where such solutions to meeting a young person's needs and risk are not successful, or where more specialist advice is required, FCAMHS intervention may be sought. This can give rise, particularly where specialist in-patient provision is required, to a dilemma for service providers and commissioners, namely the tension between the need for specialism available in only a few centres in the UK and the geographical dislocation of the young person from their family and familiar local surroundings.

This organisational framework represents a graded or tiered approach to high-risk young people with mental health problems (similar to that proposed by Reference Williams, Bailey and DolanWilliams (2004)). It should serve as a guide and not be rigidly and unquestioningly adhered to – the complex contexts and situations in which high-risk young people may present require a more flexible approach to ensure that exceptional circumstances giving rise to high professional concern (which, with this particular group of young people, arise quite frequently) are dealt with rapidly and effectively. In such circumstances, FCAMHS involvement may serve either to contain anxiety or to escalate professional concern.

Dedicated FCAMHS provision refers to services commissioned specifically to fulfil the functions outlined in Box 2. In practice this has resulted in the development of in-patient and community services whose functions should be complementary and have some degree of overlap. Other services may provide some of these functions, but these services usually do not have the capacity or expertise to undertake the full range of functions provided by FCAMHS.

Community provision

Community FCAMHS provision has developed significantly since the introduction of in-patient services, but remains heterogeneous in terms of both geographical coverage and commissioning arrangements, resulting in large areas of the UK with no access to any specifically commissioned local or regional community FCAMHS (Reference Dent, Peto and GriffinDent 2013). Areas without access to such provision may have to rely on ‘spot-purchased’ assessments and advice about case management and intervention from services with national coverage. Advantages of a service commissioned for a given catchment over spot-purchasing arrangements are discussed by Reference Dent, Peto and GriffinDent et al (2013). There remain ongoing difficulties with establishing a suitable commissioning framework to ensure equitable access to services with regional catchments in England and elsewhere.

In some areas where it has been possible to develop and sustain a commissioned catchment-based regional forensic service, evaluation and validation of a working service model (as described by Dent et al) has received widespread approval. In brief, community FCAMHS should be small and should consist of clinicians with specialist awareness and experience of working with high-risk young people, who frequently have complex needs and are involved with a number of different agencies. A community FCAMHS may include psychiatrists, clinical and forensic psychologists, nurses, social workers and other allied disciplines. Dent et al propose that the services should ideally serve a given catchment area (total population of about 2–2.5 million) and should form a specialist (‘tier 4’) part of existing CAMHS provision. Team members should have highly developed liaison skills (with local, regional and national services; Fig. 1) and an understanding of the varying statutory jurisdictions and range of community and residential settings that influence and contain high-risk young people. Above all, such services should understand how to facilitate and mediate positive change and containment for young people who give cause for significant family and professional concern; paramount in such circumstances is accessibility, the provision of clear formulations, attention to detail and emphasis on practical case management. In addition, FCAMHS should be able to provide therapeutic interventions for young people where they are best placed to do this either because of the young person's specific needs or the absence of other appropriate service provision (Joint Commissioning Panel for Mental Health 2014).

FIG 1 A service model for community forensic child and adolescent mental health services (FCAMHS).

SCH, secure children's home; STC, secure training centre; YOI, young offender institution; YOS, youth offending service.

The ascertainmentFootnote d and consultation role of community FCAMHS, in terms of identifying high-risk young people with mental health and other needs, is of great importance. This is especially true because a significant proportion of such young people will not be within the youth justice system and their risks and needs may not have been adequately assessed. For this reason, such services should be easily accessible to all professionals and should respond to family and professional concerns rather than solely to proven and established high-risk situations where mental health need has been definitively established.

Clinical needs of high-risk young people and the role of FCAMHS

There has been a tendency for the needs of high-risk young people to be regarded as different from those of their non-offending peers and for the systematic evaluation of their needs to be truncated. This occurs partly because the intrusion of perceived risk and high-risk behaviours tends to cause multidisciplinary systems to become organised around (and frequently paralysed by) such concerns at the expense of evaluation of needs, and partly because there are frequently difficulties with continuity of care and meaningful engagement with such young people. Alternatively, young people who come to be regarded as particularly disadvantaged and impaired by their life circumstances by professionals involved in providing support to them become subject to a search for successive poorly defined ‘therapeutic’ solutions at the expense of attention to high levels of risk of harm to others. In practice, risk assessment should form an integral part of any needs assessment for a young person, just as risk management should be part of any management plan designed to meet needs. Equally, the meeting of unmet need in high-risk young people usually forms an integral part of risk management.

The role of specialist FCAMHS is to assist colleagues in a range of agencies working with high-risk young people in identifying mental health need together with other vulnerabilities and needs that may impinge directly on a young person's mental health, and to undertake and support risk assessment and risk management. Although the emphasis of such work varies between the intense focus of secure in-patient settings and the more macroscopic and systemic emphasis of community FCAMH teams, many of the principal clinical requirements remain the same. These include:

1. • strong emphasis on engagement skills with young people who may react in a hostile way and whose difficulties are frequently difficult to treat

2. • capacity for longitudinal case involvement and appreciation of the value of continuity of professional involvement

3. • flexibility of response to different clinical presentations, professionals and families

4. • wide experience of universal and specialist provision for young people

5. • specific knowledge of evidence-based mental health interventions for young people, together with knowledge of additional interventions likely to be of benefit for high-risk sexual, violent and antisocial behaviours

6. • strong formulation and case management skills (including structured evaluation of risk and its management)

7. • emphasis on the need for carefully planned transitional arrangements for high-risk young people, in particular the transition from child and adolescent to adult mental health services.Footnote e

MCQs

Select the single best option for each question stem

1. 1 Which of the following is not an example of key legislation applicable to children and young people in forensic settings?

   1. a Mental Health Act 1983 (as amended)

   2. b Disability Discrimination Act 1999

   3. c Children Act 1989

   4. d Mental Capacity Act 2005

   5. e United Nations Resolution 46/119.

2. 2 What proportion of adolescents in youth justice settings have an intellectual disability?

   1. a 5%

   2. b 10%

   3. c 15%

   4. d 20%

   5. e 25%.

3. 3 Which of the following secure settings for under-18-year-olds accommodate the highest numbers of young people in England?

   1. a Secure children's homes

   2. b Secure training centres

   3. c Young offender institutions

   4. d Low secure in-patient units

   5. e Medium secure in-patient units.

4. 4 Which of the following conditions is most frequent in offending populations under the age of 18?

   1. a Mood disorder

   2. b Psychosis

   3. c Conduct disorder

   4. d Intellectual and developmental disability and other learning difficulties

   5. e Attention-deficit hyperactivity disorder.

5. 5 Which of the following is a necessary feature of FCAMHS?

   1. a Insistence on detailed written referrals as the initial contact from agencies concerned about a high-risk young person

   2. b Specialist understanding of the working of the youth justice system, but not of other educational or residential provision for young people

   3. c Location in a prison setting

   4. d Detailed knowledge of the Children Act and Mental Health Act

   5. e Location in a medium secure unit.

MCQ answers

1

b

2

e

3

c

4

c

5

d