CAMHS services in our physically distanced world

Dr Christopher Abbott and Dr Bruce Clark
Dr Christopher Abbott is Associate Medical Director for CAMHS at South London and Maudsley NHS Foundation Trust. He is also Consultant Child and Adolescent Psychiatrist in a CAMHS crisis team, and has special interests in urgent care, psychosis and the impact of ADHD on adolescent behaviour. Dr Bruce Clark is Clinical Director for CAMHS at South London and Maudsley NHS Foundation Trust. He is also Consultant Child and Adolescent Psychiatrist leading the National and Specialist CAMHS OCD, BDD and Related Disorders Service at The Maudsley Hospital, the only such specialist team in the UK.

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On March 23rd 2020, the way healthcare was provided in England had to change overnight. With the COVID-19 pandemic sweeping across the country, CAMHS staff had to adapt to the news that they must provide routine services from home where possible and all non-urgent face-to-face contact must cease to prevent the spread of the virus. Six months on, after a relatively calm summer, we are seeing a steady increase in cases once again and it is clear that we will be living with COVID-19 for quite some time to come. We now need to take stock of what we have been providing to young people over the last six months and plan a way forward for our services in this physically distanced world.

One of the most striking changes to general CAMHS was the move of all routine work to online platforms, including new assessments and therapeutic interventions. Working with children and young people does put CAMHS at an advantage, as from the start of the pandemic young people embraced the digital platform and found the technology needed easy to set up and use. For many teenagers, video calling was a normal part of everyday life before the pandemic, and with it came a flexibility that is simply not possible in the traditional out-patients model.

Certain patient populations, as a result of their mental health issues, have found initial engagement through online work helpful. Whilst an anxious or depressed patient may welcome the ease of initial online contact, we have to think about what is lost from the therapeutic interaction. Many factors are impacted, including both the nature of the therapeutic relationship, as well as the range of exposures and other clinical opportunities. We must revisit more astutely how we review mental states to get the fullest picture of the clinical presentation. The delicate rapport that is built is also easy to lose when it is formed over a screen. A challenging, yet vital, conversation can be ended by the young person with the press of a button and the therapist may find it impossible to quickly re-engage in a way we previously took for granted when sitting in a room together.

Perhaps we should place ever more emphasis on the collection of feedback data as we come to realise that our mental state assessments, and the cues we use to complete those, are very dramatically limited in online interactions. Given current restrictions of using personal protective equipment, the same will apply in more urgent face-to-face work. We perhaps never thought we would find ourselves trying to develop rapport and monitoring subtle socio-emotional cues in the context of wearing protective face coverings.

That said, a significant amount of therapeutic work of various modalities has taken place over the last six months and clinicians have worked hard to innovate and use technology to provide therapy to those in need. Art therapists have used drawing apps on iPads donated by charities, family therapy and parenting classes have taken place over Zoom and CBT sessions have continued over Microsoft Teams. While this has allowed CAMHS to provide care throughout the lockdown period, we are left with the question; how effective has our online intervention been? Few, if any, studies have been carried out into the effectiveness of these therapies carried out remotely.1  We are yet to see the long-term outcomes for our patients who have received an entirely virtual therapeutic offer during the pandemic. If this practice is to continue, and there is definitely an argument for some form of virtual working after the pandemic has ended, studies into its effectiveness will be of great importance to ensure we continue to provide evidence-based interventions.

When considering the impact of a physically distanced world, one must also think about the impact this has on CAMHS staff members. Trainees progress through training with an increasing percentage of their time without direct face-to-face contact and day-to-day interaction with peers. What will our training institutions need to do to ensure we are meeting the highest standards of training?

Working in isolation can lead to feelings of anxiety and frustration and also may result in therapeutic interventions drifting from the evidence base. Face-to-face contact with colleagues has always fostered the development of skills and ensured that the therapy being provided remains within evidenced-based norms, through formal and informal supervision.2

Now more than ever, regular supervision is of the upmost importance, as well as good use of reflective spaces and team meetings. Informal ‘team time’ can also be put into place in this virtual world with many teams implementing ‘coffee time’ online before their meetings. Team debrief time and huddles have become routine parts of the day, allowing junior team members the opportunity to talk to senior colleagues about complex cases they may be struggling with. We cannot deny the benefits that have been created through engaging colleagues over online platforms; most notable is the flexibility it gives us to attend large group meetings, lectures and supervision with an array of colleagues, possibly spread out over a large geographical area. The elimination of travel time releases hours back into clinicians’ day, which in turn can be used for patient facing activities.

The pace and degree of change we have seen across the NHS has been unparalleled in its history. As we reflect on lessons learned, there are clearly things we need to continue to improve and there will still be a great number of changes to come. Perhaps one of the most positive lessons is that we have shown that we can adapt quickly with a fleet of foot that we might have previously thought unimaginable. Our focus should always remain on our patients and what they tell us, whilst using our professional standards and networks to drive forward the highest quality service for young people.

References

1. Hollis C, Falconer CJ, Martin JL, et al. Annual Research Review: Digital health interventions for children and young people with mental health problems – a systematic and meta-review. J Child Psychol Psychiatry 2017; 58: 474–503.

2. Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Serv Res 2017; 17: 786.

Discussion

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WE need to monitor our interventions & research outcomes of innovations so that we do not waste overtaxed resources on ineffective or damaging interventions. Leslie Scarth ,FRCPsych,Consultant Child Psychiatrist(retired) EDinburgh

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We have indeed come along way in such a short period of time. As we build back better we need to better understand the impact of online platforms on all conditions, such as eating disorders and neurodevelopmental. Additionally, who – and where – are the benefits i.e. focal CYP and/or those who care for them. When in the pathway holds greatest impact. With rising and higher acuity in YP seen is there an opportunity to engage earlier and prevent conditions worsening- escalating?

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