Version 1
Version 2
Version 3
Version 4
Version 5 -Final Version
Version 6 -Revised Version
Version 7-Cornwall amended version
Version 8-Comments &
Revisions
Version 9- Updated to incorporate in revised service operational policy
Version 10 -New Version to differentiated between tier 2 and tier 3 CAMHS as requested by Commissioners and to reflect update service specification
Version 11
Dr Sheheryar Jovindah
Cate Simmons
Colin Terry and Cate Simmons
Dr Tim Hawkins and Cate Simmons
Agreed in consultation with the Mental
Health and Psychological Well-being
Partnership and Universal Stakeholders.
Helen Ferguson. Updated in line with service model changes in consultation with
CAMHS Patient Quality and Safety
Committee
Dr Mark Woodgate, Dr Matthew Gilbert,
Sheenah Jones, Linda Bennetts revision for the Cornwall CAMHS eligibility criteria.
Mark Woodgate, Sheenah Jones &
Matthew Gilbert
Ken Sampson, Angela Taylor, Sheenah
Jones and CAMHS Forum
Annick Pearce , Ken Sampson & CAMHS
Forum, then Jenny Cove/Carol Green
January 2007
June 2007
September 2007
November 2007
December 2007
February 2010
30 July 2010
23 August 2010
February 2012
December 2012
Spring 2013
Summer/Autumn 2013 Ken Sampson & Carol Green CAMHS input from Jo Lewis, Community
Paediatrician.
August 2013

These criteria have been developed with the following principles:
1. Partnership Services for Children, Young People & Families (CAMHS) core purpose is to address the Psychiatric and Mental Health needs of children and young people (under 18) in Cornwall, including the Isles of Scilly. Behavioural disturbance may or may not be driven by mental health disorder.
2. Promote and support emotional and psychological well being in young people. Support universal services and comprehensive CAMHS practitioners in developing skills and knowledge of how to identify and meet the needs of children and young people who have difficulties with Emotional and
Psychological Well-Being.
3. Support and facilitate the provision of comprehensive CAMHS care packages and targeted interventions where the primary need is not a mental health difficulty. This may be delivered through consultation that may not lead to a Specialist CAMHS intervention.
Working formulation
Attention Deficit
Hyperactivity
Disorder
(ADD / ADHD)
Brief Description

Pervasive hyperactivity, impulsivity and inattention, which is developmental inappropriate and clinically significant, which has a major impact on functioning.
School Refusal

Difficulties in attending school and prolonged absences.
Initial intervention from other Tier 1 / 2 services prior to CAMHS involvement

If child is 4 or below refer to Community
Paediatrician for assessment.

In mild cases with educational impairment suggest behaviour support service or
Education Psychology.

Also parents should initially be advised to attend
‘Incredible Years’, ‘Take Three’ or
‘Time Out from ADHD’ parenting groups

Initial intervention via Pastoral Support,
Education Welfare Officer or Educational
Psychology
Primary Mental Health
Service – Tier 2

Consultation by Tier 2 to be provided following initial intervention by tier
1 where appropriate.

If there are severe and persistent symptoms Tier
2 consultation or
Specialist Child & Adolescent
Mental Health Service –Tier 3
For children between the ages of 5-17 (inclusive)

Tier 3 will provide an assessment & intervention if there are severe symptoms with significant psycho-social disability.

Tier 3 to provide assessment
& intervention where there are co-morbid mental health problems
[ Assessment & intervention is compliant with our ADHD care guidelines which are guided by
‘ADHD’. NICE. CG 72. Sep-08]

Assessment & Intervention of complex, severe and persistent symptoms.
September 2013


Emotional upset which may include anxiety, angry outbursts, or low mood.

Initiate a CAF assessment, which guides intervention.
Simple or
Specific
Phobias
Anxiety based
Disorders
Generalised anxiety, social anxiety, panic attacks/disorder
Depression

A fear that must result in substantial distress or in avoidance that impacts significantly on the young person’s everyday life.

Marked and persistent worries, anxieties are not consistently focused on any one object or  situation. Typical worries focus on the future, on past behaviour and on personal competence and appearance.
Inability to relax, selfconsciousness, need for frequent reassurance, somatic complaints.

Symptoms have caused clinically significant distress or social impairment

Depressed mood, loss of interest and enjoyment, reduced energy, poor attention and concentration, low self-esteem and selfconfidence, ideas of guilt and unworthiness,

For 16+ suggest choice of IAPT provider




For 16+ suggest choice of IAPT provider
Universal tier 1 professionals to support guided self help.
For 16+ suggest choice of IAPT provider
Universal tier 1 professionals to support guided self-help eg from KOOTH.com

Mild symptoms - watchful waiting by universal Tier
1 professionals.

Consultation at Tier 2.

Tier 2 direct CBT based intervention.

A consultation should be sought from Tier 2.

Tier 2 direct CBT foundation level based intervention.

Tier 2 will provide consultation, advice and training where required.

Moderate with low risk provided consultation or assessment and treatment in Tier 2.

If co-morbid disorders identified.
[Assessment & intervention is aware of ‘Social & Emotional
Wellbeing in Primary Education’.
NICE. PH12. Mar-08]

Severe and persistent symptoms identified through consultation or following direct intervention from Tier 2 will be assessed & treated by Tier 3.

If significant risk identified straight to Tier 3.

Severe and persistent symptoms identified through consultation or following direct intervention from Tier 2 will be assessed & treated by Tier 3 at intermediate / advanced level.

If symptoms or risk increase or multi-disciplinary approach requirement identified straight to Tier 3.

Tier 3 to provide assessment
& intervention, including medication, family therapy or
CBT at intermediate
September 2013

Bi-polar
Affective
Disorder
Deliberate Selfharm pessimistic view of the future, ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite.

Young children may present with regression in milestones, challenging behaviour or medically unexplained physical symptoms.

Symptoms of mania or cheerfulness, high energy levels, tendency to tell fantastic and sometimes grandiose stories

Self-harm in the form of taking an overdose, selfmutilation or using any other method. hypomania. Irritability more common than euphoria. Social disinhibition, excessive


GP assessment to exclude medical causes.
Universal/Targeted Services provide support for Children / Young people who self-harm short term with limited risk or no co-morbid difficulty.

Tier 2 consultation.

Tier 2 to provide supervision, training, consultation, assessment and direct work.
/advanced level.

Complex presentations may receive Child & Adolescent
Psychotherapy.

Medication may be initiated by a Consultant Child
Psychiatrist, in consultation with multi-disciplinary team &
GP.
[ Assessment & intervention is compliant with our Childhood
Depression care guidelines which are guided by ‘The treatment of depression in children and young people’. NICE. CG 28. Sep-05]

If significant indicators of diagnosis, Tier 3 to provide assessment & intervention as appropriate.
[ Assessment & intervention is guided by ‘Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care’.
NICE. CG 38. Jul-06]

Where significant risk of death, permanent physical damage or uncertainty straight to Tier 3.

Any high risk to life self-harm should be referred to
Emergency Department. The jointly agreed protocol for the management of self-harm will be followed.

Deliberate self-harm that requires within 24 hours
September 2013

Psychosis
Reactions to trauma and
Post Traumatic
Stress Disorder


Hallucinations, delusions, thought disorder, negative symptoms with associated social dysfunction
Traumatic event is persistently reexperienced, intrusive images, traumatic dreams, and repetitive re-enactment in play, distressed at reminders.
Continued avoidance of stimuli associated with trauma or numbing of responsiveness, which includes avoidance of

Urgently refer all children and young people with a first presentation of sustained psychotic symptoms (lasting 4 weeks or more) to a specialist mental health service,

Watch and wait for four weeks by universal services.

If related to domestic violence, parental drug or alcohol misuse, or sexual abuse refer to appropriate Tier 1 / Tier 2 targeted services. i.e
CLEAR and JIGSAW. response will be seen by Tier
3.

Self-harm that is severe, or high risk that requires a 5-day response will be seen by Tier
3.

Tier 3 assessment & treatment as required.
[ Assessment is compliant with our
Self Harm Practice Guidance which is guided by ‘Self-harm: short-term treatment and management’. NICE. CG 16. Jul-
04]

Advice and consultation.

If suspicion of psychosis confirmed straight to Tier 3.

Tier 3 will assess and treat in all cases and liaise with Early
Intervention Team as clinically appropriate for over 14s
[ Psychosis and schizophrenia in children and young people:

Consultation and supervision as appropriate. recognition and management.
NICE. CG 155. Jan-13]

PTSD suspicion confirmed straight to Tier 3.

Tier 3 to provide assessment and intervention as appropriate in moderate to severe cases.
September 2013

thoughts, feelings, locations, situations.
Feeling of being alone or detached, reduced interests and restricted emotional range.

Increased arousal, sleep disturbance, irritability, poor concentration, memory problems, hyper vigilance, and alertness to any perceived danger and exaggerated startled response.
Obsessive
Compulsive
Disorder
(including Body
Dysmorphic
Disorder)

Obsessions are unwanted repetitive intrusive thoughts.
Most common obsessions focus on contamination, disasters and symmetry.
Compulsions are unnecessary repetitive behaviours or mental activities such as counting. Common compulsions may involve rituals, washing or cleaning, checking or repetitive behaviours.

For 16+ suggest to choice of IAPT provider

Universal services to support guided selfhelp

Tier-2 provides consultation to support the work of universal or targeted service.

Tier 2 will respond to
OCD with mild functional impairment with assessment and short focused intervention at foundation level.
[Assessment & Treatment is guided by ‘Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care’
NICE. CG 26. Mar-05]

Moderate to severe functional impairment – Tier 3 to provide assessment and intervention at intermediate / advanced level.

Medication as appropriate.
[Assessment & Treatment is guided by Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dimorphic disorder’. NICE. CG 31. Nov-05]
September 2013

Tic Disorders inclusive of
Tourette’s
Syndrome

Involves chronic motor or vocal tics (or combination of the two).

If associated with other Health concerns GP to provide initial assessment and investigation.

Mild cases and simple Tic disorders of short duration which are not having a significant impact on the child or young person, take a watch and wait approach.

Consultation to be provided.

Moderate/severe Tier 3 to provide assessment and intervention, including medication as appropriate.
Eating
Difficulties and
Disorders
Developmental or Emotional based eating
Difficulties
Anorexia
Nervosa (AN)
Bulimia
Nervosa
(BN)
Eating Disorder
Not Otherwise
Specified
(EDNOS)

Food Refusal,
Restricted Eating or other developmental concerns

Anorexia nervosa is characterised by deliberate weight loss, induced and/or sustained by the patient.
Body weight is maintained at least 15% below the expected
(either lost or never achieved) or a trend of rapid weight loss with intent to continue. The weight loss is selfinduced by avoidance of adequate food, selfinduced vomiting, selfinduced purging,

Universal Services – Health Visitor/ school Nurse to make assessment and intervene as appropriate

GP to do a physical health check including height, weight calculation as junior Marsipan guidelines See below
(www.rcpsych@ac.uk/files/pdfversion/CR168.pdf)

Tier 2 to provide consultation, joint working or assessment &
Brief intervention.

If suspicion of Anorexia
Nervosa (BMI 18.5 or under) or Bulimia Nervosa confirmed straight to Tier 3.

Tier 3 to provide assessment and intervention as appropriate, while accessing
Eating Disorder Service via
Clinical Nurse Specialist for
Children & Adolescents with
Eating Disorders or other specialists as appropriate.
September 2013

Mild Emotional and
Behavioural difficulties excessive exercise, use of appetite suppressants and/or diuretics. There is body image distortion and in post pubertal females secondary amenorrhoea.

Bulimia nervosa is characterised by a persistent preoccupation with eating and periods of over eating in which large amounts of food are consumed in short periods of time.
Associated symptoms include - self-induced vomiting, purgative abuse, alternating periods of starvation, and use of drugs such as appetite suppressants.

We do not treat Obesity without co-morbid mental disorder as specified.

Childhood emotional and behavioural difficulties that are causing concern or distress or are impacting on health, development and welfare.

Universal and Targeted Services to offer support and assessment. Eg, School nurse, Family
Information service.

Tier 2 consultation with universal professionals if initial intervention ineffective.
[ Assessment & Treatment is compliant with our Children &
Adolescent Eating Disorder care guidelines which is guided by
‘
Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa an d related eating disorders’.
NICE. CG 09 Jan-04]
September 2013

Moderate –
Severe disturbance of mental health and/or significantly challenging behaviour associated with intellectual impairment, genetic conditions or acquired brain injury

Learning disability is a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence); with a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development.

Challenging behaviour
(including self-injurious behaviour) - culturally abnormal behaviours of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities.

Persistent sexual behaviour that infringes the rights of others.

Assessment and intervention by special/allocated school nurses.

Refer immediately to the Multi-
Agency Referral Unit (MARU).

Consultation to universal and targeted services from
CAMHS/LD
Sexually harmful
Behaviour
(SHB)
Autistic
Spectrum
Disorder (ASD)

Social impairment which includes; qualitative impairments in reciprocal social interaction, inadequate appreciation of socioemotional cues, lack of

If child is 4 or below refer to
Community Paediatrician for assessment.

If the young person is 16 or above refer to Out Look South
West

Tier 2 consultation as appropriate

Tier 3 assessment & treatment as appropriate.

No co-morbid condition refer to
Gweres Kernow service who specialise in SHB

If co-morbid may joint work with specialist clinical psychologists from
Gweres Kernow.

Initial assessment from Tier 3
CAMHS as appropriate.

Specialist assessment from ASD assessment team.
September 2013

September 2013 responses to other peoples emotions, lack of modulation of behaviour according to social context, poor use of social signals and lack of social emotional reciprocity.

Communication impairment which includes; lack of social usage of language skills, impairment in make-belief and social imitative play, lack of reciprocity in conversational interchange, poor flexibility in language expression, lack of creativity and fantasy and thought processes.

Restricted and repetitive activities and interests, which include; resistance to change, insistence on routines and rituals, hand flapping and o ther stereotypy’s, ordering play, attachment to unusual objects, fascination with unusual aspects of the world and consuming preoccupations with restricted subjects.

Children and Young People with ASD only where there is a suspicion of mental disorder
(separate from the features of
ASD)

Working formulation
Oppositional
Defiant
Disorder
& Conduct
Disorder
Enuresis and
Faecal soiling
Brief Description

Often looses temper, argues with adults, defies adult requests, deliberately annoys others, shifts blame to others, touchy, easily annoyed, angry, resentful, spiteful or vindictive.

Enuresis: A disorder characterised by voiding of urine, by day and/or by night, which is abnormal in relation to the individual’s developmental stage and which is not a consequence of a neurological disorder, epileptic attacks or to structural abnormality of the urinary tract. In primary enuresis children have never acquired normal bladder control, whereas a child who acquires bladder control for at least 6 months and then loses it again is said to have secondary enuresis.

Faecal soiling: Repeated voluntary or involuntary passage of faeces, in places not appropriate for that purpose in the child’s own social cultural setting. Soiling
Initial intervention from other
Tier 1 / 2 services prior to
CAMHS involvement

Initial assessment from universal professionals

Take 3 parenting course

Initial physical screen by GP,
Early stage of presentation should be signposted to
Health Visitor or School
Nurse for intervention

Referral to the continence advisors
Primary Mental Health Service
–
Tier 2

In complex cases consultation can be sought from a Tier 2 to determine whether the client meets criteria for co-morbid mental health problem (as above).

In complex cases with a comorbid psychological or family disturbance consultation can be sought from a Tier 2 to determine whether the client meets criteria for co-morbid mental health problem (as above)
Specialist Child & Adolescent
Mental Health Service –Tier 3
[See ‘Conduct disorder in children - parent-training/education programmes: guidance. NICE.
TA102. Jul-06]
September 2013

more than once a month after the age of 4 is generally regarded as an elimination disorder.
Chronic
Fatigue
Syndrome (or
ME)

An onset of unexplained, persistent fatigue unrelated to exertion and not substantially relieved by rest that causes a significant reduction in previous activity levels.

All suspected cases of CSF initially to be referred to
General Paediatrics for medical physical assessment.
Substance
Misuse
Palliative care

Problematic drug and alcohol use.

Emotional or psychological disturbance in response to a life limiting/life threatening condition in a child/young person.

Young people presenting with drug or alcohol intoxication
(refer to substance misuse specialist).

Where the substance misuse is problematic but a mental health or psychological wellbeing difficulty is not identified on referral, refer to YZUP where the C&YP meets their eligibility criteria.

Referred to Paediatric Liaison
Services at Royal Cornwall
Hospital, Derriford or North
Devon District Hospital respectively from the child/young person’s
Paediatrician.
 Consider Penhaligon’s
Friends.
September 2013
[See ‘Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care’. NICE. CG 99.
May-10]

Tier 3 will assess & treatment co-morbid conditions.
[See ‘Chronic Fatigue Syndrome /
Myagic encephalomyelitis. NICE.
CG 53. Aug-07]

If the substance misuse is comorbid with possible mental health diagnostic criteria. Tier
3 to provide assessment and intervention as appropriate.

Emotional

Emotional and behavioural
Distress around disturbance around parental parental separation & disharmony, separation and divorce
– over several years
Divorce
Bereavement

Abnormal or prolonged grief
Somatoform
Disorder that has not responded to targeted interventions (severe and complex presentations).

Physical symptoms that may be related to a psychological contribution or a degree of uncertainty and which have an impact on the child’s normal
Safeguarding
Concerns functioning/development.

Where there is a suspicion of actual or potential safeguarding concern
(around neglect or emotional, physical or sexual abuse)

Universal Services will provide support.


Targeted Services to provide support and intervention.
Eg CRUISE, Penhaligons
Friends.
Paediatric Liaison via Acute
General Paediatrics

Refer immediately to the
Multi-Agency Referral Unit
(MARU).

Tier 2 will provide consultation advice or signpost to appropriate services.

Tier 2 will provide consultation
Targeted services to guide their care of the C&YP, if there are concerns about co-morbid disorders.

Consultation available to universal services from Tier 2 for management in primary care

Response by Tier 3 for assessment and treatment of co-morbid mental health problem, as specified, and/or therapy for complex cases.

Refer immediately to the Multi-
Agency Referral Unit (MARU)

Refer immediately to the Multi-
Agency Referral Unit (MARU)
Attachment
Difficulties

Is characterised by persistent abnormalities in the child’s pattern of social relationships, which are associated with emotional disturbance and reactive to changes in environmental circumstances.
Fearfulness and hypervigilance that do not respond to comforting are characteristic, poor social interaction with peers is

Refer to Child in Care
Psychology Team if CIC if appropriate.

Universal services to work with the family using the
Solihull approach

Consider initiating a CAF

Provide consultation, using the
Solihull approach, to Universal or
Targeted Services from Tier 2 if child is under 5

Will contribute to multi-agency assessment.

Contribute to multi-agency package of support or care, via
Common Assessment
Framework.

Response by Tier 3 following consultation and initial assessment as appropriate if co-morbid mental health difficulties exist.
September 2013

Emerging borderline personality disorder typical. Aggression towards to self and others is very frequent, misery is usual. The disorder occurs as a direct result of severe parental neglect, abuse, or serious mishandling. These children show strong contradictory or ambivalent social responses that may be most evident at times of partings and reunions. In disinhibited attachment disorder children show an unusual degree of diffuseness in selective attachments during the first five years and this is associated with generally clinging behaviour in infancy and/or indiscriminately friendly, attention seeking behaviour in early or middle childhood.

Borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour.

Common Assessment
Framework to be in place.
No specific Attachment Disorder
Intervention pathway currently exists at Tier 2 or Tier 3.

Consultation from Tier 2 as part of multi-agency approach

Will contribute to multi-agency assessment.

Tier 3 assessment and treatment of co-morbid disorders or where there is significant risk to life or others.
No specific Emerging Borderline
Personality Disorder Intervention pathway currently exists at Tier 2 or
Tier 3.
[ Assessment & management is guided by
‘
Borderline personality disorder: treatment and management’ NICE. CG 78 Jan-09]
September 2013


Response for Children in Care (CIC) or those known to Youth Offending Service (YOS) will be different to the above as they have a specially commissioned a fast track service. A child or young person in care may be referred to the local CAMHS Team, but unless they require an urgent or high priority response, the referral should be redirected via the Children in Care Psychology Team.

Whilst all members of clinical staff provide consultation, the Primary Mental Health Workers in the team provide the majority of consultation to
Universal Services where a child or young person is not known to CAMHS. Information, advice and guidance are always available by contacting the
Child & Adolescent Mental Health Service.
September 2013