Re-commissioning of Mental
Health and Challenging Behaviour
Services for CYP with Learning
Disabilities/Autistic Spectrum
Disorder
Catherine Swaile
Senior Commissioning Manager
Introduction
Hertfordshire Community Trust in collaboration with Barnet Enfield
and Haringey Mental Health NHS Trust and ADD-Vance won the
recent bid for mental health and challenging behaviour services for
children and young people with Autistic Spectrum Disorder/Learning
Disabilities.
•
Hertfordshire Community Trust will be the main provider and will
recruit the majority of staff with support from BEH to provide
psychiatry and medical supervision.
•
BEH currently operate a similar service called SCAN and HCT
currently provide the Challenging Behaviour Psychology Service.
•
ADD-Vance will be co-facilitating workshops for parents on a range
of related topics.
PALMS MODEL
• Positive behaviour
• Autism
• Learning disability
• Mental Health
• Service
Multi-disciplinary Team (MDT)
The MDT will include:
• A Consultant Psychiatrist
• Clinical Psychologists
• A Speech and Language Therapist
• Occupational Therapist
• Media Therapist
• Learning Disability Nursing
• Specialist Positive Behaviour Practitioners
• Systemic Therapist
• Positive Behaviour Support Workers
Pathway
Referrals, triaged within one week on a weekly rotation basis by clinical
staff. PALMS will employ highly skilled clinicians for triage to enable
accurate identification of need, assessment of risk, ensure timely access
and an effective use of resources.
The pathway shows a number of outcomes from triage with
the CYP being guided to:
• Second opinion (1),
• Standard pathway (2)
• Priority pathway (3)
PALMS approach can be stepped up or stepped down according to need.
CYP not meeting the remit of PALMS will be signposted to other services
as appropriate.
1. Second Opinion
The multi-disciplinary team, particularly the Consultant
Psychiatrist, Clinical Psychologists and Speech and Language
Therapist will offer expert advice and close working with regards to
second opinions and complex presentations in relation to ASD
diagnosis to colleagues including Community Paediatricians.
PALMS will utilise and develop the expertise of clinicians in
differentiating between:
what is a mental health concern
what is challenging behaviour
what is understood in the context of ASD/LD
2. Standard Pathway of Support
• Initial Assessment Appointment (IAA)
The aims of the IAA will be to identify:
• Strengths
• Needs
• Primary and secondary goals
• The most appropriate support
• A clear collaborative plan
Standard Pathway of Support
• An IAA will be offered within 28 days, the service hub
will hold bookable slots for IAAs with a choice of days,
times and locations.
• An IAA factsheet and social story will be provided
alongside photographs of the clinician(s) and location.
• IAAs will be undertaken by PALMS’ clinicians at Band 5
and above who will be trained to ensure consistency of
approach.
• Criteria will also be developed to support staff to make
the appropriate decision about which model of
intervention is appropriate for families.
Standard Pathway of Support
• Joint assessments with other services such as the local
CAMHS clinic and Community Paediatricians would be
considered at this stage.
• A flexible approach will be taken determining the best
way to engage the CYP.
• This could include an appointment at a clinic location,
through social stories, visuals, joining them in a
preferred activity and at a preferred location.
• The CYP and their families will also chose who they
wish to bring to the IAA including other professionals
currently working with the CYP.
Treatment
• All interventions will be tailored to need, with the
multi-disciplinary team able to draw on a breadth of
therapeutic models including: behavioural, systemic
and narrative and a wealth of methodology including
visuals, modelling and video feedback.
• A range of locations will be available for
interventions, matching the appropriateness of
timing and the family’s resilience, alongside what can
feasibly and safely offered.
• Joint working within PALMS and with relevant
partners will be key to ensuring a holistic approach
that does not overwhelm the CYP/family.
Access to Tier 4
At any stage of treatment, access to out of county Tier 4
Mental Health Services may be identified by the PALMS
clinician working with the family or requested by the family
and/or other agencies.
To ascertain the need for this referral there will be:
• A comprehensive assessment
• Liaison with all relevant professionals
• A Review by the multi-disciplinary team in
consultation with commissioners
Treatment: Workshops
All families on the standard pathway will attend a one off workshop
unless the Initial Assessment Appointment identifies that this would
not be appropriate, some of these will be co-facilitated with ADDVance.
Example workshops:
• Understanding ASD/LD,
• Explaining ASD/LD to all family members
• Supporting parents to put themselves in their child’s shoes
and walk alongside their child and alongside ASD/LD
• The role of communication, understanding and expression.
Groups
• A range of groups will be offered to CYP, siblings and
parent/carers.
• It is anticipated that for a number of presenting concerns such as
toileting and sleeping, a group approach will be appropriate.
• However, individualised and tailored approaches will always be
considered, such as a Sleep Scotland approach.
• All groups will be facilitated by one lead professional with other
professionals within and external to PALMS and/or parent/carers
co-facilitating specific sessions. For example, OT with regards to a
sensory diet and/or a Communications Disorder Team professional
with regards to home and school consistency.
Groups
Possible groups to include:
•Understanding of and adjustment to diagnosis
•Toileting, feeding and sleeping
•Understanding and managing challenging behaviour
•Understanding and managing mental health
•Sexual education
•Developing resilience
•Managing your emotions
Parent/Carer as Therapist (PAT)
• Experience and the evidence base for both challenging behaviour
and mental health, demonstrate the need to work within the world of
the Child/Young Person to effect change. This approach means a
lot of time will be spent working with the parent/carer rather than the
Child/Young Person.
• PAT could be the intervention of choice when:
• There is difficulty in applying group work
• Individual support to view how different strategies fit in their
family life
• Adjustment to diagnosis
• Strategies have not been successful
• Reactive strategies currently used
• Difficult experience/difficulty engaging with services in the past
Individual Interventions with CYP
• The role of individual interventions is recognised for those CYP with
combined challenging behaviour and mental health issues and will
be offered within PALMS by a range of clinicians.
• Individual intervention might be entertained when:
• Need for the child’s voice to be heard and their world to be
explored
• Recognised as an appropriate intervention for the
assessed concern(s) such as OCD, low mood
• Supporting CYP to find alternative strategies
• Understanding and adjustment to their diagnosis
Individual Interventions with CYP
Individual intervention approaches offered will include:
•Positive Behaviour support
•Intensive interaction
•Externalising, for example, Sneaky Poo
•Play therapy
•CBT
•AIM principles (for sexualised behaviours)
•Medication will be carefully considered in consultation with the
Child/Young Person and family, The multi-disciplinary team, the wider
network including the GP and Community Paediatrician. Clinically the
use of medication will be led by the Consultant Psychiatrist and
monitored/audited with the Service Lead.
3. Priority Pathway of Support
A priority pathway is appropriate when:
•Suicidal statements with intent.
•Family at immediate risk of break down
•Child at immediate risk of care placement
•Child or others in home at immediate risk of harm or exclusion
•High frequency, duration and intensity of behaviours and their impact
will also be considered
This will involve an assessment of a CYP’s emotional wellbeing to
identify any mental health concerns, level of risk and appropriate
support required both immediate and longer term. As a result of this
the CYP and their family may move in to the standard pathway of
support or on to the PALMS Crisis Team.
PALMS Crisis Team
It is anticipated that a small number of families will receive an
intensive and responsive bespoke package of PALMS’ support which
could include:
• Extended assessment, which may include a functional behavioural
assessment and/or a detailed assessment of mental
health/emotional well-being.
• Assessment of communication functioning
• Assessment of sensory needs
• Preference assessments
• Community observations including in the home, school, respite and
leisure activities before, during and after interventions
PALMS Crisis Team
Also included:
•Behavioural recordings
•Intense psycho-education for parents/carers/siblings
•Individual Therapy
•Frequent PAT sessions
•In home support involving adaptation of approach and modelling
•Partnership working with all relevant agencies including Integrated
Services for Learning, Social Care and KCLP
Consultation and training
• Links with all relevant agencies through the PALMS
Local Implementation Group and establishment of
regular meetings with key partners including Mental
Health Leads and ASD/LD Leads in Community
Paediatrics, GPs, Education, A&E and the police will
enable opportunities for sharing, learning, building
partnerships, clarifying pathways and addressing
barriers.
• PALMS will provide training, consultation and support to
partner agencies including universal health services,
education, social care and the police.
Outcome Monitoring
• Measurement and review of clinical outcomes will be an
integral part of practice, in turn leading to improved
service quality and effectiveness.
• Core pre- and post-measures as well as individually
chosen outcome measures will monitor the CYP’s
journey throughout PALMS, identify change, progress
and continuing needs and also inform the wider system
regarding the service’s effectiveness.
• This will be reviewed in the Integrated Local
Implementation Group and will also be shared with
commissioners.
Signposting, Transition and
Discharge
• One of the aims of PALMS will be to ensure that no CYP should
‘slip through the net’ and this principle will be equally considered at
the end of their journey with PALMS.
• When transition is required a clear action plan will be created so
that people understand their roles and responsibilities.
• Discharge will be agreed collaboratively with a clear tailored plan,
summary of input, and when appropriate a relapse prevention plan.
• Families will be able to access PALMS follow up consultation over
the phone for 6 months after discharge. The website will have a
specific ‘after discharge’ section and a blog will be considered in the
development of PALMS.
Access
• The service will be located using core
hubs, semi-hubs and spokes in
accessible community locations.
Additionally sessions will be available
within the home and school setting.
• This will be agreed on an individual
basis, assuring the most
therapeutically relevant location.
• It is anticipated that a significant
proportion of input will be provided in
the home. Particularly for those
requiring an extended assessment
from the PALMS crisis team and
where it is identified that in-home
modelling and support is required.
• PALMS will provide assessments and
interventions in the evenings and
weekends as it can be difficult for
parents/carers or both parents/carers
to attend sessions if they are in
employment and/or due to the many
other appointments they have to
attend.
• PALMS hopes that by offering evening
and weekend sessions parents will be
able to attend out of their working
hours and when they have fewer
commitments.