Key Note Speech - CYP IAPT Conference 2014

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. When we started on this
journey…

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. International Perspective on CAMHS: US studies

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. Current service provision: a snapshot
Fragmentation of services
for children and young people

7. Fragmentation of services for young people aged 12-25
Artificial structural divisions in terms of
Under 18
Over 18
Age

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. Fragmentation of services for children & young people
Artificial structural divisions in terms of
Statutory vs voluntary providers

10. Fragmentation of services for children & young people
Artificial structural divisions in terms of
Physical Mental
Separation of physical and mental health

11. Many service designs are not young person friendly
Inaccessible
in terms of location, time,
criteria for access

12. Many service designs are not young person friendly
OCD CLINIC
Problem centred not person centred

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. 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. 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. 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. Template for appropriate CYP services: key components
Improving access
Access & engagement

18. Template for appropriate CYP services: key components
Improving access
Access & engagement
Awareness
Increasing MH
awareness &
decreasing
stigmatisation

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. 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. 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. 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. “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. 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. 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. 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. A few achievements of
CYP-IAPT…

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. With permission from Scott Lunn
Why ROMs?
The Derby experience
With thanks to Scott Lunn

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. Cases ceased to accumulate from June
With permission from Scott Lunn
INPUT=OUTPUT

32. Length of stay declines by 12%
With permission from Scott Lunn

33. How good is CYP-IAPT at integrating ROMs?

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. 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. 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. 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. 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. 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. 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. 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. 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. The Problems
&
The Future

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. Improving access to
parenting training

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. 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. 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. 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. Evidence-base for:
Other parenting programmes,
the best of the rest

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. Body of evidence
Less evidence does
not necessarily
mean less effective
Most frequently used Other programmes
programmes

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. Other things I would still like to see:
Make CYP-IAPY even more young person-centred

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. Empowering children, young people and carers
Participate
in service design
Participate in training of
practitioners & managers
Understand and
modify treatment
progress via PROMs

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. 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. CYP-IAPT and integration initiatives

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. Prevent social exclusion by integrating services
Housing
Mental
health
services
Employment
Social
support

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. CYP-IAPT and physical health

64. Involve physical healthcare in mental healthcare
and vice versa
Physical
healthcare
Mental
healthcare

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. CYP-IAPT and prevention

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. 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. CYP-IAPT and resilience enhancement

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. 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. CYP-IAPT, quality control
and the future

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. 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. 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