Child Inpatient Psychiatry National Service – Review
Case Vignettes
Case 1
9 year old girl presents with 3 month history of dietary restriction, rapid weight loss low
mood, increasing irritability with separated parents. Treated in OP CAMHS but
unresponsive to standard treatment, continuing to lose weight, BMI now 11.4, hypotensive,
bradycardic, limiting fluid intake to 500ml per day, urea starting to rise. Parents complaining
about OP CAMHS team for lack of progress and disagreeing about in whose house she eats
best. Child described as ‘high achiever’ but perfectionistic about her work. Does have one
good friend in school but has been refusing to see her outside school or attend usual
activities such as Brownies. Spends much of her time in her room, covertly exercising.
Mum suspects the scratches that have appeared on her arms are self-inflicted but child
denies this.
Case 1 - Local Service Action/Response:
Ayrshire & Arran - Case 1
An admission to local paediatric ward with intensive support from CAMHS would be
implemented if required in order to support weight restoration and to get fuller assessment of
need.
Following discharge from paediatric ward the young person would be offered intensive
therapeutic input by care coordinator and the Community Eating Disorder team (there may
also be meal time support or Family Behaviour Therapy if warranted) with regular review by
Consultant Psychiatrist involved.
The young person’s physical health would be monitored either by GP or paediatric ward in
local hospital following agreement with CAMHS
There would be regular multi disciplinary meetings regarding care and reviews of care plan
and risk management plan.
Borders - Case 1
Review Intensive Treatment Service input and Management Plan including meal time
support at home. Urgent review of case and progress with CAMHS,
paediatrics/dietician/child/parents. Consider inpatient treatment, possibility of short term
admission to local paediatric ward in first instance, may need CAMHS inpatient admission.
Dumfries & Galloway - Case 1
No CAMHS in patient or day patient facilities locally
May have consider some intense day help from the community CAMHS team if meal
management was possible but highly likely that this is an admission of this 9 year old to local
paediatric ward for physical management that day. Junior Marsipan guidelines probably
amber or red. Full physical assessment, bloods, ECG monitoring etc
Dietician involvement to plan refeeding
Liaison with Caledonia House about admission and transfer if appropriate and physically
safe to do so.
If the young person needed detained to be admitted to our local paediatric ward then we
would provide 24 hr nursing on the paediatric ward and RMO cover...
Fife - Case 1
Fife CAMHS has a tier 4 Intensive Therapy Service that provides a home based intervention
for young people with severe and complex mental health difficulties. Age range is 8-18 yrs
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on paper however we would accept younger if presentation dictated that an intensive
intervention would be beneficial. Young people and children with eating disorders or
disordered eating would be managed initially within our Tier3 Geographical generic CAMHS
teams however if presentation deteriorated referral would be made to the ITS. First line
intervention would be FBT with additional individual work as required. ITS staff provide meal
supports also if required, Dietetic input and medical monitoring within the community.
Forth Valley - Case 1
This is the type of day where staff in Forth Valley would almost certainly seek an opinion
from Caledonia House and likely admission there. We currently do not have the option of
either an Intensive Home treatment team or day hospital service within our area. If prompt
admission was not possible our only alternatives would be to try and support a paediatric
admission. We are unable to provide support to paediatrics at weekends/out of hours and
this would be less than ideal for any thing other than immediate stabilisation of physical
health.
Greater Glasgow & Clyde - Case 1
Locality CAMHS with support from the Home Intensive Treatment Team\Connect-ED eating
disorder service (both of the latter services usually deal with adolescents but are available
for under 12’s); New joint care pathway between these two services now devised. This will
allow for more intensive monitoring of physical observations, fluid and dietary intake,
mealtime management support along side interventions for potential self harm and social
isolation.
The Children’s Hospital to exclude other reasons for difficulties identified;
Child inpatient unit for advice re care and admission if required.
Grampian - Case 1
This child would be referred to and managed in the Lowit Day-Unit. If in-patient medical
treatment was required, then this would also be managed between the Lowit Day-Unit and
the medical wards. As treatment progresses, she would be gradually re-integrated back to
her previous educational setting. Moray CAMHS would liaise locally with paediatric
colleagues for a medical review and whether admission was required to the paediatric ward
with psychiatric input. Use of the Lowit unit in Aberdeen would also be explored, with likely
transfer to paediatrics in Aberdeen.
Highland - Case 1
Case 1 is relatively straight forward requiring immediate medical admission for refeeding and
medical stabilisation.
Lanarkshire - Case 1
Refer to IP at Caledonia House. In the meanwhile continue to ensure that physical state is
monitored closely and if any further deterioration ask local paeds to admit. If steady, work
with parents to feed her, mealtime management with support from CITT our intensive
intervention team. Limit activity – no school and poss bed rest. Mental state exam to ensure
no treatable psychosis etc
Lothian - Case 1
1. Liaise with Intensive Treatment Services
2. Admit to RHSC in Edinburgh with CAMHS support
3. Review condition once in RHSC with CAMHS support / if no improvement consult with
national inpatient unit and make referral
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Tayside - Case 1
Previously this would have been a typical case that would have been referred to the Day
Service. If there are risks associated with the child’s physical health we may have accessed
a bed in a paediatric ward until physical health had improved, this would have been
supported by the Day Service. We may have also had informal conversations with Yorkhill to
make them aware that we may have a potential referral.
Currently the MACX teams in each of the localities have different ages ranges that they
would work with. So in the event that the MACX team accept the referral, they would provide
input to the child at home, in my capacity of a Specialist Nurse in Systemic Family
Psychotherapy I may also be involved to offer Family Therapy input to the family. Again we
may need to admit to a paediatric ward; however I am unsure of the capacity of the MACX
team to support the admission. I would also be advising that it may be beneficial to have a
conversation with Yorkhill.
In the event that MACX team do not accept the referral because of the child’s age, in my
capacity of a Specialist Nurse in Systemic Family Psychotherapy I may also be involved to
offer Family Therapy input to the family working alongside the core worker, this type of
support would be significantly less intensive... Again we may need to admit to a paediatric
ward, however out pts would be unable to support the admission. I would also be advising
that it may be beneficial to have a conversation with Yorkhill.
(No responses from Western Isles, Shetland or Orkney – would use Grampian)
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Case 2
8 year old boy presents with ‘out of control’ behaviour, aggression towards children and
adults, very overactive, not managing in school, frequently being sent home to mother for
aggression and swearing in school environment. Also very picky about what he will eat and
wear. Mother describes him as never leaving her side at home, following her into bathroom,
etc. Now refuses to attend his mainstream school. Described as ‘friendless’ and
intimidating other children. Has been tried on various ADHD medications, stimulants led to
loss of appetite and insomnia (although has always been a poor sleeper). Atomoxetine not
found to be helpful and seems more depressed. Mother had PND after his birth and is
currently receiving antidepressants from GP. Father is currently well but works away from
home, previously had alcohol dependency. Family history of schizophrenia on Dad’s side of
the family. Mother getting to the point where she can no longer cope with him at home.
Refusing to attend OP CAMHS and becomes violent if Mum tries to insist. Spends much of
his day in his bedroom, naked playing his DS.
Case 2 - Local Service Action/Response:
Ayrshire & Arran - Case 2
Home visits would be arranged with care coordinator and another clinician. Multi agency
meeting and plan of care would be put in place. Parenting group referral made.
A referral would be made to the neuro developmental assessment clinic which is a full day
assessment clinic with a range of professionals involved including psychology, speech and
language therapy, occupational therapy, nursing and psychiatry.
Borders - Case 2
Assessment for Autism Spectrum Disorder. Refer to locality integrated children’s service
(SW) for support for mum in parenting including school attendance. Joint work with
CAMHS/ICS/School in assessing situation and jointly managing. Referral to reporter to
Children’s Panel may be needed
Dumfries & Galloway - Case 2
Local CAMHS service
Home visit
_Need to reconsider the diagnosis and explore other neurodevelopmental illness like ASD or
FASD and consider an attachment disorder.
Need for multidisplinary meeting with school, family and SW. Any paediatric involvement.
What behavioural interventions have been tried.
Need for support for Mum
Consideration of respite admission with local authority and assess. Might be a child
protection issue if Mum not able to cope
Fife - Case 2
Again, following input from Generic OP teams, referral would be made to CAMHS ITS
initially for assessment of presentation and subsequent treatment. In this situation we would
also liaise extensively with community resources; our FACTS team and the school. ITS has
sessional Family Therapy input which would be a consideration.
Forth Valley - Case 2
We would try to carry out a neuro-developmental assessment using information we could
gather, and attempt to visit the boy at home. We would aim to liaise and link with local
educational psychology and social work services. If things did not improve, assessment
proved impossible we would refer to Caledonia House for case discussion and potential
admission for diagnostic assessment and treatment.
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Greater Glasgow & Clyde - Case 2
Review input and findings from locality CAMHS (already involved but seeing parent(s) now
rather than child?);
Seek (further?) neurodevelopmental assessment from local CAMHS & ASD team;
Review multi-agency assessments\input re GIRFEC process;
Seek medication review\advice from Child IPU in context of developmental history and
medication reactions;
Seek to engage parents in effective parenting approach given child’s identified needs and
parent situation & seek to resolve access to appropriate education with partner agencies;
Seek someone who can make a relationship with the child on an ongoing basis.
Following this if required, the HIT Team can assist re engagement with the patient at home,
provide support with attendance at school and OP CAMHS appointments. (Home visits can
be done in 2s if risk of aggression is high)
Grampian - Case 2
This child would be referred to and managed in the Lowit Day-Unit. Work would be done with
parents and family directly, whilst also working with the child. Social Work would be brought
in to provide support and to consider the measures necessary to implement mental health
care.
In Moray, referral to the Lowit Unit would be explored, with other variables being taken in to
consideration e.g. other children in the family or location of extended family, to decide
whether the Lowit Unit or Yorkhill would be most appropriate.
Highland - Case 2
Case 2 primarily a behavioural assessment of parenting and school management and
diagnostic evaluation e.g. ASD.
Lanarkshire - Case 2
Refer to Sw.
Assess for attachment disorder, ADHD and ASD, Poss rule out epilepsy.
How to engage? May require Caledonia House IP or Foster care
Consider role of Medication_, family therapy etc
Lothian - Case 2
1. Initial home based engagement of child to develop trust and therapeutic relationship/initial
assessment.
2. Observation in school if manages to attend and/or attendance at child planning meeting to
ascertain presentation in school and ensure educational supports in place (e.g. hospital and
outreach teaching).
3. Find out if any paediatric assessments completed.
4. Screening questionnaires for Autism Spectrum disorder and ADHD and assessment of
social functioning/communication
5. Sensory assessment
6. Assessment of family dynamics and parenting.
7. Multi-disciplinary formulation meeting – further intervention would be based on outcome of
this but most likely:
a. parents attend incredible years parents group
b. child attends Day programme – may need build up to attendance in Incredible Years
Dinosaur School group and intensive behaviour management support.
c. Liaison with school/education/parents re advice/strategies.
d. Medication if necessary.
e. Role for social services.
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Child may be referred for an ADOS if assessments indicate this. If diagnosis of ASD
likely/given then this would guide interventions thereafter.
Tayside - Case 2
Previously this would have been a typical case referred to the Day Service for a
comprehensive multi disciplinary assessment.
Currently - As above if the referral is accepted by MACX they could be involved to try to
engage the boy in an assessment at home, in my role as a Specialist Nurse in systemic
Family Psychotherapy I may be involved to offer systemic input with the systems around the
family. If SW were not involved a referral would be made. The care would be reviewed on an
out pt basis on a regular basis and the option of admission would also be on our radar.
If the MACX team would not accept the case because of the child’s age, in my role as a
Specialist Nurse in systemic Family Psychotherapy I may be involved to offer systemic input
with the systems around the family. I would work alongside the CAMHS out pt team.
However I would not be hopeful as to what impact we would have and it is likely that we
would be seeking admission to Yorkhill.
(No responses from Western Isles, Shetland or Orkney – would use Grampian)
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Case 3
11 year old girl with severe LD and Autism presents with increasing frequency of aggressive
outbursts towards parents and siblings which seem to have no trigger. She has sleep
disturbance in the form of initial, middle and late insomnia which initially responded to
Melatonin but now doesn’t. She has been on various ADHD medications but nothing has
helped, in fact her symptoms appear to worsen. Although she has always been a very active
child, aggression has only just been part of the picture in the last year. She has always
demonstrated a number of sensory soothing behaviours, such as bouncing, spinning as well
as shielding her ears from noise, loud as well as low grade buzzing type noises. She
attends a special needs school where Mum recently discovered she had been mistreated by
a teacher who was subsequently dismissed. This seems to coincide with the onset of the
aggressive behaviour and insomnia. Her brother has a diagnosis of GAD, mother has had
depression, all other family members are well. SW have suggested residential school but
parents are not willing for this and siblings are said to be very distressed at the thought.
Case 3 - Local Service Action/Response:
Ayrshire & Arran - Case 3
This type of case would be managed within Rainbow House Psychological and Community
Paediatric Department with consultation from Consultant Psychiatrist within CAMHS
regarding medication
Borders - Case 3
Assessment at LD clinic. Review management plan including level of support to child and
family. Review diagnosis and consider SSRI to treat depression and anxiety. Review
management plan and appropriate behaviour strategies in school.
Dumfries & Galloway - Case 3
We would ask our local LD consultant child psychologist for some consultation about what to
do about the behaviours.
Consider a short respire admission to children’s unit providing a break and area for
assessing behaviours.
Need to establish if this might be secondary to anxiety and do the behaviours change in
different settings or persistent. Might warrant an anti anxiety medication.
Ask OT for some advice about measures to help with sensory soothing and sleep.
I would expect we would manage this all locally within CAMHS
Fife - Case 3
NHS Fife have recently developed a CAMH LD service which would accept this referral. The
referral however would sit within LD and not CAMHS
Forth Valley - Case 3
The local LD CAMHs team would get involved in assessing this girl at home and in school.
We may involve our community paediatrician if there was any suggestion physical
illness/discomfort was part of the picture. Again consultation with and potentially admission
to Caledonia House would be considered. Experience locally is that it is not uncommon for
children like this to go to residential schools, although perhaps this is more of an issue in
over 12s where we lack any inpt psychiatry resource for children with LD.
Greater Glasgow & Clyde - Case 3
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Review input from locality CAMHS, Community Paediatrics and LDCAMHS and plan a multiagency response with partners to possible trauma;
Sensory integration assessment;
Discuss family support needs. The HITT Team will also take referrals from LD CAMHS. The
care would be directed by the LD team with the HIT Team being able to provide specific
interventions more frequently.
LD-CAMHS would normally carry out a functional analysis of behaviour to advise on specific
strategies in relation to challenging behaviour (which may also take into account high levels
of activity and poor sleep). These strategies would be tried and adapted with the help of LDCAMHS support workers and HITT team. Would normally work with social work and school
to identify and advise agencies who could provide intensive community care. ADHD
medication would also be reviewed in the context of her developmental delay.
Grampian - Case 3
This child would be referred to and assessed in the Lowit Day-Unit. Work would be done
with parents and family directly, whilst also working with the child. Social Work would be
brought in to provide additional support if necessary. Assessment would identify autism
specific needs and identify appropriate support strategies. Appropriate medication would be
initiated and response carefully and closely monitored. Liaison with the local LD service
would also take place to ensure appropriate follow up.
In Moray, consideration would be given as to what may work best given the geographical
location (as in case 2). Access to specialists would be beneficial i.e. sleep specialist’s but
consideration would need to be given to the upset of routine in moving between paediatric
ward and the Lowit unit. This would require careful discussion between Moray CAMHS and
the Lowit Unit.
Under GIRFEC principles, an IAF meeting should be called. Local authority provision would
be explored as to provision via local autism services as a possible alternative/first options.
Highland - Case 3
Case 3 LD Services, family support, day hospital and respite.
Lanarkshire - Case 3
With severe LD she would be seen by specialist CAMHS-LD team. _ Support for Asd is
available through specialist non CAMHS Non NHS service but S&LT and Camhs often work
productively together to develop strategies. Good CAMHS-LD nurses with experience and
expertise. Less available is OT with specialist sensory training. Family work would seem to
be central
Lothian - Case 3
1. Referral to CAMHS LD
2. At referral, or during course of CAMHS LD involvement, a decision would be made
as to the appropriateness of intensive intervention from CAMHS LD Intensive
Treatment Service (ITS) to become involved.
3. CAMHS LD ITS would then link up with all services involved with child through
GIRFEC.
4. Assessment of Childs behaviour would be carried out in all environments, home and
school, and across the 24 hour period
5. OT and SaLT assessments carried out to look at sensory and communication issues
6. Ongoing medication review by Psychiatry
7. Formulation involving the whole MDT leading to a behaviour support plan (BSP)
being drawn up which is reviewed weekly at MDT meeting
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8. If possible all interventions would then be carried out where the child is now i.e. at
home and at school and once again throughout the 24 hour period. These
interventions would be done in conjunction with the family and school staff with the
aim of improving the capacity of the family and education staff in meeting the child’s
needs.
9. Progress would be reviewed in conjunction with all agencies involved through
GIRFEC s well as weekly MDT meetings
10. Assessment would also provide high quality information and strategies that can be
used to assist Local Authority and care providers in future planning of child’s needs
11. Following intervention of CAMHS LD ITS the child would remain open to CAMHS LD
on an out patient basis until the age of 18
Tayside - Case 3
Previously this would have been a typical case referred to the Day Service for a
comprehensive multi disciplinary assessment.
Currently - As above if the referral is accepted by MACX they could be involved to try to
engage the boy in an assessment at home, (? Trauma issues in addition to the information
known) and encouraging the boy to attend for a sensory assessment (if not previously
done)in my role as a Specialist Nurse in systemic Family Psychotherapy I may be involved
to offer systemic input with the systems around the family. The care would be reviewed on
an out pt basis on a regular basis and the option of admission would also be on our radar for
a second opinion/assessment.
If the MACX team would not accept the case because of the child’s age, in my role as a
Specialist Nurse in systemic Family Psychotherapy I may be involved to offer systemic input
with the systems around the family. I would work alongside the CAMHS out pt team.
However I would not be hopeful as to what impact we would have and it is likely that we
would be seeking admission to Yorkhill for a second opinion/assessment.
(No responses from Western Isles, Shetland or Orkney – would use Grampian)
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Case 4
8 year old boy presents with very odd symptoms, seeing faces on inanimate objects,
attributing feelings to inanimate objects and high levels of distress. He hoards everything,
including little pieces of paper as he cannot bear to hurt their feelings by throwing them out.
He has severe separation anxiety and is not able to attend school at all. Previously parents
had to fight with him every day to get him to school as he would use delaying tactics, such
as refusing to wash or dress in school uniform. Once in the car he would insist on going
exactly the same route to school every day. If the bell has rung before he gets into the
playground he has a ‘meltdown’, screaming, kicking and lashing out and has to be peeled off
his Mum by staff. He has insomnia and poor appetite. He tells Mum monsters are watching
him at night and he hears them say horrible things about what a bad boy he is and how they
will take him away and kill him. Dad is described as quite a rigid person who struggles with
the unexpected. He is also a hoarder which drives his wife crazy. He freezes in the face of
conflict due to experiences from own childhood growing up with unpredictable, violent
alcohol-dependant father. Mum is an anxious individual who has run out of patience with her
son, having struggled to manage him from birth. She herself had an emotionally abusive
mother.
Case 4 - Local Service Action/Response:
Ayrshire & Arran - Case 4
Weekly input with psychologist along with an assessment by psychiatry
Multi agency meetings and plan of care
Discussion with psychotherapist regarding suitability
Assessment to rule out intrinsic difficulties
Family work also completed.
Borders - Case 4
Detailed assessment of child and parents functioning via regular input from Intensive
Treatment Service (may need to be daily). Clear management plan involving
parents/school. Referral to ICS (Social Work) for further assessment of home situation and
support with behaviour and school attendance.
Dumfries & Galloway - Case 4
_ Local CAMHS service
1. meet with family and boy
2. thorough neurodevelopmentl history and consider SALT for assessment of language
and communication
3. Consider visual difficulties and ask for paediatric developmental assessment.
4. need to address anxieties possibly a homelink worker to see if there is a different
way to help him leave the house. (Homelink worker is accessed through school)
5. school observation to assess difficulties away from Mum.
6. Possible assessment by play therapist
Possibly after this we would phone Caledonia House and ask for consultation about what to
do next.
Fife - Case 4
Tier 3 initially- Geographical Generic team. Potential referral to childrens anxiety
management group. Play Therapy with OT staff and Family Therapy intervention.
Possible referral to ITS if situation does not improve and worsens.
Forth Valley - Case 4
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Progressing a neuro-developmental assessment would seem the logical first step in
conjunction with working with education/s/w to look at available schooling options that may
be easier. Dependant on progress consultation with Caledonia House might be considered.
Greater Glasgow & Clyde - Case 4
Seek an urgent assessment of the child’s needs and risks from CAMHS and other agencies;
Seek intensive community-based intervention from all agencies to provide support re
behavioural\emotional needs and risks identified with named person and lead professional
co-ordinating;
Seek advice re mental health\medication from Child IPU and day care\admission if required
as part of the integrated care plan.
HITT could provide input into various community settings e.g. social exposure work.
The CAMHS team can request a Psychotherapy Assessment that will give a fuller
description of how this child makes sense of the world, assess the attachment styles in
operation and assess the parental availability for change in the relationship with the child.
Any issues in relation to Emotional Neglect or Abuse will also be identified and suggestions
for intervention provided. This can provide information for the whole system to use and will
also indicate if Child Psychotherapy and parallel parent work should be used in a trial of
intervention.
Grampian - Case 4
This child would be referred to, assessed and managed in the Lowit Day-Unit. Work would
be done with parents and family directly, whilst also working with the child. Separation
problems would be managed directly in the initial stages of the work. Social Work would be
brought in to provide additional support if necessary. Appropriate medication would be
initiated and response carefully and closely monitored. Paediatric assessment would be
sought if an organic aetiology was a concern.
In Moray, a judgement would be made about referral and admission to the Lowit Unit.
Consideration needs to be made about the impact of changes at night and at weekends
given mother and fathers personalities. Account would have to be taken as to mum running
out of patience with her son as to whether the patient would be better served by an
admission to a unit with 24 hour CAMHS staff available.
Highland - Case 4
Case 4 possibly a psychotic child high levels of therapeutic contact ideally day hospital type
or CPN home contact.
Assessment also possible with in-patient team from Yorkhill and/or in-patient assessment
and treatment.
All cases require high levels of community based family work.
The response is dependant on what resources can be made available locally.
This is just my immediate first impression, to respond to the review one would need to
canvas a range of opinion from all disciplines.
Lanarkshire - Case 4
AS always and for above cases too, a staged and stepped response encompassing
principles of assessment and management and to cut a long story short at this point think
about role of meds to create a window to work on other stuff. Would not refer to IP unless
no progress.
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Lothian - Case 4
1. If possible attendance on the day programme with parents initially to build therapeutic
relationship.
2. Assessment of child
3. Assessment of parenting and family dynamics
4. Developmental history and obtain info from paediatrics if available.
5. Liaison with school/education colleagues regarding presentation there and attendance at
child planning meetings.
6. Role of medication to reduce anxiety if child cannot engage/attend programme
7. Psychiatric assessment e.g. OCD, Autism, Anxiety.
8. Sensory assessment
9. Play based assessment
10. Multi-disciplinary formulation – intervention would be based on the outcome of this:
a. Attendance on day programme for intensive support and intervention or if
necessary home based support in partnership with Intensive Treatment Service.
b. Parenting support and intervention e.g. Incredible years parenting
c. Medication
d. Work with education to resume school when appropriate.
e. Role for social services
Tayside - Case 4
Previously this would have been a typical case referred to the Day Service for a
comprehensive multi disciplinary assessment.
Currently - As above if the referral is accepted by MACX they could be involved to try to
engage the boy in an assessment at home, in my role as a Specialist Nurse in systemic
Family Psychotherapy I may be involved to offer systemic input with the systems around the
family. If SW were not involved a referral would be made. The care would be reviewed on an
out pt basis on a regular basis and the option of admission would also be on our radar.
If the MACX team would not accept the case because of the child’s age, in my role as a
Specialist Nurse in Systemic Family Psychotherapy I may be involved to offer systemic input
with the systems around the family. I would work alongside the CAMHS out pt team.
However I would not be hopeful as to what impact we would have and it is likely that we
would be seeking admission to Yorkhill.
(No responses from Western Isles, Shetland or Orkney – would use Grampian)
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