professor peter fonagy - cyp iapt national clinical lead

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 Managerwith Faye Henney and Harriet Hamilton

When we started on this

journey…

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)

International Perspective on CAMHS: US studies

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 relationshipbetween 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

Fragmentation of services for children and young people

Current service provision: a snapshot

Fragmentation of services for young people aged 12-25

Artificial structural divisions in terms of

Under 18

Over 18

Age

Fragmentation of services for children & young people


Different lines of funding

DH DfE

DWPLA

Health

Social services

Education

Employment



Statutory vs voluntary providers



Separation of physical and mental health

Physical Mental

Many service designs are not young person friendly

Inaccessiblein terms of location, time,

criteria for access

Many service designs are not young person friendly

Problem centred not person centred

OCD CLINIC

Many current service designs are not young person friendly

Stigmatising; little YP involvement in decision making

OCD CLINIC

OCD OCD OCD OCD OCD

OCD OCD OCD OCD OCD

Many current service designs are not young person friendly

High dropout rates (40-60%)

OCD CLINIC

OCD OCD OCD OCD OCD

OCD OCD OCD OCD OCD

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

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

Template for appropriate CYP services: key components

Improving access & engagementAccess


AwarenessIncreasing MH

awareness & decreasing

stigmatisation





stigmatisationParticipation

Enhancing youth, carer and community participation






EBPDelivery of evidence-based practices







EBPDelivery of evidence-based practices

Accountability

Improving outcomes

accountability



CYP-IAPT

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

• 4,060 References

We know what the evidence says

“Evidence Based Implementation ofEvidence Based Medicine”

“…implementation research needs to come into

its own to capitalize what is known and find

out what strategies work or do 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)

What we need is…

Imbalance of “Design Time” and “Run Time”

Run TimeLocal conditions

Adaptation/reinvention

Aiming for at-least-equal effects

Design TimeDevelop & specify

Test feasibility and safety

Test efficacy/ effectiveness

Based on Chorpita & Daleiden, 2014

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

Fix – Solution

that Works in

Short Run

Vicious cycle

Unintended

Consequences that

Make the Original

Problem Worse

Delay

We need to do

something

NOW!

CYP IAPT

Collaboratives

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

A few achievements of

CYP-IAPT…

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.

With permission from Scott Lunn

Why ROMs?The Derby experience

With thanks to Scott Lunn

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.



Cases ceased to accumulate from June

INPUT=OUTPUT

Length of stay declines by 12%


How good is CYP-IAPT at integrating ROMs?

Mean percentage of CYP IAPT CAMHS staff using ROMs in 2014 in Year I, Year II & Year III partnerships

Source: Partnership annual report to central team.

Perc

ent

of clinic

ians u

sin

g R

OM

s

Year I0

Year II

20

40

60

80

Year of Recruitment

70.3% 75.6%

N=65

F(1,32)=27.4, p=0.00001

Year III

30.0%

CYP IAPT CAMHS staff using ROMs in 2013 and 2014 in Year I and Year II partnerships


Perc

ent

of clinic

ians u

sin

g R

OM

s

20130

2014

20

40

60

80

Year of Report

31.1%

73.3%

N=41

F(1,32)=20.7, p=0.00001

Year I and Year II CYP IAPT partnership staff using ROMs in 2013 and 2014


Perc

ent

of clinic

ians u

sin

g R

OM

s

20130

2014

20

40

60

80

Year I Partnerships

64.4%72.4%

2013 2014

11.1%

73.9%

Year II Partnerships

F(1,32)=23.0, p=0.00001

0

10

20

30

40

50

60

70

80

90

100

2013 2014

London and South East North West (Salford and Manchester)

Oxford and Reading (Reading University) North East

South West

Year II CYP IAPT partnership staff using ROMs in 2013 and 2014 by Collaborative

Percent of Clinicians

Year I CYP IAPT partnership staff using ROMs in 2013 and 2014 by Collaborative

0

10

20

30

40

50

60

70

80

90

100

2013 2014

London and South East North West (Salford and Manchester)

Oxford and Reading (Reading University)

Percent of Clinicians

0%

10%

20%

30%

40%50%

60%

70%

80%

90%

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

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

What are ROMs for?

0%

20%

40%

60%

80%

100%

Outcome data in peer supervision Discuss service level outcome to

inform planinng

Report outcomes data to

comissioners

London and South East North East North West Oxford and Reading South West

Significant differences between collaboratives in the contexts where partnerships report using ROMs in

2014 for different purposes

Percent of Partnerships

Mean percentage of Year I and Year IIPartnerships accepting self referrals in 2013 and 2014


Perc

ent

of Part

ners

hip

s

20130

2014

20

40

60

80

Year of Report

69.5% 75.3%

N=41

F(1,35)=1.59, p=0.20

Self-referrals:


Perc

ent

of clinic

ians u

sin

g R

OM

s

20130

2014

20

40

60

80

86.2% 83.3%

2013 2014

76.3% 77.9%

N=41

Wilk’s L(2,37)=0.98,

p=0.63

Partnerships achieving participation milestones and including parents across years and collaboratives

Achieving milestones

Including Parents

100

Participation:

The Problems

&

The Future

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

Improving access to

parenting training

“Training/education programmes are the first line of treatments for parents or carers of preschool children.”

“Group-based PT/education programmes are usually the first line of treatments for parents or

carers of children and young people with ADHD and moderate impairment.”

“Offer a group parent training programme to the parents of

children and young people aged between 3 and 11 years…”

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

REFERENCE LIST – INCREDIBLE YEARS

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

Evidence-base for:

REFERENCE LIST – TRIPLE P

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

Evidence-base for:

Evidence-base for:

Other parenting programmes,

the best of the rest

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, FRCPsychDirector of the National Academy for Parenting Research

Body of evidence

Less evidence does not necessarily mean less effective

Other programmesMost frequently used programmes

How should parenting interventions be judged?

Parent training

Support from RCTs

Clear manual permitting training

Instrument to assess fidelity

Practice-based evidence

0

2

4

6

8

10

12

14

Before After

Parent training versus control

Intervention Control

Other things I would still like to see:

Make CYP-IAPY even more young person-centred

Make services (young) person centred

Covering transition from adolescence

to young adulthood

Integrating MH provision with other services

Youth-orientated

access point

Young person controlled

referral process

Shared decision-making

Empowering children, young people and carers

Participate in service design

Participate in training of practitioners & managers

Understand and modify treatment

progress via PROMs

Empowering young people enables them to….

1. Take control of their care

2. Establishtreatment goals

3. Choose the route to health that’s best for them

4. Improve their own health

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)

CYP-IAPT and integration initiatives

Close ties with other Tier 1 to Tier 3 programmes

YP MH services

Provide a platform for early identification and intervention

Interface/integrate with early psychosis youth services

Establish strong links with school counselling

programmes

Professor Mick Cooper, DPhil (Psych),

CPSY, Dip Counselling, AvDip

Psychotherapy,

Prevent social exclusion by integrating services

Mental health

services

Housing

EmploymentSocial

support

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

CYP-IAPT and physical health

Involve physical healthcare in mental healthcare and vice versa

Physical healthcare

Mental healthcare

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

CYP-IAPT and prevention

Involve the educational system in MH education

Mental

Health

Education

Anti

Bullying

Workshop

There is mandated physical health, sex (relationship) and drug abuse 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)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Incident suicide attempts Severe suicidal ideation

12 months follow-up

Youth Mental Health Awareness Programme (YMHAP)

Question, Persuade and Refer (QPR)

Screening by Professionals

Controls

OR: 0.52

[0.29 - 0.94]OR: 0.53

[0.29 - 0.96]

• 11,110 adolescents

• Average age= 14.8

• 168 schools

• 10 European countriesAustria, Estonia, France, Germany, Hungary,

Ireland, Israel, Italy, Romania, Slovenia & Spain

Three suicide prevention programmes (RCT)

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 attemptsOR: 0.52 [0.29 - 0.94]Reduction of severe suicidal ideationOR: 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

CYP-IAPT and resilience enhancement

“Differential sensitivity”

Self-regulationpredicts resilience

Peer influenceprotective against risk-promoting environments

Involvement in community and extracurricular activitiesimpact on biological stress response system

better overall adjustment

Family resourcesprotective against ACEs

Racial socialisationpositive outcomes in school, overall wellbeing,

less depression, higher self-concept

The Chicago Center for Family Health Resilience FrameworkCCFH

Parent-Child Interactive TherapyPCIT

Families OverComing Under StressFOCUS

HomeFront StrongMSPAN

The Child Illness and Resilience ProgramCHiRP

The Penn Resilience ProgramPRP

Steps Toward Effective and Enjoyable ParentingProject STEEP

Nurse-Family Partnership (US)NFP

Toddler-Parent PsychotherapyOklahoma State University Center for Family Resilience

University of IllinoisFamily Resilience Center

CorStone Family Resilience ProgramFRP

University of WisconsinFamily Resilience Program

Inner Resilience ProgramIRP

Open Doors’ Resilient KidsCCFH Bounce Back and Thrive!

BBT

Potential resilience enhancing

programmes for CYP-IAPT

CYP-IAPT, quality control

and the future

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.

What needs to happen?

We cannot wait complacently for new discoveriesMillions 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 essentialAnd 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 otherfor each of us to carry out our work

We need to mobilise all the individuals and organisations that have astake in YP’s future

To make changes to the current system to improve care for YPs

professor peter fonagy - cyp iapt national clinical lead

Healthcare