Adolescents with developmental disabilities who have forensic needs are a very complex population and present unique challenges to those who care for them.
Those who are referred to secure psychiatric services often have a variety of co-morbid disorders, some unrecognised for long periods due to difficulties in carrying out comprehensive assessments (Barlow & Turk 2001) or because of the phenomenon described in amongst the developmentally disabled as 'diagnostic overshadowing' where abnormal behaviours are attributed to the presence of intellectual disability alone (Mason et al 2004).
Psychiatric disorders are up to four times more prevalent in adolescents with intellectual impairment than adolescents without impairment, however only a small minority young people receive any form of specialist service (Emerson 2003, Tonge et al 2001). Diagnoses amongst this population frequently include developmental problems including Autism and Attention Deficit Hyperactivity Disorder, Developmental Dyspraxia/Developmental Coordination Disorder, Tourettes and Tic disorders.
In addition to this a number of environmental insults notably developmental trauma (including neglect and physical and sexual abuse), head injury and substance misuse are extremely common. Some have also gone on to develop a variety of formal mental illness including atypical affective disorders, anxiety disorders (including complex PTSD or Developmental Trauma Disorder) and a range of psychoses, although these are not always easy to recognise.
Specialist Registrar, Forensic CAMHS, West of Scotland
The only health board that has an established Community Adolescent Forensic Mental Health Service in Scotland is NHS Greater Glasgow and Clyde and it only available to patients within the Greater Glasgow area.
The Adolescent Forensic Team consist of:
- Senior Clinical Specialist (Interim Clinical Lead)
- Consultant Child & Adolescent Psychiatrist
- Forensic Nurse Therapist
- Nurse Therapist
- Social Worker
- Assistant Clinical Psychologist
- Trainee Forensic Psychologist
- Consultant Clinical/Forensic Psychologist
- 2x Secretary
80% of referrals come from Social Work. Remaining (20%) of referrals come from inpatient units, other health professionals, the secure estate and others.
Services the team offer include Forensic and Clinical interventions. Forensic Interventions include specialist risk assessments, formulations of risk and evidence based individual, behavioural and prevention programmes to programmed manualised approaches for risk reduction.
Clinical interventions involve comprehensive mental health care and treatment. This includes medication and psychological approaches. The team also offer in-reach services to inpatients and secure settings. They also offer consultancy and advice to all stages of services both health and social work who are working with high risk individuals.
FCAMHS services in Scotland
There are pockets of individuals but none that offer a stage 4 comprehensive multidisciplinary integrated service. There are no secure Inpatient services in Scotland for children and young people. The national commissioning group accepts referrals for admission.
When enquiring about FCAMHS services around the country I got strong response from my trainee colleagues both in Forensic Psychiatry and CAMHS. There is a keen interest in the subject and disappointment in the lack of training opportunities. Some of the quotes are as follows:
- “I am interested in FCAMHS and would like to know more about the scope for training in Scotland”. Aberdeen
- “do think that a bit more FCAMHS training in the generic CAMHS training would be good given the lack of FCAMHS in everywhere but Glasgow”. Glasgow
- “I would be very interested in FCAMHS training. I thought it was one of the greatest MMC failures that this opportunity had been removed”. Glasgow
Adolescent Forensic Psychiatry training in Scotland
The Forensic CAMHS training in available in the West of Scotland training scheme. It’s a five year training programme, the first two years in CAMHS the next two in Forensics, with the final year in Forensic CAMHS. The core CAMHS training involved one year of generic community CAMHS and one year at the regional adolescent inpatient unit.
Other Specialist CAMHS training available is at the national child in- patient unit, paediatric liaison, Scottish Centre for Autism, Learning Disability CAMHS, Looked after and Accommodated Child and Adolescent Mental Health Services, and Addictions.
The core Forensic training involved one year at the regional medium secure unit, 6 months of Community Forensics and 6 months of Learning Disability Forensics.
Other Forensic experience available: High Secure placement at the state hospital, low secure placement, female offenders, prison Psychiatry (Adult males, young offenders, and female offenders) and working with sex offenders.
The final year of training involves 3 months in a FCAMHS in-patient unit in England, 6 months with the community FCAMHS Team in Glasgow and 3 months to cover any special interest including being attached to the mental welfare commission.
I would like to say thanks to the Community Forensic CAMHS team, Dr Aileen Blower and all my SpR/ ST colleagues within Forensic Psychiatry and CAMHS in Scotland for helping me collate this information.
The independent sector provision for adolescent forensic psychiatry continually has to reinvent itself as the NHS provision catches up with the need which is being provided by the independent sector.
Prior to the NCA funded NHS medium secure beds, much of the independent sector provision was for mentally disordered young offenders who had major mental illnesses. There was also provision for adolescent females (and less so males) who were self-harming to such a degree that they required the levels of nursing care that are provided in secure settings.
With the advent of the NCA NHS medium secure beds, the greater need now is for provision of secure beds for mentally disordered offenders with emergent personality disorders (male and female). There are ongoing ethical and moral debates with the adolescent and child and adolescent fraternity about whether these young people should receive care within the context of mental health provision and whether there is evidence based effective care that can be offered.
Those of us working in these services believe that these young people do not receive the appropriate care in the other statutory services and are seeking to offer care that will improve their prognosis. Good research into this care is also essential for the future provision of services for these young people.
Another level of service offered through the adolescent forensic independent sector is for low secure adolescent beds. There are insufficient of these in the NHS and by April 2010 it is a statutory duty through the amendments to the Mental Health Act that age appropriate beds are made available where possible.
At present there is no clear countrywide network of community forensic CAMH services.
We (members of the Special Interest Group) are, however, aware that a number of services across the UK do consider themselves to fulfil the functions of a community forensic mental health service for young people. The SIG would be interested in forming a directory of community forensic CAMH services and we would be happy to coordinate this via this website.
As a first step towards this I am providing a link to an information document for referrers which outlines the organisation and functions fulfilled by our team in Oxford. Key issues relating to the service include:
- Regional specialist commissioning agreements and funding
- A dedicated service for a catchment population of 2.2million
- A strong emphasis on liaison work and support for other services working with young people
- Strong local, regional and national links within CAMHS, YOS and other agencies