A CAMHS Clinical Journey

This is an example of a full pathway that includes Choice, Core and Specific partnership (most young people only need Choice and Core Partnership). Here’s how it works for one family…

Referral

Sarah and her son Ryan (10) are referred to CAMHS by their GP as Ryan’s behaviour is very difficult, and the GP is concerned about the impact on Sarah’s mental health. The GP writes that Sarah says Ryan’s teacher thinks he may have ADHD. Sarah is worried as Ryan is beginning to hang around with older lads who get into trouble. They last came 4 years ago. Ryan’s dad David died in a car accident a year ago. Sarah has been depressed and being seen by the local adult mental health service. She does not have another partner.

Anywhere CAMHS look at referral letters daily. The difficulties described meet the eligibility for the service, although it is not clear which school Ryan goes to or why his teacher thinks he has ADHD, as the GP did not include this information.

Admin send a letter (or could phone) to Sarah asking her to ring in and choose a Choice appointment to suit her. They are sent information about the service, including a description of the aims of the Choice appointment. It tells them that if they want to have some help from the service after this then they will be able to book an appointment to see someone in the team who is best placed to help them, who may not be the person they see in Choice. If they were a particularly vulnerable family e.g. not able to read or had found it hard to engage previously, then they would be contacted by phone or the referrer asked to help them book in.

Clinical staff Clare, Renu and Andrew had each previously put several available dates they could do Choice appointments into the Choice diary. When Sarah phoned in, admin offered two Choice appointments at different times and on different days.

Sarah chose Friday at 11 am with Clare.

Choice

Sarah and Ryan turn up on Friday at 11 am and have their Choice appointment with Clare. They talk about what the problems are, what they have tried and what they would like to be different.

Clare listens carefully and works hard to find out what they want. She makes use of all the information available to her from the referrer and old CAMHS notes. In her head she is actively considering risk issues and whether any diagnoses may be appropriate (including screening for ADHD). She finds out enough to develop a shared initial understanding/formulation with Sarah and Ryan. They agree that they need to clarify whether Ryan has ADHD, as he certainly has some symptoms noticed by Sarah from a young age. However, they acknowledge that this is not the whole story. Ryan’s dad’s death and Sarah’s subsequent depression are big events that have affected them both.

Together they decide that CAMHS would be able to help them. Sarah wants to get on better with Ryan and for him to not get into trouble – she fears he may get arrested soon. She also wants to know if he has ADHD as she has heard that a pill can help. Ryan wants to see his friends and for his mum to stop nagging him and let him go out more.

Clare describes what types of things could be offered and what the available evidence for each approach is. She also describes her experience of what helps others in similar situations. They talk parenting approaches, about what ADHD is and how it is assessed, family relationship work and bereavement work. Having decided on a Choice point together they discuss some things to try at home [Pre-Partnership work]. They agree that feedback from the teacher is needed and that the local youth service may be able to offer Ryan some activities, mentoring and a parenting programme for Sarah. Sarah agrees to complete an ADHD screening questionnaire (possibly Conner’s) and gives permission for Clare to contact her adult mental health worker, Ryan’s teacher (also for screening questionnaires) and refer them to the YISP. Clare gives them some leaflets and websites to look at, including NICE guidance on parenting work and ADHD.

Core Partnership

Clare knows that clinicians Andrew and Brenda have the extended core skills to help them with the issues. She finds the Partnership diary and offers Sarah and Ryan available dates with both. They decide they would prefer a male clinician and so book their first Core Partnership appointment with Andrew, for 3 weeks time on a Wednesday at 3 pm. Andrew and Brenda have previously each put available dates for new Core Partnership into the Partnership diary.

Clare writes a summary of the Choice session and copies this to Sarah and Ryan and the network (her GP, the teacher and Sarah’s Community Psychiatric Nurse), having obtained consent to do so. She writes to the school to get some feedback from them, enclosing a Teacher Conner’s questionnaire. She refers them to the YISP.

Clare talks about the Choice work at the weekly meeting for Choice appointment review.

In 3 weeks Sarah and Ryan meet with Andrew. Andrew finds out how they have been doing since they met Sarah in Choice, including how the things they had tried at home had gone. Are their goals the same? Are there things they did not talk about in Choice that are useful to talk about? He does not repeat the Choice appointment but actively makes use of all the information gathered previously.

Together they look at the completed Conner’s questionnaires and feedback from Ryan’s teacher and decide that further investigation of possible ADHD is needed. They agree that the initial understanding of the issues remains the same as discussed with Sarah, but the additional impact of Sarah’s postnatal depression following Ryan’s birth has resulted in some attachment issues that complicate the picture.

Specific Partnership Consult

Andrew asks Dr. Margaret, one of the psychiatrists, to join the work to complete an ADHD assessment whilst he works with Ryan and Sarah in Core Partnership. Dr. Margaret joins for some Specific Partnership assessment work. She builds on the information gathered by Clare in Choice and by Andrew in Core Partnership. Sarah and Ryan do not have to repeat their story.

Ongoing Core work

Andrew and Margaret talk about the work they are doing in the weekly peer group supervision.

In Core Partnership Andrew is liaising with school, Sarah’s community nurse and youth worker. He is supporting Sarah and Ryan in building up their relationship and they talk a lot about Ryan’s dad. After a few sessions of Core Partnership work, a review is held. Margaret joins them, as does the youth service worker. It is clear now that Ryan does NOT have ADHD, but that his behaviour is a reaction to life events and Sarah’s depression and exhaustion.

Adding Specific Partnership

Things are going well but all think that Ryan may benefit from some individual work around losing his dad. Now that Andrew has got to know them he thinks that some Art therapy may suit Ryan as he finds talking hard. He describes Art therapy to them. They like the sound of it and so Andrew asks Clare, who has these skills, to join them for some Specific Partnership work with Ryan. YISP offer Sarah a parenting group and Andrew continues to liaise with school.

Andrew is the key worker and regularly updates the Care Plan following reviews with Sarah, Ryan, Clare and the YISP worker. He ensures they have feedback from Ryan’s teacher to feed in to the review.

After 10 sessions of Art therapy, things have improved. Sarah understands her relationship with Ryan better and how to manage him. Ryan does not feel so cross with his mum. They have talked a lot about Ryan’s dad dying and how much they miss him.

Outcome

Clare finishes her work with Ryan and Andrew continues for a few more sessions with Sarah and Ryan until they all decide that their goals have been reached i.e. Ryan is not getting into trouble in the same way, is doing activities with others his own age through YISP, Sarah is more confident about managing him and school find him more settled. Following a final review all agree that the work is done and the case is closed. Sarah knows how to return if needed, which other services locally may be able to help and what sort of things they can do at home to keep on track.