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Developments in Child and Adolescent Mental Health Services

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Title: Developments in Child and Adolescent Mental Health Services
Language: English
Authors: Gilliland, David, Gallagher, Peter, Growcott, John
Source: Child Care in Practice. Jan 2005 11(1):51-61.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 11
Publication Date: 2005
Document Type: Journal Articles
Reports - Descriptive
Education Level: Early Childhood Education
Descriptors: Health Services, Mental Health Programs, Children, Adolescents, Delivery Systems, Strategic Planning, Child Development, Disadvantaged Youth, Comprehensive School Health Education, Performance Factors, Educational Development, Foreign Countries
Geographic Terms: Ireland
DOI: 10.1080/1357527042000332790
ISSN: 1357-5279
Abstract: This paper highlights the main issues that are present in the field of child and adolescent mental health services with regard to strategic development. It identifies the major themes that have emerged concerning the commissioning and delivery of services, and also highlights the difficulties faced by particular groups of children. The authors present their views of the developments within this field from the perspective of their professional experiences.
Abstractor: As Provided
Number of References: 24
Entry Date: 2008
Accession Number: EJ820703
Database: ERIC
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  Value: <anid>AN0016176154;j2301jan.05;2019Mar06.12:47;v2.2.500</anid> <title id="AN0016176154-1">Developments in child and adolescent mental health services. </title> <p>This paper highlights the main issues that are present in the field of child and adolescent mental health services with regard to strategic development. It identifies the major themes that have emerged concerning the commissioning and delivery of services, and also highlights the difficulties faced by particular groups of children. The authors present their views of the developments within this field from the perspective of their professional experiences.</p> <p>Keywords: Child & Adolescent; Mental Health; Vulnerable Groups; Issues in Commissioning & Delivery of Service</p> <hd id="AN0016176154-2">Background</hd> <p>There is increasing recognition of the impact of mental health disorders in children and young people, with an awareness of the effect such conditions can have on functioning in adult life as well as adverse implications for the young person's ongoing development. The term mental health problem can be used to describe a very broad range of emotional and behavioural difficulties that may cause concern or distress. Typically, difficulties viewed within this continuum would include eneuris, encopresis, mood disorders (including depression and psychotic presentation), behavioural problems and attention deficit hyperactivity disorder.</p> <p>The Health Advisory Service's ([<reflink idref="bib11" id="ref1">11</reflink>]) thematic review of Child and Adolescent Mental Health Services (CAMHS) highlighted the components of mental health as including the following capabilities:</p> <p></p> <ulist> <item> 1. the ability to develop psychologically, emotionally, intellectually and spiritually;</item> <p></p> <item> 2. the ability to initiate and sustain mutually satisfying relationships;</item> <p></p> <item> 3. the ability to become aware of others and to empathise with them;</item> <p></p> <item> 4. the ability to use psychological distress as a developmental process, so that it does not hinder or impair further development;</item> <p></p> <item> 5. an ability to play and to learn so that attainments are appropriate for age and intellectual level; and</item> <p></p> <item> 6. developing a moral sense of right and wrong.</item> </ulist> <p>Graham ([<reflink idref="bib9" id="ref2">9</reflink>]) estimated the prevalence of mental disorder being as high as 25%, with 7–10% having moderate to severe problems. On the basis of these figures, it could be argued that in a total population of 250,000, of which 20–25% are younger than 18 years old, between 5,000 and 12,000 children would have a mental health disorder at any one time. Graham and Hughes ([<reflink idref="bib10" id="ref3">10</reflink>]), in <emph>So Young So Sad So Listen</emph>, estimate that in a hypothetical secondary school of 1,000 pupils, 50 young people could be seriously depressed each year.</p> <p>Meltzer <emph>et al</emph>. ([<reflink idref="bib17" id="ref4">17</reflink>]) in their study of prevalence rates found that 10% of children aged 5–15 years had a mental disorder. Five per cent had clinically significant conduct disorders, 4% were assessed as having emotional disorders (anxiety and depression) and 1% were rated as hyperactive.</p> <p>There was also a recognition that the prevalence of such disorders may be increasing as the Bicentennial Report <emph>The Health of our Children</emph> (HMSO, [<reflink idref="bib15" id="ref5">15</reflink>]) suggests that, "although our children are healthier, they are less happy".</p> <p>It is recognised that a variety of factors contribute to the development of such disorders and can include genetic influences (including temperament), family factors (parental mental health problems, marital friction, inconsistent parenting) and environmental factors (housing and economic disadvantage). Research has shown that three key groups of factors appear to protect children and adolescents, which are: firstly, self-esteem, sociability and autonomy; secondly, family composition, warmth and absence of parental discord; and thirdly, social support systems that encourage development of personal coping skills (Garmezy, 1985; Rutter, [<reflink idref="bib21" id="ref6">21</reflink>], [<reflink idref="bib22" id="ref7">22</reflink>]).</p> <p>In the light of such understanding, there have been a number of developments with regard to defining the optimum way to commission and provide services in this field.</p> <hd id="AN0016176154-3">Four-tier Model</hd> <p>The first report to attempt to bring an element of coherence to the planning of child and adolescent mental health services was <emph>Together we Stand</emph> (Health and Advisory Service, [<reflink idref="bib11" id="ref8">11</reflink>]). This review concluded that the overall goal of comprehensive child and adolescent mental health services should be that of delivering "seamless, multi-sectoral, mental health services for children, adolescents, young people and their families" (Health and Advisory Service, [<reflink idref="bib11" id="ref9">11</reflink>], p. 11). It also highlighted the need to ensure that there were adequate commissioning arrangements reflecting the diversity of provision. The report is particularly noteworthy for the proposed four-tier model of service delivery. The main functions of the four tiers have been summarised by the Audit Commission report <emph>Children in Mind</emph> ([<reflink idref="bib1" id="ref10">1</reflink>]).</p> <p>Tier I is a primary level service that includes interventions by general practitioners, health visitors, juvenile justice workers, school nurses and teacher. These staff:</p> <p></p> <ulist> <item> 1. identify mental health problems early in their development;</item> <p></p> <item> 2. offer general advice and, in certain cases, treatment for less severe mental health problems; and</item> <p></p> <item> 3. pursue opportunities for promoting mental health and preventing mental health problems.</item> </ulist> <p>Tier II is a level of service provided by professionals working on their own who relate to others through a network rather than within a team, and can include:</p> <p></p> <ulist> <item> 1. Clinical child psychologists.</item> <p></p> <item> 2. Educational psychologists.</item> <p></p> <item> 3. Paediatricians.</item> <p></p> <item> 4. Community child psychiatric nurses or nurse specialists.</item> <p></p> <item> 5. Child psychiatrists.</item> </ulist> <p>This service offers:</p> <p></p> <ulist> <item> 1. training and consultation to other professionals (who might be within Tier I);</item> <p></p> <item> 2. consultation for professionals and families;</item> <p></p> <item> 3. outreach to identify severe or complex needs where children or families are unwilling to use specialist services; and</item> <p></p> <item> 4. assessment that may trigger treatment at this level or in a different tier.</item> </ulist> <p>Tier III is a specialist service for the more severe, complex and persistent disorders. Contributors could include:</p> <p></p> <ulist> <item> 1. Social workers.</item> <p></p> <item> 2. Clinical psychologists.</item> <p></p> <item> 3. Community psychiatric nurses.</item> <p></p> <item> 4. Child and adolescent psychiatrists.</item> <p></p> <item> 5. Art, music and drama therapists.</item> <p></p> <item> 6. Child psychotherapists.</item> <p></p> <item> 7. Occupational therapists.</item> </ulist> <p>This is usually a multi-disciplinary team or service working in a community child mental health clinic and offering:</p> <p></p> <ulist> <item> 1. assessment and treatment of child mental health disorders;</item> <p></p> <item> 2. assessment for referrals to Tier IV;</item> <p></p> <item> 3. contributions to the services, consultation and training at Tiers I and II; and</item> <p></p> <item> 4. participation in research and development projects.</item> </ulist> <p>Tier IV is described as "infrequently used but essential tertiary services such as day units, highly specialised out-patient teams and inpatient units for older children and adolescents who are severely mentally ill or at suicidal risk" (Audit Commission, [<reflink idref="bib1" id="ref11">1</reflink>], p. 7).</p> <p>Within Northern Ireland there are particular issues with regard to the current situation in respect of the tiered model.</p> <p>Tier I work is being undertaken by a variety of professionals, but there is frequently limited structure or input in terms of staff development or clinical support for this group.</p> <p>At Tier II there appears to be a number of professionals operating. Community paediatricians, health visitors with particular training in behaviour therapy, staff in family centres, educational psychologists, education welfare officers and colleagues in the Youth Justice System are among the professionals most commonly represented in this group.</p> <p>Particular problems emerge with regard to the need to adequately train staff within Tier II and offer them appropriate consultation and support from Tier III. The development of the Tier II system arguably offers a considerable challenge for service providers in the near future.</p> <p>In Tier III, each Community Trust has its own specialist child and adolescent mental health team, but in many situations extensive waiting lists operate. This places considerable pressure on such systems if attempts were also made to provide training and support to colleagues at Tier I and Tier II.</p> <p>At Tier IV specialist input for child and adolescent mental health services is provided by Foster Green Hospital and the Young People's Centre In-Patient Unit. Despite this, there is an ongoing likelihood that young people may continue to be admitted to adult wards and consideration may need to be given to the issues arising from this practice. This issue was highlighted in a recently conducted survey of CAMHS services in Northern Ireland by The Children's Law Centre (O'Rawe, [<reflink idref="bib19" id="ref12">19</reflink>]). It was found that that in 2001/2002 there were an estimated 90 children and young people admitted to adult units province wide, a figure that is proportionally five-fold higher than that in England and Wales.</p> <hd id="AN0016176154-4">Commissioning Services</hd> <p>Any service development model must take account of this diversity of provision and much of the debate in this field is focused on how this might best be achieved. The need to ensure adequate commissioning assumes a high priority in many documents—<emph>Together We Stand</emph> (Health Advisory Service, [<reflink idref="bib11" id="ref13">11</reflink>]), <emph>Children in Mind</emph> (Audit Commission, [<reflink idref="bib1" id="ref14">1</reflink>]), <emph>Standards</emph><emph>in Child & Adolescent Mental Health Services</emph> (Health Advisory Service, [<reflink idref="bib12" id="ref15">12</reflink>]a).</p> <p>Partly because of the diverse nature of the provision in the field of CAMHS and the involvement of professionals across traditional boundaries, the commissioning process is inherently complex. This is further complicated by the difficulty in deciding whether to locate such commissioning in the field of mental health or children's services. In addressing this issue, the organisation Young Minds ([<reflink idref="bib24" id="ref16">24</reflink>]) argued that while neither option was wholly satisfactory, a strong preference was indicated for setting CAMHS in the children's services arena. It argued that to place it within mental health services exposed the risk that adult services would be prioritised over Children's work.</p> <p>The Audit Commission ([<reflink idref="bib1" id="ref17">1</reflink>]) report argues that effective commissioning should involve establishing a lead officer within the commissioning agency who would operate as part of a multi-agency group involving, among others, education, health and social services, primary health care and juvenile justice. The task of this group would be to identify priorities for addressing unmet needs and for comprehensive service development.</p> <p>Children's Services Planning offers a template within which an integrated, strategic approach to the planning and commissioning of CAMHS services can be taken forward. The complexity of CAMHS in organisational terms will provide a significant challenge to the effectiveness of the children's services planning model. However, the framework, involving as it does key agencies and disciplines in the voluntary, community and statutory sectors, provides a potentially viable mechanism for progressing this agenda.</p> <hd id="AN0016176154-5">Emerging Issues</hd> <p>It is possible to identify certain issues that require particular attention.</p> <p></p> <ulist> <item> 1. The need to adequately focus the commissioning process using as a basis for dialogue in this area the production of a service specification. The Audit Commission ([<reflink idref="bib1" id="ref18">1</reflink>]) in particular stresses the desirability of this, and the Health Advisory Service ([<reflink idref="bib12" id="ref19">12</reflink>]a) suggests that this should cover areas such as:</item> <p></p> <item> 1. work at Tiers II, III and IV;</item> <p></p> <item> 2. work with Looked After Children;</item> <p></p> <item> 3. children with learning disability and mental health needs;</item> <p></p> <item> 4. support arrangement for Tier I; and</item> <p></p> <item> 5. the range of treatments available.</item> <p></p> <item> 2. The needs of particularly vulnerable groups of young people should be recognised.</item> <p></p> </ulist> <p>• 1.</p> <p></p> <ulist> <item> i. Children with learning disability and also with mental health needs. Graham ([<reflink idref="bib9" id="ref20">9</reflink>]) found that 40% of children with an IQ below 50 could be expected to have severe mental health problems and children with an IQ of less than 70 may have a prevalence of disorder, which is up to four times that of a general population. Organisationally, such children can be dealt with by adult or children's services (depending on the level of severity and local structural arrangements) and the need to provide a responsive seamless service presents a particular challenge. One possible resolution of this is to consider joint appointments.</item> <p></p> <item> ii. Looked After Children are recognised as being a particularly vulnerable group. The study by McCann <emph>et al</emph>. ([<reflink idref="bib16" id="ref21">16</reflink>]) of a Looked After population shows that prevalence rates in adolescents were 67% (with a figure of those in residential care being 96%). The prevalence rate for the control group was 15%. One of the most worrying aspects of this study was that 23% of the young people suffered from major depressive disorder. Similarly, the study by Dimigen <emph>et al</emph>. ([<reflink idref="bib6" id="ref22">6</reflink>]) showed a considerable proportion of young people had a serious mental health disorder at the time of becoming looked after, but were not being presented for psychological help. This raised particular issues of appropriate screening of such young people to ensure that the mental health needs are recognised. It also highlights the need to have in place, appropriate consultation and support services to those looking after such children.</item> <p></p> <item> iii. Children with a physical illness are at higher risk of developing mental health problems, and this constitutes a significant issue that requires addressing (Challen <emph>et al</emph>. [<reflink idref="bib3" id="ref23">3</reflink>]).</item> <p></p> <item> iv. The needs of young people with substance misuse problems accompanied by mental health difficulties was also highlighted for particular attention. Witchen et al. ([<reflink idref="bib23" id="ref24">23</reflink>]) refer to general population-based studies indicating that adolescent substance misuse is usually associated with other mental health disorders.</item> <p></p> <item> The Health Advisory Service (2001) report <emph>The Substance of Young Needs</emph>, in arguing for the development of a four-tier approach to this problem, highlights a potentially crucial role played by CAMHS services, including:</item> <p></p> <item> 2. arranging to add addiction skills to the assessment and treatment repertoire within CAMHS;</item> <p></p> <item> 3. arranging to work more closely with drug and alcohol services; and</item> <p></p> <item> 4. considering the appropriateness for appropriately trained staff being appointed to joint posts in a range of disciplines.</item> <p></p> <item> The report argues that within a proposed four-tier model, a particular model of specialist Tier III service could comprise of a specialist substance misuse team within CAMHS.</item> <p></p> <item> 3. The need to provide a degree of integration across the various tiers is a particular issue. For many Tier II staff this can be provided by offering access to Tier III colleagues for consultation and support, but the support and developmental needs of staff at Tier I can be more difficult to address. One response recommended by the Health Advisory Service Report <emph>Together we Stand</emph>" ([<reflink idref="bib11" id="ref25">11</reflink>]) was the development of primary mental health worker posts. These posts are normally occupied by professionals with training and expertise in CAMHS and their role includes:</item> <p></p> <item> 1. consolidating the skills of primary care workers and supporting education in CAMHS work;</item> <p></p> <item> 2. aiding recognition of CAMHS disorders and referral to more specialist tiers; and</item> <p></p> <item> 3. assessing and treating some individuals with mental health problems who were considered appropriate for management at Tier I.</item> <p></p> <item> A Department of Health ([<reflink idref="bib4" id="ref26">4</reflink>]) review on primary mental health workers concluded that "the development of CAMHS in primary care seems to be highly dependent on the new primary mental health worker posts" (p. 7). It noted that one-third of Trusts surveyed had developed such posts and a further 25% had plans to do so.</item> <p></p> <item> 4. The need to provide 24-hour and emergency cover for young people presenting with mental health problems was also highlighted within the Audit Commission report as an issue requiring particular attention.</item> <p></p> <item> 5. Particular focus should be given to the need to adequately manage CAMHS, preferably as an integrated whole, and a number of local authorities in the United Kingdom have opted for a single manager whose brief is to ensure that developments within the various spheres of CAMHS take place in a complimentary manner. The Audit Commission Report in the review of Trusts' performances found that "what distinguished the high scoring Trusts above all seemed to be clear, informed, imaginative, and understanding management of the service" (1999, p. 74)</item> </ulist> <hd id="AN0016176154-6">Moving the Agenda Forward</hd> <p>To move forward the agenda, a number of areas require addressing.</p> <p></p> <ulist> <item> 1. The extent to which there exists, at Tier III services, a critical mass of clinical staff of sufficient numbers to make appropriate and timely responses to treatment demands as well as providing indirect work needed to develop and support Tiers I and II.</item> <p></p> <item> The Royal College of Psychiatrists argue that there should be 1.5 whole time equivalent Consultant Child Psychiatrists per 100,000 total population to provide for 0–16 year olds (Royal College of Psychiatrists, [<reflink idref="bib20" id="ref27">20</reflink>]).</item> <p></p> <item> Recent research on staffing levels in CAMHS specialist teams throughout the United Kingdom (Bradley <emph>et al</emph>., [<reflink idref="bib2" id="ref28">2</reflink>]) indicated that the median figure was 5.2 staff per 100,000 population. Goodman ([<reflink idref="bib8" id="ref29">8</reflink>]), in his critical analysis of the four-tiered model, put forward an argument (on the basis of acknowledged prevalence rates for disorders that require such specialist intervention), for a population of 250,000 being serviced by 13 staff. Clearly any consideration of service development within Northern Ireland must take account of this issue and ensure a sufficient number of appropriately trained staff including psychiatrists, psychologists, nursing and social work personnel are available within the specialist teams.</item> <p></p> <item> 2. The area of mental health promotion is another important theme within the development of CAMHS. With the publication of a recent inter-departmental paper in Northern Ireland on mental health promotion, <emph>Promoting Mental Health Strategy & Action Plan 2003–2008</emph> ([<reflink idref="bib5" id="ref30">5</reflink>], 2003), there is certain guidance offered within the field of child and adolescent mental health services. This document makes reference to a number of school-based programmes that have been developed and evaluated. These are characterised by focusing on improving social skills, reducing substance misuse and aggressive behaviour and, developing coping skills to deal with life situations.</item> <p></p> <item> 3. There is a particular need to identify and address the training and consultation needs of staff who are operating at the Tier II level.</item> <p></p> <item> 4. The expansion of primary mental health worker posts would appear to be essential if there is any anticipation of enhancing the capacity of primary care workers.</item> <p></p> <item> 5. The ongoing problem of young people admitted to adult mental health hospitals will require addressing, and linked to this is the need to provide appropriate 24-hour cover for CAMHS.</item> </ulist> <p>Particular guidance has been offered in the United Kingdom with the CAMHS Grant Guidance 2003/04 (Health Service Circular LAC [<reflink idref="bib14" id="ref31">14</reflink>]/2) laying down an expectation that by 2006 a comprehensive CAMHS service will be available in all areas. They note that, "from 2003/04, CAMHS funding will be increased substantially to reflect the government's commitment to improve the overall level of provision". They stress that commissioners require a clear definition and description of such a service but identify areas that should be considered. Such guidance should prove helpful for service planning within Northern Ireland and a number of extracts from this document prove illuminating.</p> <p>The underpinning principles suggest that services should be available to all children and young people regardless of their age, gender, race, religion, ability, class, culture, ethnicity or sexuality. In addition to this it is stressed that effective CAMHS commissioning is a multi-agency activity and requires that the commissioners have the requisite skills, knowledge, time and executive authority to undertake the task. Both the commissioning and delivery of services must be informed by a multi-agency assessment of need that is updated regularly.</p> <p>With regard to the range of services that should be available, a number of the main points to be highlighted include the following:</p> <p></p> <ulist> <item> 1. The range of services and their settings should reflect the specific needs of young people and children using the service.</item> <p></p> <item> 2. The need to put in place arrangements to ensure that 24-hour cover is provided to meet urgent needs is noted.</item> <p></p> <item> 3. There needs to be a balance of service provision in order that all levels of need can be met as required. This in practice means that:</item> <p></p> <item> a. within primary level services (Tier I), those in contact with children need to have sufficient knowledge of children's mental health to be able to identify those who need help, offer advice and support to those with mild or minor problems, and have sufficient knowledge of specialist services to be able to refer on appropriately when necessary;</item> <p></p> <item> b. child mental health workers and child mental health specialists (Tier II) need to be available to support, train and liaise with, consult to and provide direct work with other agencies providing services for children; and</item> <p></p> <item> c. specialist multidisciplinary teams in all localities should be able to provide:</item> <p></p> <item> 1. specialist assessment and treatment services;</item> <p></p> <item> 2. services for the full range of mental disorders in conjunction with other agencies as appropriate;</item> <p></p> <item> 3. a mix of short-term and long-term interventions and care according to the complexity and chronicity of the child or young person's problems;</item> <p></p> <item> 4. a full range of evidence-based treatments;</item> <p></p> <item> 5. consultation and training; and</item> <p></p> <item> 6. access to specialist services that are commissioned on a regional or multi-district basis, including inpatient care.</item> <p></p> <item> Specific reference is made regarding workforce and training issues, including the need to ensure:</item> <p></p> <item> 4. the professional mix within specialist services and teams is balanced to ensure availability of an appropriate representation of skills; and</item> <p></p> <item> 5. the necessary resources to support the training and development requirements of the CAMHS workforce should be available.</item> </ulist> <p>With regard to organisational issues, three significant points are made. Firstly, agreed protocols should be in place to manage waiting lists and times according to need. Secondly, where interfaces exist between services, as between adult and children's mental health services, arrangements should be negotiated to ensure clarity and effectiveness of separate and joint service responsibilities and smooth transitions of care. Thirdly, where service delivery demands effective partnerships between agencies (e.g., children and young people with complex, persistent and severe behavioural disorders), joint protocols should be agreed at senior officer level between the NHS, social services and education.</p> <p> <emph>Improving Mental Health Services in Wales</emph> (National Assembly for Wales, [<reflink idref="bib18" id="ref32">18</reflink>]), the CAMHS strategy for Wales, commissioned a content analyses of the major documents relating to this sphere within the United Kingdom. From this, six common themes were identified and have global significance for service delivery:</p> <p></p> <ulist> <item> 1. Establishing multi-agency ownership of CAMHS.</item> <p></p> <item> 2. Basing services on the CAMHS concept in which all relevant sectors of care play their key and acknowledge roles to achieve the goal of delivering integrated and comprehensive services.</item> <p></p> <item> 3. Basing service planning on the assessed needs of the child population.</item> <p></p> <item> 4. Conducting audit and mapping of current services in order to determine local priorities for development.</item> <p></p> <item> 5. Adopting an evidenced-based approach to practice.</item> <p></p> <item> 6. Adopting a strategic approach to designing and delivering CAMHS based on a common strategic framework that is used as a tool for future understanding and development.</item> </ulist> <hd id="AN0016176154-7">Conclusion</hd> <p>The article seeks to contextualise the development of a non-hierarchical tiered service structure integrating primary, secondary and tertiary levels of intervention within a managed network of provision.</p> <p>The article affirms the need for a coherent approach to service development informed by a dynamic workforce strategy; a transparent assessment of need process and attendant service remit; an organisational structure with delineated management arrangements underpinned by a robust governance framework; and an integrated strategic planning and commissioning process informed by clear priorities and linked to an appropriate resource base.</p> <p>The following would appear to be central to the development of an effective CAMHS provision:</p> <p></p> <ulist> <item> 1. Coherent organisational structures with clear managerial arrangements, a robust governance framework and transparent clinical and managerial accountability.</item> <p></p> <item> 2. Integrated planning and commissioning processes informed by a regional dimension, facilitating needs assessment and linking service development priorities, implementation strategies and resource base.</item> <p></p> <item> 3. A workforce strategy embracing uni-professional and multi-professional training requirements, recruitment, retention and opportunities for innovation in relation to practitioner and management grades. In this regard, the development of Primary Mental Health workers appears to offer particular benefits.</item> <p></p> <item> 4. The development of a critical mass at Tier III.</item> <p></p> <item> 5. The accessibility of specialist services at Tiers II and III to Primary Care staff.</item> <p></p> <item> 6. A robust and functioning Tier I & II system.</item> <p></p> <item> 7. Access to specialist in-patient provision.</item> <p></p> <item> 8. The promotion of a service culture within which children and their parents/carers are meaningfully involved in the appraisal and development of provision.</item> </ulist> <ref id="AN0016176154-8"> <title> References </title> <blist> <bibl id="bib1" idref="ref10" type="bt">1</bibl> <bibtext> Audit Commission(1999)Children in Mind, London</bibtext> </blist> <blist> <bibl id="bib2" idref="ref28" type="bt">2</bibl> <bibtext> Bradley, S, Kramer, T, Garralda, ME, Bower, P, Macdonald, W, Sibbald, B and Harrington, R. (2003). Child and adolescent mental health interface work with primary services: a survey of NHS provider trusts. Child and Adolescent Mental Health, 8(4): 170</bibtext> </blist> <blist> <bibl id="bib3" idref="ref23" type="bt">3</bibl> <bibtext> Challen, AH, Davies, AG, Williams, RJW and Baum, JD. (1998). Measuring psychological adaption to diabetes. 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  Data: Developments in Child and Adolescent Mental Health Services
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  Data: <searchLink fieldCode="AR" term="%22Gilliland%2C+David%22">Gilliland, David</searchLink><br /><searchLink fieldCode="AR" term="%22Gallagher%2C+Peter%22">Gallagher, Peter</searchLink><br /><searchLink fieldCode="AR" term="%22Growcott%2C+John%22">Growcott, John</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Child+Care+in+Practice%22"><i>Child Care in Practice</i></searchLink>. Jan 2005 11(1):51-61.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
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  Data: 11
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  Data: 2005
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  Data: Journal Articles<br />Reports - Descriptive
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  Data: <searchLink fieldCode="EL" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health+Programs%22">Mental Health Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Delivery+Systems%22">Delivery Systems</searchLink><br /><searchLink fieldCode="DE" term="%22Strategic+Planning%22">Strategic Planning</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Development%22">Child Development</searchLink><br /><searchLink fieldCode="DE" term="%22Disadvantaged+Youth%22">Disadvantaged Youth</searchLink><br /><searchLink fieldCode="DE" term="%22Comprehensive+School+Health+Education%22">Comprehensive School Health Education</searchLink><br /><searchLink fieldCode="DE" term="%22Performance+Factors%22">Performance Factors</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Development%22">Educational Development</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22Ireland%22">Ireland</searchLink>
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  Data: 10.1080/1357527042000332790
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  Data: 1357-5279
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  Label: Abstract
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  Data: This paper highlights the main issues that are present in the field of child and adolescent mental health services with regard to strategic development. It identifies the major themes that have emerged concerning the commissioning and delivery of services, and also highlights the difficulties faced by particular groups of children. The authors present their views of the developments within this field from the perspective of their professional experiences.
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        Value: 10.1080/1357527042000332790
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      – SubjectFull: Mental Health Programs
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      – SubjectFull: Children
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      – SubjectFull: Adolescents
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      – SubjectFull: Delivery Systems
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      – SubjectFull: Strategic Planning
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      – SubjectFull: Child Development
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      – SubjectFull: Disadvantaged Youth
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      – SubjectFull: Comprehensive School Health Education
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