1. Merton Specialist CAMHS Merton Children’s Trust Board 18th September 2015

2. Dedicated & Local Team StructureND
CLD
MST
MST R K S M W
SPA in Sutton and Merton progressing well.
SPR
SPR
SPA
SPA
SPA

3. Services from Merton Tier 3 Team
Mental state examination, diagnostic assessment and medication where required
Psychological assessment and treatments such as cognitive behavioural therapy (CBT)
Monitoring, treatments and care coordination
Interface working to meet social care and other needs
Psychodynamic assessment and counselling
Family work, family therapy, parents support and psycho-education
Opportunities for children and young people to be ‘participants’

4. Conditions that present in referrals to the service
Psychosis
Mood Disorders
Eating Disorders
Dangerous Self Harm
Significantly impairing Anxiety Disorders of a diagnosable level (e.g. OCD, PTSD)
Complex ADHD/ASD/Tourette’s (Tic Disorders) (i.e. comorbid/ with MH problems)
Children with Learning Disabilities who have a mental health condition

5. Focus on Outcomes – Clinical (1)
Merton CYP IAPT
Merton Consent Rate = 28.32%
Assessment Measures*
Goal(s) set*
Current View / EET*
Feedback Measures**
CYP IAPT Consented Clients
69.14%
(186/269)
18.22%
(49/269)
45.72%
(123/269)
16.33%
(8/49)
All CAMHS Clients
37.58%
(357/950)
13.89%
(132/950)
30.53%
(290/950)
6.73%
(15/223)
Equivalent CYP IAPT Wave Comparison***
54.40%
Wave 3
8.20%
28.60%
16.30%
Paired Goals**
Paired Measures**
Paired + EET 90%**
CHI-ESQ Completion**
34.69%
(17/49)
28.57%
(14/49)
6.12%
(3/49)
22.42%
(50/223)
15.70%
(35/223)
0.90%
(2/223)
15.25%
(34/223)
13.10%
31.90%
16.80%
19.20%
* criteria = 1st recorded event in reporting quarter
last updated: 07/09/ :03
** criteria = 3 or more events and closed episode
*** source: Q CORC CYP IAPT Report

6. Focus on Outcomes - Experience (2)

7. Case Example (1) Presenting issues
Child A attended CAMHS having presented with a long standing fear of vomiting, and an interlinked problem of being fearful of sleeping alone. She lives with her parents and younger sister and attends school regularly (Year 10).
Following initial assessment, Child A was seen with her mother for a total of eight sessions. Work included cognitive restructuring, behavioural experiments and graded exposure (CBT), as well as work with her mother’s beliefs that appeared to be maintaining the problem. Mum herself suffered from panic attacks and anxiety as a teenager which re-emerged at times.   
Outcome
Child A developed skills to recognise when she was misinterpreting bodily signs and reframe them as signs of anxiety rather than physical illness, as well as challenge her negative beliefs about the likelihood and danger of vomiting and her own under-estimation of her capacity to cope.
Child A started to sleep alone, and at friend’s houses, as well as eat in restaurants and be around people who were unwell. Investigating parental beliefs was an important step towards supporting the young person through this troubling time.
Behavioural Experiment
Further challenging was done by use of behavioural experiments. Child A linked feeling sick to being sick. In order to test this out, we needed to generate a situation where nausea was induced. She chose to go to a theme park and go on progressively harder rides. Using the template set out by Rouf et al. (2004) in behavioural experiments (see Appendix 4) we were able to establish prediction for the outcome if the feared belief were true, and what it would mean if it did not occur. Child A was able to carry out this experiment and it strengthened her belief that feeling nauseous did not necessarily lead to vomiting.
Graded Exposure
Child A had identified certain situations outside of home that triggered anxiety, which she would either avoid or escape from. These included being near ill people (especially vomit related illnesses) or being in a restaurant. Child A drew up a graded list of such situations and then worked her way up the hierarchy, such as sitting in the sick room at school and going for meals out. She was able to draw on both her positive self-statements and her breathing techniques to remain in the situation until her anxiety passed, and this strengthened her belief that ‘it’s only anxiety, it will pass’.
Graded Exposure:
Child A had identified certain situations outside of home that triggered anxiety, These included being near ill people (especially vomit related illnesses) or being in a restaurant. Emily drew up a graded list of such situations and then worked her way up the hierarchy, such as sitting in the sick room at school and going for meals out. She was able to draw on both her positive self-statements and her breathing techniques to remain in the situation until her anxiety passed, and this strengthened her belief that ‘it’s only anxiety, it will pass’.
Managing the Sleep Problem:
Child A struggled with getting to sleep on her own, as she would become anxious about being sick. The predictions about sleeping alone were identified using downward arrow techniques:
If I don’t sleep with Mum, I’ll be anxious
If I’m anxious, I won’t sleep
If I don’t sleep, I’ll have a terrible day
If I have a terrible day, I’ll be sick
Conclusion:
Child A developed skills to recognise when she was misinterpreting bodily signs and reframe them as signs of anxiety rather than physical illness, as well as challenge her negative beliefs about the likelihood and danger of vomiting and her own underestimation of her capacity to cope. She started to sleep alone, and at friend’s houses, as well as eat in restaurants and be around people who were unwell. Towards the end of the session, she had an experience of vomiting, in which she coped well, which also added to her positive beliefs. Investigating parental beliefs was an important step towards getting them on board and acting in a way that reinforced the image of Emily coping

8. Case Study (2)
Problem:
Boy aged 6 referred by school (school also referred to Social Care)
Disruptive behaviour, poor concentration, hyperactivity, inappropriate language and volatile relationship between separated parents.
Initial intervention
ADHD assessment which identified a conflict between parents reinforced by professionals’ views that the young person’s behaviour was a result of the parental relationships. Diagnosed with ADHD and medication prescribed.
Treatment:
Child protection plan for emotional abuse: Social worker to monitor parental behaviour and separate parenting classes for each parent. CAMHS input includes medication and annual reviews with contribution to the child protection core group meetings and conferences. Ongoing consultation with the school to monitor young persons mental wellbeing.
Outcome: Child Protection plan in place and case overseen by a consultant psychiatrist.