Taxonomy of need

There seem to be three distinct groups of young people needing continuity of care after the age of 18.

1. Those who CAMHS assess as having a severe and enduring mental disorder, who also meet the eligibility criteria for AMHS.
2. Those who CAMHS assess as having a severe and enduring mental disorder, who do not meet the eligibility criteria for AMHS.
3. Vulnerable young people who use a number of services, though not necessarily CAMHS, who have pronounced and multiple needs that may not express themselves clearly as mental health problems.

1. Those who CAMHS assess as having a severe and enduring mental disorder, who also meet the eligibility criteria for AMHS.

They usually have a clear cut psychosis, or severe depression.
What do they need?
A good protocol, the use of CPA and some help from CAMHS in preparing them for using adult services.

2. Those who CAMHS assess as having a severe and enduring mental disorder, who do not meet the eligibility criteria for AMHS.

Includes:
a) Attention Deficit Hyperactivity Disorder (ADHD)
ADHD was stated time and again as a real issue for adolescents and young adults. Some AMHS managers and practitioners were very aware of and sympathetic to this problem, but were concerned to protect their boundaries and considered it an issue primarily for commissioners. AMHS needs to be commissioned to provide for young adults with ADHD and this will include appropriate training and support for AMHS practitioners taking on a new role.

b) Autistic Spectrum Disorder (ASD)
Similarly ASD, including Asperger’s syndrome posed a challenge, particularly when the young person was exhibiting very challenging acting out behaviour.
It was said that eligibility for an adult service depends upon the presence of an associated learning disability. This of course excludes those with high functioning ASD, including Asperger’s Syndrome.

c) Those in out of area placements
Out of the area placements are used for low volume, high need cases and include prisons, care institutions, forensic and other specialist units. Is it a case of out of area out of mind?

d) Eating disorders
There is reluctance in some places to transit young people to adult services at 18. The disinclination is about perceived culture differences, in which a young person of 18 about whom there has been optimism, will encounter older, “hardened” cases who may transmit cynicism.

e) Conduct disorder/emerging PD
Many young people with CD are likely to have an emerging or borderline personality disorder and they fall through the net primarily because there is insufficient provision to meet their needs effectively. These young people continually present to substance misuse services/workers and are also in evidence within the youth offending service caseload (YOS). Described as those who are “both trouble and troubled”, very few of them require forensic services, yet all have the potential for forensic approaches later on and many return to the system via criminal justice. Some adult practitioners wondered whether PD should be thought of as developmental and whether it could be identified earlier. Conversely we were told that child and adolescent psychiatrists are reluctant to diagnose PD under the age of 18.


3. Vulnerable young people who use a number of services, though not necessarily CAMHS, who have pronounced and multiple needs that may not express themselves clearly as mental health problems.

All young people with mental health need may be viewed as vulnerable; however there is a group of young people whose emotional and psychological well being is threatened by circumstances and life events, albeit they may
not have a diagnosed mental disorder. These young people may come from particularly disadvantaged or chaotic families; they might be looked after by the local authority; could include asylum seekers and refugees; they may have a learning disability. In many cases these young people experience a combination of such factors. Some of this group will have received assessment and treatment from CAMHS, but equally a significant proportion will not. Without a specified mental disorder it is extremely unlikely that they would meet the criteria for an adult mental health service, indeed it would be unlikely to meet their needs. As one interviewee stated, “There is no safety net.”

Includes:
a) Learning disabilities
The issue is about young adults receiving a seamless service that addresses both the LD and the mental health problem, but often one will be treated at the expense of the other. AMHS are the gate keepers for referrals and will not take those people who are under the age of 18.

b) Those misusing substances
Local drug and alcohol services experienced an insufficient dialogue with mental health services, both AMHS and CAMHS. There is no automatic referral to adult services because these young people may not meet the criteria.

c) Refugees and asylum seekers
People interviewed from the voluntary sector reported that counselling and talking therapies are seen as a western concept and this would prevent many young people from these communities asking for help. Translation and interpreting services can be costly, particularly to smaller voluntary organisations.

d) Depression and anxiety
Types of young people classified as vulnerable included those with low level to moderate depression. Children with depression often self harm and frequently have a range of other associated social and health problems. On that basis they would normally receive a service from specialist CAMHS. It was reported that these young people fall below the threshold for adult mental health services, yet have needs that may be too complex to be met within primary care.

e) Looked after children
Large numbers of vulnerable young people are to be found within the looked after population, including care leavers and unaccompanied minors. These are young people who would almost automatically be eligible for a CAMH service, yet despite their high levels of need, they may not have a specified mental disorder. These young people, it was said, “are the meat in the sandwich between CAMHS and AMHS”.
Looked after young people and care leavers may not have a “mental disorder” but are very often mentally distressed, with nowhere to go. Increasingly across the country, young people looked after by the LA are seen as a priority for specialist CAMHS, since as a group they have a far higher risk of developing mental health problems. The mismatch occurs between different age boundaries, with CAMHS ending at 18 and the LA having responsibility for care leavers to the age of 25Some young adults have been in the health and social care systems for their whole lives, having “years upon years of disturbance in their lives”.

f) Difficult to engage/unknown
Some young people do not wish or are not able to engage with CAMHS and they would also be unlikely to engage with adult services. Some young black people have said that they do not receive enough therapy. One practitioner told us there is still institutional racism, stating that a black person with psychosis is less likely to receive a referral to a talking therapy than a white person.

We heard about large numbers of unaccompanied minors from refugee groups, whose mental health needs go largely unmet by the statutory services.