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Professor Peter Fonagy - CYP IAPT National Clinical Lead

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Key Note Speech - CYP IAPT Conference 2014

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Professor Peter Fonagy - CYP IAPT National Clinical Lead

  1. 1. Children and Young People’s Programme Professor Peter Fonagy National Clinical Advisor, CYP IAPT Kathryn Pugh Programme Lead, CYP IAPT Anne O’Herlihy Extended Scope Programme Manager with Faye Henney and Harriet Hamilton
  2. 2. When we started on this journey…
  3. 3. International Perspective on CAMHS • Alarms regarding the ineffectiveness and fragmentation of community-based mental health care for children and families (Bickman 2008; Kazak et al.,2010; Knitzer 1982; Warren et al. 2010; Warren et al. 2010, 2006). • majority of children receiving community-based ‘‘usual care (UC)’’ do not show clinical improvement (Manteuffel et al. 2008; Warren et al. 2010). • large meta-analytic review reported few differences between UC treatment and control groups, with reported effect sizes near zero (Weisz, 2004)
  4. 4. International Perspective on CAMHS: US studies
  5. 5. Summary of International Perspective on CAMHS • No convincing evidence of a strong aggregate clinical impact of usual community-based care for children and families • No consistent findings demonstrating a relationship between provider characteristics (such as, discipline, education, or experience) and differential effectiveness (Beutler et al. 1994, 2004; Wampold 2001). • Findings regarding child characteristics associated with effectiveness are also inconsistent
  6. 6. Current service provision: a snapshot Fragmentation of services for children and young people
  7. 7. Fragmentation of services for young people aged 12-25 Artificial structural divisions in terms of Under 18 Over 18 Age
  8. 8. Fragmentation of services for children & young people Artificial structural divisions in terms of DH DfE LA DWP Health Social services Education Employment Different lines of funding
  9. 9. Fragmentation of services for children & young people Artificial structural divisions in terms of Statutory vs voluntary providers
  10. 10. Fragmentation of services for children & young people Artificial structural divisions in terms of Physical Mental Separation of physical and mental health
  11. 11. Many service designs are not young person friendly Inaccessible in terms of location, time, criteria for access
  12. 12. Many service designs are not young person friendly OCD CLINIC Problem centred not person centred
  13. 13. Many current service designs are not young person friendly OCD CLINIC OCD OCD OCD OCD OCD OCD OCD OCD OCD OCD Stigmatising; little YP involvement in decision making
  14. 14. Many current service designs are not young person friendly OCD CLINIC OCD OCD OCD OCD OCD OCD OCD OCD OCD OCD High dropout rates (40-60%)
  15. 15. On top of these problems… • There is massive unmet need: only 13% of adolescent males with a clinical diagnosis receive treatment • Increased prevalence of at least some mental health problems in young people (e.g., self-harm) • Inconsistent use of evidence-based interventions across services resulting in sub-optimal outcomes • Missed opportunities for potential prevention, caused by delay in accessing services • Lack of understanding about child mental health (mental health literacy) in services outside mental health care (GPs, education) • In most services there is no routine outcome measurement and no requirement to monitor outcomes
  16. 16. Summary 2011 from CAMHS Perspective • Quality • Significant shortages of trained professionals • Current level of CAMHS staff training is ‘poor and getting worse’ with pressures on costs • Access • Difficulties with access (very few services offer a self-referral route) • Poor handling of transition between child and adult services • Inappropriate provision of adult services at T4 to young people • Assurance and Safety • Data that could and should be used for performance improvement, self-critical professional practice and commissioning is rarely collected
  17. 17. Template for appropriate CYP services: key components Improving access Access & engagement
  18. 18. Template for appropriate CYP services: key components Improving access Access & engagement Awareness Increasing MH awareness & decreasing stigmatisation
  19. 19. Template for appropriate CYP services: key components Improving access Access & engagement Awareness Increasing MH awareness & decreasing Participation stigmatisation Enhancing youth, carer and community participation
  20. 20. Template for appropriate CYP services: key components Improving access Access & engagement Awareness Increasing MH awareness & decreasing Participation stigmatisation EBP Delivery of evidence-based practices Enhancing youth, carer and community participation
  21. 21. Template for appropriate CYP services: key components Improving access CYP-IAPT Access & engagement Awareness Increasing MH awareness & decreasing Participation stigmatisation EBP Delivery of evidence-based practices Accountability Improving outcomes accountability Enhancing youth, carer and community participation
  22. 22. The book that has it all!! • ANXIETY DISORDERS • DEPRESSIVE DISORDERS • DISTURBANCE OF CONDUCT IN CHILDREN • DISTURBANCE OF CONDUCT IN ADOLESCENTS • ATTENTION DEFICIT HYPERACTIVITY DISORDER • TOURETTE SYNDROME • PSYCHOTIC DISORDERS • PERVASIVE DEVELOPMENTAL DISORDERS • SELF-INJURIOUS BEHAVIOR • EATING DISORDERS • SUBSTANCE USE DISORDERS • CHILDREN WITH PHYSICAL SYMPTOMS • SPECIFIC DEVELOPMENTAL DISORDERS • CHILD MALTREATMENT • SUMMARY OF FINDINGS AND DISCUSSION We know what the evidence says • 4,060 References
  23. 23. “Evidence Based Implementation of Evidence Based Medicine” “…implementation research needs to come into its own to capitalize what is known and find out what strategies What we work need or do is… not work in implementing changes in clinical practice.” Grol & Grimshaw (1999) Journal on Quality Improvement, 25 (10) p. 503 ‘The does it work in Grimsby test’ Dr Peter Fuggle (2014) Personal communication (with apologies to all who live in Grimsby)
  24. 24. Imbalance of “Design Time” and “Run Time” Run Time Local conditions Adaptation/reinvention Aiming for at-least-equal effects Design Time Develop & specify Test feasibility and safety Test efficacy/ effectiveness Based on Chorpita & Daleiden, 2014
  25. 25. Run-Time Challenges: Why we needed the collaboratives  Managing uncertainties of intervention – context fit o Unplanned adaptation of implementation parameters o Unplanned adaptation of intervention itself  Intervention rejection  Implementation problems  Unequal outcomes o Intervention failure? o Implementation failure? o How would we know? Problem Symptom or Pressure Symptom-Correcting Process We need to do something NOW! Fix – Solution that Works in Short Run Vicious cycle Unintended Consequences that Make the Original Problem Worse Delay CYP IAPT Collaboratives
  26. 26. Evidence-Based Intervention: CYP IAPT THE WHAT: Clinical interventions Treatment model Treatment component (e.g., exposure, fear ladder) Diagnostic assessment Treatment package (e.g., IY or PPP) Classroom management programme THE HOW: Context of interventions Access to service Leadership training Clinical skills training Feedback protocol for outcomes (e.g., service performance “report card”) Partnership in decision making
  27. 27. A few achievements of CYP-IAPT…
  28. 28. A simple evidence based implementation of EBP? • CYP IAPT was conceived as a centrally initiated modification of CAMHS in the direction of EBP • It is achieving remarkable degree of culture change in terms of the acceptability of principles of EBP interpreted broadly through a modest investment in: • service change • training service leads • supervisors and therapists • Learning collaboratives made up of universities and local area partnerships offer mutual support, problem-solving and learning networks.
  29. 29. With permission from Scott Lunn Why ROMs? The Derby experience With thanks to Scott Lunn
  30. 30. Derby – Introducing ROMS • Encourages clinicians to be more focused on package of care through use of ‘Goal Based Outcomes’. • Time spent within the service is dramatically reduced, prevents therapeutic drift and allows the young person to have more control and say about the service which is being provided. • Evidences to commissioners the level of service being provided and how effective it is. With permission from Scott Lunn
  31. 31. Cases ceased to accumulate from June With permission from Scott Lunn INPUT=OUTPUT
  32. 32. Length of stay declines by 12% With permission from Scott Lunn
  33. 33. How good is CYP-IAPT at integrating ROMs?
  34. 34. Mean percentage of CYP IAPT CAMHS staff using ROMs in 2014 in Year I, Year II & Year III partnerships F(1,32)=27.4, p=0.00001 30.0% Source: Partnership annual report to central team. Percent of clinicians using ROMs 70.3% 75.6% Year I 80 60 40 0 Year II 20 Year of Recruitment N=65 Year III
  35. 35. CYP IAPT CAMHS staff using ROMs in 2013 and 2014 in Year I and Year II partnerships F(1,32)=20.7, p=0.00001 Source: Partnership annual report to central team. Percent of clinicians using ROMs 31.1% 2013 80 60 40 0 73.3% 2014 20 Year of Report N=41
  36. 36. Year I and Year II CYP IAPT partnership staff using ROMs in 2013 and 2014 73.9% Source: Partnership annual report to central team. Percent of clinicians using ROMs 64.4% 2013 80 60 40 0 72.4% 2014 20 Year I Partnerships F(1,32)=23.0, p=0.00001 11.1% 2013 2014 Year II Partnerships
  37. 37. Year II CYP IAPT partnership staff using ROMs in 100 90 80 70 60 50 40 30 20 10 0 2013 and 2014 by Collaborative London and South East North West (Salford and Manchester) Oxford and Reading (Reading University) North East South West Percent of Clinicians 2013 2014
  38. 38. Year I CYP IAPT partnership staff using ROMs in 2013 and 2014 by Collaborative 100 90 80 70 60 50 40 30 20 10 0 London and South East North West (Salford and Manchester) Oxford and Reading (Reading University) Percent of Clinicians 2013 2014
  39. 39. Significant increases in the contexts for the use of ROMs: Percentage of Year I & Year II Partnerships using data from ROMs in 2014 for different purposes Percent of Partnerships 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Therapists discussin supervision meetings Discuss outcome data w ith service Leads use to inform service planning Managers discuss service level outcome Review ed and discussed w ith partners Year II Year I What are ROMs for?
  40. 40. Significant differences between collaboratives in the contexts where partnerships report using ROMs in 100% 80% 60% 40% 20% 0% London and South East North East North West Oxford and Reading South West Outcome data in peer supervision Discuss service level outcome to inform planinng Report outcomes data to comissioners 2014 for different purposes Percent of Partnerships
  41. 41. Self-referrals: Mean percentage of Year I and Year II Partnerships accepting self referrals in 2013 and 2014 F(1,35)=1.59, p=0.20 Source: Partnership annual report to central team. Percent of Partnerships 69.5% 75.3% 2013 80 60 40 0 2014 20 Year of Report N=41
  42. 42. Partnerships achieving participation milestones and including parents across years and collaboratives 76.3% 77.9% Source: Partnership annual report to central team. Percent of clinicians using ROMs 2013 80 60 40 0 2014 20 86.2% 83.3% 2013 2014 N=41 Wilk’s L(2,37)=0.98, p=0.63 Achieving milestones Including Parents 100 Participation:
  43. 43. The Problems & The Future
  44. 44. Challenges with implementing CYP IAPT Across year I, II and III CAMHS partnerships • The bigger we get, the further trainees have to travel and the mentoring relationship becomes more challenging • Increase in referrals and reduction in staffing (up to 20% reported)-demand outstripping capacity, impact on staff, • Service re-tender or restructuring and leadership and management restructuring, • Reductions or cuts in Tier 2 and LA provision. • IT and governance issues - time with data input and double entry, local battles with IT departments and electronic patient record providers • Data set for CYP IAPT is not mandated nationally
  45. 45. Improving access to parenting training
  46. 46. “Training/education programmes are the first line of treatments for parents or carers of preschool children.” ““Offer Group-a group based parent PT/education training programmes programme are to the usually parents the first of line children of treatments and young for people parents aged or carers of children and young between 3 and 11 years…” people with ADHD and moderate impairment.”
  47. 47. NICE recommended parenting interventions • Substance misuse among vulnerable young people • Parental skills training • Parental monitoring • At least 3 motivational interviews aimed at parents and carers each year • Autism • Social-communication intervention: play strategies with parent and teachers • Antisocial behaviour and Conduct Disorder • Aged 3-11: Group or individual parenting training programme • Aged 11-17: Multisystemic Therapy, which has a strong parenting component • ADHD • Pre-school children: Parent-training/education • School-age: Group parent training + individual child intervention (CBT, medication) • Depression and Anxiety • Parental involvement is recommended. No specific parent intervention
  48. 48. REFERENCE LIST – INCREDIBLE YEARS Evidence-base for: Axberg, U., Hansson, K., & Broberg, A. G. (2007). Evaluation of the Incredible Years Series - an open study of its effects when first introduced in Sweden. Nord J Psychiatry, 61(2), 143-151. doi: 10.1080/08039480701226120 Baker-Henningham, H., Walker, S., Powell, C., & Gardner, J. M. (2009). A pilot study of the Incredible Years Teacher Training programme and a curriculum unit on social and emotional skills in community pre-schools in Jamaica. Child Care Health Dev, 35(5), 624-631. doi: 10.1111/j.1365-2214.2009.00964.x
  49. 49. REFERENCE LIST – TRIPLE P Evidence-base for: Aghebati, A., Gharraee, B., Hakim Shoshtari, M., & Gohari, M. R. (2014). Triple p-positive parenting program for mothers of ADHD children. Iran J Psychiatry Behav Sci, 8(1), 59-65. Bodenmann, G., Cina, A., Ledermann, T., & Sanders, M. R. (2008). The efficacy of the Triple P-Positive
  50. 50. Evidence-base for: Other parenting programmes, the best of the rest
  51. 51. Evaluation of other parenting programmes Cotton, Daphne; Reynolds, Jenny and Apps, Joanna. Training for parenting support: Qualitative research with employers, managers, providers and practitioners in ten local authorities in England. London: Family and Parenting Institute, 2009. Allen, J. L., Faulkner, N., Legge, K., Chivers, C., Wormald, C., Oliver, B., & Dadds, M. Talking and Listening with your Child (TLC): An Innovative Parent-Child Emotion Conversation-Based Adjunct to Parent Training. Paper in symposium titled: “National Academy for Parenting Research: A Collection of Papers presenting Parent-Focused Resources and Programmes.” British Association for Behavioural and Cognitive Psychotherapy, Manchester, United Kingdom, July, 2010. Salmon, K., Dadds, M.R., Allen, J., & Hawes, D.M. ‘Can emotional language skills be taught during parent training for conduct problem children?’ Child Psychiatry and Human Development 40.4 (2009): 485-498. Van Bergen, P., Salmon, K., Dadds, M. R., & Allen, J. L. ‘Training mothers in emotion-rich reminiscing.’ Journal of Cognition and Development, 10.3 (2009): 162-187. Scott, S, Sylva, K, Doolan, M, Price, J, Jacobs, B, Crook, C and Landau, S. (2010) Randomized controlled trial of parent groups for child antisocial behaviour targeting multiple risk factors: the SPOKES project. Journal of Child Psychology and Psychiatry 51, 48-57 Scott, S, O’Connor T, Futh A, Price J, Matias C & Doolan M. (in press) Impact of a parenting program in a high-risk, multi-ethnic community: The PALS trial Journal of Child Psychology and Psychiatry Professor Stephen Scott, CBE BSc, MB Bchir (Cantab), FRCP, FRCPsych Director of the National Academy for Parenting Research
  52. 52. Body of evidence Less evidence does not necessarily mean less effective Most frequently used Other programmes programmes
  53. 53. How should parenting interventions be judged? Parent training Support from RCTs 14 12 10 8 6 4 2 Clear manual permitting training Instrument to assess fidelity Practice-based evidence 0 Parent training versus control Before After Intervention Control
  54. 54. Other things I would still like to see: Make CYP-IAPY even more young person-centred
  55. 55. Make services (young) person centred Covering transition from adolescence to young adulthood Integrating MH provision with other services Youth-orientated access point Shared decision-making Young person controlled referral process
  56. 56. Empowering children, young people and carers Participate in service design Participate in training of practitioners & managers Understand and modify treatment progress via PROMs
  57. 57. Empowering young people enables them to…. 2. Establish treatment goals 3. Choose the route to health that’s best for them 1. Take control of their care 4. Improve their own health
  58. 58. Reduce access barriers caused by stigma & lack of knowledge  Improve mental health literacy through activities at local and national levels we should be educators  Policy makers, commissioners and providers need a better understanding of  Natural history of mental disorder: likelihood of natural recovery, need for maximal resources at age of peak onset, need for continuity of services at this age  Massive impact of social context on the course of disorder  Resilience as well as risk factors  Too little is known about availability of effective evidence-based services; more needs to be done to promote good experiences of care (Layard & Clark, 2014)
  59. 59. CYP-IAPT and integration initiatives
  60. 60. Close ties with other Tier 1 to Tier 3 programmes Provide a platform for early identification and intervention YP MH services Interface/integrate with early psychosis youth services Establish strong links with school counselling programmes Professor Mick Cooper, DPhil (Psych), CPSY, Dip Counselling, AvDip Psychotherapy,
  61. 61. Prevent social exclusion by integrating services Housing Mental health services Employment Social support
  62. 62. What is required for a better service for CYPs? An integrated, youth-centred, outcomes-oriented system Joined up care and multiagency cooperation • No young person should have to deal with gaps in their care. • We can expand and build on the CAMHS transformation partnership model through effective commissioning and sufficient resourcing. • We need a deepening of relationships with commissioners and the encouragement of joint commissioning with partner agencies in order to improve integrated care pathways and achieve a thorough understanding of evidence-based practice. • We need to create a single information system for young people (e.g., CYP IAPT) – IT problems compromise many service improvement initiatives
  63. 63. CYP-IAPT and physical health
  64. 64. Involve physical healthcare in mental healthcare and vice versa Physical healthcare Mental healthcare
  65. 65. Involve physical healthcare in mental healthcare and vice versa Integrated healthcare Strong co-occurrence between mental and physical health problems Integration makes economic and health care sense and is likely to be destigmatizing
  66. 66. CYP-IAPT and prevention
  67. 67. Involve the educational system in MH education  There is mandated physical health, sex (relationship) and drug abuse Mental Health Education Anti Bullying Workshop education in schools  Few secondary schools include mental health literacy in their syllabi  Despite the known high prevalence of MH difficulties, young people are not effectively signposted to services  Education is an effective form of prevention (e.g. suicide attempts and suicidal ideation)  Schools are an ideal platform for the delivery of prevention services in relation to  Bullying including cyberbullying  The sequelae of acute mental health problems (e.g. suicide)
  68. 68. Three suicide prevention programmes (RCT) 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 12 months follow-up OR: 0.52 [0.29 - 0.94] OR: 0.53 [0.29 - 0.96] Incident suicide attempts Severe suicidal ideation Youth Mental Health Awareness Programme (YMHAP) Question, Persuade and Refer (QPR) Screening by Professionals Controls • 11,110 adolescents • Average age= 14.8 • 168 schools • 10 European countries Austria, Estonia, France, Germany, Hungary, Ireland, Israel, Italy, Romania, Slovenia & Spain Wasserman et al., in press. The Lancet At 12 months follow up, the only programme better than controls was the Youth Mental Health Awareness Reduction of suicide attempts OR: 0.52 [0.29 - 0.94] Reduction of severe suicidal ideation OR: 0.53 [0.29 - 0.96] Question, Persuade and Refer (QPR): Gatekeeper training for teachers and school staff Youth Mental Health Awareness: Aimed at pupils Screening by Professionals with referral of at-risk pupils Control: No intervention
  69. 69. CYP-IAPT and resilience enhancement
  70. 70. “Differential sensitivity” Peer influence protective against risk-promoting environments Self-regulation predicts resilience Involvement in community and extracurricular activities impact on biological stress response system better overall adjustment Family resources protective against ACEs Racial socialisation positive outcomes in school, overall wellbeing, less depression, higher self-concept
  71. 71. The Chicago Center for Family Health Resilience Framework CCFH Parent-Child Interactive Therapy PCIT Families OverComing Under Stress FOCUS HomeFront Strong MSPAN The Child Illness and Resilience Program CHiRP University of Wisconsin Family Resilience Program The Penn Resilience Program PRP Steps Toward Effective and Enjoyable Parenting Project STEEP Nurse-Family Partnership (US) NFP Toddler-Parent Psychotherapy Oklahoma State University Center for Family Resilience University of Illinois Family Resilience Center CorStone Family Resilience Program FRP Inner Resilience Program IRP Open Doors’ Resilient Kids CCFH Bounce Back and Thrive! BBT Potential resilience enhancing programmes for CYP-IAPT
  72. 72. CYP-IAPT, quality control and the future
  73. 73. What the future should bring • Incorporating a public health framework of prevention and health promotion with treatment • Mental health promotion may be woven into the lives of our children • Innovative methods for early detection and manipulation of neurobiological risk and protective factors • Technological and communication advances may enable entirely new psychosocial assessment and intervention.
  74. 74. What needs to happen? We cannot wait complacently for new discoveries Millions of children often languish in suboptimal mental health services We do not need a further reorganisation We just need to reform the practice within them Collaboration between professionals and agencies is essential And this is not something that can be created only by throwing money at it We need a client-focused, outcome-oriented approach to all aspects of working with families This is less about organisations: Not about organising 15 professionals around a family It’s about empowering and supporting each other for each of us to carry out our work
  75. 75. We need to mobilise all the individuals and organisations that have a stake in YP’s future To make changes to the current system to improve care for YPs

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