Child And Adolescent Mental Health Practice

Published Date: 02 Nov 2017

SCHOOL OF HEALTH

COURSE WORK FRONT SHEET

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Name

Amy Wyatt

Enrolment No:

G20239977

Course

Child and Adolescent Mental Health Practice

Personal Tutor

Sharon Pagett

Module Title

Enhancing Skills in Child and Adolescent Mental Health

Module Code:

NU3024

Module Leader

Sharon Pagett

Module Supervisor

Sharon Pagett

Assignment Title

Case Study

Word Count:

4716

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DECLARATION

I have read and understood the guidelines regarding unfair means to enhance performance within UClan Assessment Handbook; and the use of anonymity and confidentiality within the School Student Handbook and have complied with these.

I confirm that the assignment I have submitted is my own work and the source(s) of any information or material I have used (including the Internet) is properly acknowledged in line with School Student Handbook guidelines. I also confirm that details of individuals and or organisations have been anonymised and I have not breached confidentiality in accordance with School guidelines.

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Date of Submission: 18/04/2013

Signature of Student: A.Wyatt

This case study aims to critically analyse the assessment, formulation and intervention process used in my current practice. I am a staff nurse on a paediatric ward based in North West England. I care for children and adolescents with a variety of medical, social and mental health problems. For the purpose of maintaining confidentiality in accordance with the Nursing and Midwifery Council (NMC) Code of Professional Conduct: standards for conduct, performance and ethics (2008) pseudonyms will be used to ensure no patients or families are identified. This assignment is written in the first person as discussed by Hamill (1999) who outlines that writing in first person is appropriate in developing personal and professional qualities of reflection, analysis and critique. Consent has been gained from the young person discussed in this case study, along with consent from the young person’s mother whom holds parental responsibility in accordance with The Data Protection Act (1998).

Case Vignette

Jessica is a 14 year old girl who lives with her mother in a deprived, rural area in North West England. Jessica has never met her father, has a close relationship with her 28 year old sister who lives close by, and regularly sees her Grandmother whom has physical health problems. Jessica is enrolled in a local grammar school and is doing very well intellectually, however struggles to make friends and form lasting relationships. Jessica has become well known to the paediatric ward, in recent months Jessica has struggled with low mood and self harm by cutting, which was initially being managed by her G.P in the community. Jessica initially presented to the ward having taken a significant paracetamol overdose, requiring treatment with the reversal drug and was then referred to the Child and Adolescent Mental Health Team (CAMHS). Jessica was discharged home into mothers care with support from CAMHS, however has since been admitted to the ward 12 times in 4 months having taken further overdoses and significantly self harmed by cutting her arms and legs. I will be using Jessica’s most recent admission to the ward in this case study, as Jessica refused to be discharged home into mother’s care due to feeling unsafe and out of control with her feelings of self harm and suicide, and the only place she feels in control of her thoughts of suicide is on the ward. Jessica’s mother initially felt she could manage Jessica’s mental health problems at home with support from CAMHS, however on the most recent admission Jessica’s mother stopped visiting Jessica and only telephoned nursing staff once daily for an update on Jessica’s condition. Jessica expressed to staff that she felt unsafe at home because her mother did not understand her low moods, and often became angry when Jessica self harmed, Jessica’s mother found Jessica’s low mood very difficult to cope with, and refused to visit Jessica in hospital because ‘Jessica did not want her and she made things worse.’ Jessica’s sister visited her on the ward every couple of days, Grandma was unable to visit due to health problems.

Assessment

Goodman & Scott (1997) discuss how a comprehensive assessment should underpin treatment options in child and adolescent mental health, and that the assessment process is vital in engaging with the child and family. Current practice on the ward involves filling out an ‘admission pack’ which has been designed to gain a holistic view of the child/young person. The ‘admission packs’ are generalised for all patients admitted to the ward, and carefully completed cover physiologic, psychosocial and cultural information. Kluwer (2008) discusses nursing assessment forms, and says that they are advantageous in that nursing staff are expected to simply fill in the blanks, and guide us through the nursing process helping formulate, care plan, assess risk and begin discharge planning. Difficulties can arise in using nursing assessment packs as Meer and Gabert (2007) outline stating that nurses must gather information that is accurate and comprehensive.

On Jessica’s most recent admission to the ward, an admission pack was filled in, outlining basic information such as parents names, school attended, social history, dietary plans, pain control, and baseline physical observations. During the nursing admission both Jessica and her mother were present. Currently in the admission pack there is no space for psychological assessment, therefore Jessica was not asked about her current mental state. The National Institute for Clinical Excellence (NICE) (2005) guidelines on Depression in Children and Young People outline the importance of a holistic assessment when assessing children and young people with depression, outlining that the social, educational and family contact for relationships are considered, in Jessica’s case the initial questioning was not holistic on admission to the ward. Dossey & Keegan (2009) say that a nurse should use a nursing assessment to outline and prioritise a patients needs, which in this case were Jessica’s mental health needs, however due to compliance with the current nursing ‘admission packs’ used on the ward, and no space for a psychological assessment, the nurse undertaking the admission did not prioritise Jessica’s mental health needs. Higgins, Hurst & Wistow (1999) found that nurses felt filling out paperwork on admission caused them to feel that they only had a passing relationship with patients, and that the emphasis was on correct documentation as a pose to discussing their patients needs.

Once the nursing assessment had taken place, a doctor then undertook his assessment, which involved a more in depth conversation with Jessica about her current health needs and reason for feeling unsafe at home. Nursing staff were made aware of Jessica’s concerns regarding her mother ‘not understanding her depression and self harm’, and Jessica’s mother wishing for an admission to the ward until further notice due to her coping skills. The NMC Code of Conduct (2008) outlines that nurses must report findings to the multi disciplinary team, and in this case nursing staff felt it necessary to fill out a Common Assessment Framework (CAF), as identified in the Every Child Matters document (2004). Every Child Matters (2004) recognised that in order for children and young people to meet the five outcomes, system wide changes were required, therefore the CAF was introduced. The Children’s Workforce Development Council (2009) says that the CAF is a standardised approach to assessing a young persons needs and identifying how best to meet those needs, however Adamson & Deverell (2008) say that a lack of resources in rural areas may hinder the effectiveness of multidisciplinary working within the CAF process, which in Jessica’s case was an issue due to time restraints of professionals and lack of contact. Whilst filling out the CAF, nursing staff were able to gain a more holistic understanding of Jessica’s health needs, along with the difficulty her mother was having in dealing with Jessica’s self harming behaviours. Gilligan & Manby (2007) discuss the importance of considering both the parents and young persons active participation in the CAF process, and say that the family as a whole will benefit if they are involved in the assessment process, Jessica and her mother were in agreement with the CAF, and were open to multi agency working in order to get the best help possible. Cooper, Hooper and Thompson (2005) outline the importance of interviewing the young person without the parents present; Jessica was assessed without her mother which helped staff to gain an insight into Jessica’s concerns about going back into the home environment.

The day after Jessica’s admission, the CAMHS team came to the ward to do their assessment of her needs. The NICE guidelines on Depression in Children and Young People (2005) outlines that health care professionals should work with local CAMHS to enhance specialist knowledge and skills. This is vital on the paediatric ward as currently there is no risk assessment in place for nursing staff to take out, it is only when the CAMHS team arrive that a risk assessment is put in place. Foster (2009) says that paediatric nurses have a lack of confidence in their abilities to care for young people with mental health needs, and this has been outlined as a barrier to risk assessments being introduced onto the ward for young people with mental health problems. Harrison (2003) outlines that risk assessments are linked to risk management, and should be a holistic view of the patient, outlining therapeutic strategies individualized and agreed with the patient. Harrison (2003) also states that although risk assessing is a nursing skill, it should occur within a multidisciplinary context and involve other relevant disciplines. Jessica already had a good therapeutic relationship with her CAMHS worker from the community and along with providing the ward with a risk assessment individualised to Jessica; the CAMHS worker used the Children’s Depression Inventory as recommended by Kovacs (2001). This is a self assessment tool that Jessica filled out herself answering questions about her feelings and mood over the last two weeks, this outlined that Jessica was struggling with low mood, self harming behaviours, hopelessness and difficulty in maintaining relationships with her mother and peers. Gledhill (2011) outlines the need for a thorough assessment of risk relating to drug and alcohol use, self harm and suicide, the CAMHS team assessed this and outlined that Jessica was not partaking in risk taking behaviours with drugs and alcohol, however had thoughts of suicide and has self harmed on her arms and legs. Cook, Peterson & Sheldon (2009) outline that there is a reduction in the risk of suicide when there is successful treatment of depression, and therefore the CAMHS team included this in their risk assessment.

A meeting with Jessica’s named nurse, her social worker and the CAMHS team was then organised as part of the assessment process. The National Service Framework, Standard 9 (2009) discuss the importance of multidisciplinary team working in CAMHS, and say that people with the necessary skills need to be involved in a young persons care, however they do outline that "Many services have not been able to recruit all members of a multi-disciplinary team, which limits their capacity to provide a comprehensive service." The actual problems outlined in the meeting were that Jessica was at significant risk of self harming by cutting or overdosing, that Jessica was struggling with low mood, and that Jessica’s mother was struggling to cope with Jessica’s mental health needs. The potential problems outlined were that Jessica may abscond from the ward and that Jessica stated that her mother visiting made her low mood worse, and therefore did not wish to see her.

Formulation

Herbert (2001) outlines that formulation is a process by which a clinician takes all of the information gained in the assessment, and integrates this into understanding their difficulties, the history of these difficulties and how they are sustained. Havighurst and Downey (2009) outline ‘The 4 P’s’ in order to structure Child and Adolescent mental health practitioner’s thinking. This process was used by the multidisciplinary team in Jessica’s case, and aided staff to develop a formulation that leads to a well-considered intervention plan. Crowe, Carlyle & Farmar (2008) say that formulation is central in providing a link from nursing assessments, and that formulation helps the practitioner and client to interpret the issues found in the assessment process.

Using ‘The 4 P’s’ outlined by Havighurst and Downey (2009) the multidisciplinary team surrounding Jessica formulated her problems as follows, Jessica and her mother were present in the formulation meeting. Firstly the Predisposing factors were looked at, NICE (2005) recommend that there is often a family history of depression, and a thorough history regarding mental health must be obtained. It became clear that Jessica’s father (whom she had never met) suffered with mental health problems, and that Jessica’s mother had a sense of negativity towards depression due to her ex partners behaviours. According to Erikson (1963) and the psychosocial stages of development, each stage must be satisfactorily resolved in order to move on and develop into adulthood, and impairment of going through these stages may result in difficulty with attachments, social relationships and therefore mental health issues. It is clear in Jessica’s case that there are a lot of issues surrounding family dynamics, and the fact that her father had left before she was born. Havighurst and Downey (2009) stress the importance of the father being present in ‘The Mindful Formulation’, and during the formulation meeting it was clear that mother felt alone and overwhelmed. Jessica’s sister did visit Jessica often, however worked full time and had a sense of urgency when visiting, and could not attend multidisciplinary meetings due to work commitments, this also had an effect on Jessica as she felt that people were ‘too busy’ to support her.

Precipitating factors were then considered, these being the current problems that Jessica was struggling with. A lack of coping mechanisms and of social support has lead Jessica into feeling low and misunderstood. Jessica lacks coping strategies and often spends time wondering what life would have been like if her father had been around, and if her mother spent more quality time with her instead of being at work. It appeared that recent economic stress had lead Jessica and her mother to feel anxious about money, and this lead Jessica’s mother to be even less emotionally available than previously. The World Health Organisation (2007) say it is well known that mental health problems are related to poverty, inequality and other social and economic determinants of health, and Jessica’s anxiety surrounding her families economic status had triggered self harming behaviours. Jessica continues to do well at school, is aware of her own academic abilities and feels that with help she can change.

Perpetuating factors were then considered, drawing on information about current behaviours and how these behaviours are maintained. The pattern of conflict between Jessica and her mother often triggers Jessica’s low mood and self harm, Jessica’s mother often (in anger) tells Jessica she is ‘just like her father’, Jessica sees this as a negative due to the image her mother has portrayed, and therefore feels that the only outlet is to self harm. The lack of supportive mechanisms within the family home leads Jessica into feeling hopeless and misunderstood. Golden, Samuels & Southall (2003) outline that children who have suffered ‘emotional neglect’ are more likely to suffer with low self esteem and mental health problems. Jessica has a depressed thinking style, and doesn’t feel able to think of the positives and happy things happening in her life, such as exam success. Jessica also regularly accesses social media sites that encourage young people to self harm, Jessica often locks herself in her bedroom after an argument with her mother and goes on these sites. Clarke-Pearson and O’Keeffe (2012) discuss that social media sites are not safe for children to be accessing, and parents must be aware of the nature of these sites. This is a cultural aspect of a white British family living in a middle class area, many children have access to the internet and parents are unaware of the social media sites that they are accessing. Dogra & Leighton (2009) say that nurses often limit the quality of care that young people receive due the assumption that cultural issues are only to be considered in minority and non-white families, however it is clear that children and young people from White British families are affected by cultural issues today. Leichtman & Wang (2000) say that white Caucasian societies emphasise self-expression and personal uniqueness, and during the formulation it became clear that Jessica had been allowed to express herself during her childhood, and often firm boundaries were not put in place, causing further conflict during Jessica’s adolescence when her mother attempted to put boundaries in place. The Department for Education and Skills (2008) ‘Every Parent Matters’ document outlines that parents and the home environment they provide shapes their children’s well-being, achievements and prospects. It was outlined that without intervention Jessica would continue to self harm, and given her recent admission with a potentially fatal overdose this was considered a worrying factor. It was also outlined that Jessica felt unsafe in her mothers care, and further barriers towards their relationship were forming.

Protective factors were the final discussion. Jessica’s sister is a big positive in Jessica’s life, and Jessica is very aware of this. Jessica enjoys going for days out when her sister is off work, and opportunities for further strengthening of this relationship with enable Jessica to have a more positive outlook. Jessica’s awareness of her own intellectual ability have assisted her in the past in controlling her urges to self harm, her own belief in her abilities can help her to understand she can make positive changes and contributions in life.

Intervention

After the formulation meeting, a plan was made for Jessica. The main concern was Jessica’s safety, and due to her increasing self harming behaviours and overdose, it was decided that Jessica was to remain an inpatient on the children’s ward awaiting a Tier 4 CAMHS bed. The NICE guidelines for self harm (2004) state that "all children or young people who have self-harmed should normally be admitted overnight to a paediatric ward and assessed fully the following day. Alternative placements may be required, depending upon the age of the child, circumstances of the child and their family, the time of presentation to services, child protection issues and the physical and mental health of the child; this might include a child or adolescent psychiatric inpatient unit where necessary." In Jessica’s case, a CAF was initiated as discussed in the assessment process, and therefore safeguarding was considered. The Department for Education and Skills (2003) Every Child Matters document says that all agencies should work together to identify a child’s needs and safeguard children who are likely to be harmed. Jessica was in agreement with the CAF and with staying in hospital, as was her mother. It is important here to consider the rights of Jessica, as this has an impact on the interventions agreed. According to the United Nations Convention of the Rights of the Child (1989) every child has the right to be healthy, and the right to be heard. In choosing the intervention of keeping Jessica in hospital, the multidisciplinary team involved were acting in Jessica’s best interests, both in keeping her healthy, and in keeping her in an environment in which she felt safe. Foster (2009) contradicts the admission of patients with mental health problems to paediatric wards, saying that nurses do not feel adequately trained to care for these young people, therefore resulting in the young people being ‘ignored’ and considered to be a hindrance. Gutierrez and Osman (2008) found that adolescents who self harm expect to be judged harshly and told off for wasting time. They also feel ashamed, have difficulty talking about their self-harm and are afraid of the response they might get. Pembroke (1996) argues that self harm alone is not a classified illness, and this may be the view that nursing staff have, therefore causing difficulty in therapeutic relationships. Choosing to admit Jessica to the ward was considered carefully, and the CAMHS team worked closely with the ward staff to ensure Jessica was cared for appropriately.

Unfortunately due to a lack of service provision, Jessica did not receive any therapeutic interventions whilst an inpatient on the ward. Leachy, Holland & McGinn (2012) discuss the importance of early recognition and treatment of depression, and say that not treating as early as possible with therapeutic interventions can cause further harm to the patients mental state. Meltzer (2000) outlines that children and adolescents admitted to paediatric inpatient wards awaiting further treatment are at further risk of psychological and emotional challenges, and again links the problems encountered with the lack of knowledge and training of paediatric nurses, and lack of services available from CAMHS. On discussion with Jessica’s CAMHS worker, she advised that if there was availability they would have implemented family therapy to aid Jessica and her mother’s recovery. Stratton (2005) identified that family interventions in CAMHS could be effective in depression, and NICE (2004) recommend family therapy is used in moderate depression as a first treatment line. It may have been difficult to reassure Jessica and her mother that family therapy was appropriate in aiding Jessica’s well being, and both parties were of the view that they ‘made each other worse’ in argumentative situations. Dogra et al (2009) define a family member as anyone who is responsible for the young persons emotional and development needs, and therefore Jessica’s mother, sister and grandmother may have been involved in these sessions. It is important to outline that one must take into consideration Jessica’s wishes when discussing therapeutic interventions, Jessica did want her family involved in her care despite the disagreements, however Dogra & Leighton (2009) say that one must consider the desire for privacy, concerns about stigma and fear of significant harm to themselves or their family. Rutter (1999) outlines that family wide experiences impact on the implementation of family therapy in different ways, and that each individual has a different level of resilience when it comes to therapy.

Discharge

Jessica is currently still an inpatient on the children’s ward, awaiting a Tier 4 bed. Despite efforts to find service provision to commence some therapeutic interventions, this has not been possible and therefore Jessica remains on the paediatric ward with three times weekly CAMHS practitioner visits until a bed becomes available. Cooper, Hooper & Thompson (2005) outline the importance of considering institutionalization in young people admitted to hospital for long periods of time, and say that the nursing staff take care of all of their needs, which in turn hinders the development of independence. Jessica’s mother continues to telephone the ward for daily updates, however seldom visits. NICE (2005) outline that commissioners should ensure that a young person with depression requiring tier 4 services should be admitted to an inpatient unit within an appropriate timescale, however O’Herlihy et al (2001) found that there is an inability of services responding in a timely way to requests for urgent admission to tier 4 services, and the consequence is inappropriate usage of paediatric wards. Jessica has been an inpatient on the ward for 6 weeks to date. Davis, Spurr & Cox (1997) say that when a young person is referred for a tier 4 bed, it is vital to ensure that interagency support services are put into place for the young person and family, however unfortunately in this case there has been a gap within the multidisciplinary team. Social services telephone the ward staff for updates twice weekly, and make regular contact with her mother to attempt to help her to feel supported and visit the ward. CAMHS visit Jessica for ‘a chat’ three times a week. Jessica’s sister visits however works full time and often appears in a rush. It is left solely up to the medical staff on the ward to support Jessica in her mental health, and this is not always possible on a sick children’s ward.

Reflection

On looking at Jessica’s case study, and the way in which she was managed, my opinion is that her mental health needs were not appropriately met. During the assessment process it was clear that Jessica was at risk due to harming herself, and all though Jessica was kept in hospital due to her feeling unsafe due to family dynamics, the paediatric ward was also not the safest place for Jessica to reside. Spender (2007) discusses the treatment of young people with self harming behaviours on paediatric wards, and outlines that there is an ‘attention seeking’ hypothesis and that the approach to treatment is to give as little attention as possible, however Arnold (1995) suggests that being admitted to a ward should allow the young person and family time to reflect upon the difficulties that they are facing, and the young person should see it as a safe place. Jessica continued to self harm by cutting whilst an inpatient and due to the ward being a very busy environment, it was difficult for staff to provide the one to one care that Jessica needed. The positive outcome of the assessment process during admission to hospital was that a CAF was initiated, allowing the multidisciplinary team to have a standardised assessment of Jessica and her families needs. Gilligan & Manby (2007) discuss the aims of the CAF process, saying that initiating a CAF should promote early intervention regarding risk, promote sharing of information, and allow professionals to work with the child and family. This was effective in Jessica’s care, as all though visits from the multi agency team were only twice weekly, there were people working to reduce Jessica’s risks and find her a safe place to reside whilst she recovered. The CAF process also allowed multi professional meetings to take place, the benefits of this being tailor-made support for Jessica in the most efficient way. (Department for Education, 2012).

There was an obvious lack of therapeutic interventions in Jessica’s case, and this was mainly down to a lack of service provision. The Royal College of Psychiatrists (2005) found that CAMHS teams struggle to meet waiting-time targets and to provide the full range of assessments and treatments demanded of them, this is backed up by Children and Young People in Mind (2008) outlining that multi agency working is key in providing effective care for CAMHS patients however time constraints and financial constraints are causing a barrier. Jessica’s mother has become resentful of the service provision as time has gone on, it is obvious that Jessica is not getting the appropriate interventions whilst resident on a paediatric ward, and the barrier between the mother/daughter relationship is becoming more difficult. Jessica’s sister has been a positive throughout the admission, and Jessica is aware of this. If family therapy could have been put in place I feel the relationship breakdown between the family could have been lessened and this could have aided Jessica’s recovery.

It is clear from writing this case study that there is a lack of service for young people who are suffering with mental health problems and are therefore admitted to paediatric wards. Foster (2009) discusses the need for better CAMHS services, and outlines that the lack of service can potentially cause a barrier between paediatric staff and CAMHS teams. This is felt in my practice, and Jessica and her family have unfortunately been subject to this lack of service provision.

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