Publication - Report

Child and Adolescent Mental Health Services: inpatient report

Published: 10 Nov 2017

A report recommending improvements to respond better to the needs of children and young people with Learning Disability (LD) and/or autism.

347 page PDF

2.1 MB

347 page PDF

2.1 MB

Child and Adolescent Mental Health Services: inpatient report

347 page PDF

2.1 MB

ISBN 978 1 78851 425 5 (Web only publication)
PPDAS 316867


An errata was published on 12/04/2018:

Page 33 - 4.6 Demographics, diagnoses, presenting issues and admission characteristics
This section was incorrectly numbered and has been corrected.

A number of inactive weblinks throughout the publication have been removed.

The pdf and html have both been updated within the document to reflect these changes.

This document is also available in pdf format (2.1MB)


Executive Summary and Recommendations


1. Introduction

1.1 Mental health of children and young people with learning disability

1.2 Current access to mental health inpatient care

1.3 Background to policy development for specialist mental health inpatient provision for children and young people with learning disability

1.4 Focus of this work

1.5 Potential impact of this work

2. Aims and Objectives

3. Method

4. Results and Discussion

4.1 Responses from clinicians

4.2 Possible under-reporting
4.2.1 Practical difficulties in identifying historical admissions
4.2.2 Children and young people with autism but without learning disability
4.2.3 Difficulties in identifying mental health issues and need for admission
4.2.4 Other evidence of under-reporting

4.3 Responses from families and carers

4.4 Views of children and young people

4.5 Variation between Health Boards

4.6 Demographics, diagnoses, presenting issues and admission characteristics
4.6.1 Ethnic group
4.6.2 Gender
4.6.3 Age
4.6.3 Looked after and accommodated children
4.6.4 Level of learning disability and rates of autism spectrum disorder
4.6.5 Diagnoses
4.6.6 Presenting behaviours
4.6.7 Police involvement
4.6.8 Admission rates over time
4.6.8 Reasons for admission
4.6.9 Mental Health Act
4.6.10 Staff: patient ratio

4.7 Where children and young people were admitted to
4.7.1 Admissions to hospital settings
4.7.2 Admissions to age-appropriate facilities
4.7.3 Admissions to non-hospital settings or remained at home

4.8 Pathways
4.8.1 Waits for an admission
4.8.2 Length of admission
4.8.3 Transfers and multiple admissions
4.8.4 Discharge destination

4.9 Impact and outcomes of the current situation on children and young people and families
4.9.1 Impacts of waiting for a bed
4.9.2 Outcomes from admissions to wards in Scotland
4.9.3 Outcomes when a child or young person was not admitted to hospital when required
4.9.4 Outcomes from admissions to specialist units in England

4.10 Impact and outcomes of current situation on services, clinicians and their other patients
4.10.1 Summary of financial costs
4.10.2 Costs of patients admitted to specialist LD CAMH/ ASD specific wards in NHS England
4.10.2 (i) Financial risk sharing scheme
4.10.2 (ii) NSD spending on LD CAMH and ASD CAMH inpatient care
4.10.3 Direct costs to Health Boards
4.10.4 Costs to local authorities
4.10.5 Other impacts on local services and on clinicians

4.11 Numbers and profiles of patients requiring specialist inpatient care not presently available in Scotland
4.11.1 Profile of patients requiring specialist LD CAMH inpatient provision
4.11.2 Autism spectrum disorder (non-learning disability) specific provision

4.12 Other study findings
4.12.1 Community LD CAMH services
4.12.2 Robust individualised settings

5. What This Work Indicates

5.1 Service size of a Scottish LD CAMH inpatient unit
5.1.1 Estimated bed requirements from survey evidence
5.1.2 Other evidence and recommendations regarding bed number requirements

5.2 Age range catered for

5.3 Estimated average length of stay

5.4 Service specification for a specialist LD CAMH inpatient unit
5.4.1 Physical environment
5.4.2 Staff skills
5.4.3 Patient characteristics
5.4.4 Co-location with other units
5.4.5 Other service specification information

5.5 Parallel developments required in services outwith an inpatient facility

5.6 Care pathways and interface of a Scottish LD CAMH inpatient unit with other services
5.6.1 Existing inpatient units
5.6.2 Forensic CAMHS
5.6.3 Referral criteria
5.6.4 Outreach/support function to community LD CAMH services
5.6.5 Other health services:
5.6.6 Other agencies:
5.6.6 (i) New models of proactive multiagency working
5.6.6 (ii) Supporting timely and effective discharge
5.6.7 Cross-border issues

5.7 The LD CAMHS Scotland Network

5.8 Potential benefits of a specialist Scottish LD CAMH inpatient unit
5.8.1 Summary of study participants' views
5.8.2 Benefits to children and young people with learning disability requiring mental health admission
5.8.3 Benefits to community LD CAMHS and other patients
5.8.4 Financial benefits

5.9 Cautions about a specialist Scottish LD CAMH inpatient unit:
5.9.1 Travel
5.9.2 A specialist unit would not replace all use of admissions to non-specialist wards
5.9.3 Any specialist unit must be a mental health treatment facility not a long term residential care unit

5.10 Role of families

6. Full Recommendations



A1: Contributors and supporting costs

A2.1: Discussion paper re issues to consider when young people with learning disabilities are admitted to adolescent inpatient units

A2.2: The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care: Effectively implementing the Framework to improve the mental health of children and young people with learning disabilities

A3: Methodology

A3.1 Questionnaires used in the survey for clinicians
A3.1.1: Guidance notes
A3.1.2: Hospital admission form
A3.1.3: Admission to non-hospital facility form
A3.1.4: Stayed at home/usual place of residence form
A3.1.5: Example of covering e mail to professional groups
A3.1.6: Covering letter to Health Boards

A3.2: Questionnaire for families/carers
A3.2.1: Parent survey letter
A3.2.2: Parent questionnaire

A3.3 Telephone interviews with clinicians
A3.3.1: Crib sheet for telephone interviews with clinicians

A3.4: Interviews with parents/carers
A3.4.1: Family Interview Schedule
A3.4.2: Approach to interviewing parents/families

A4: Results

A4.1 Introduction/overview
A4.1.1 Data management
A4.1.2 Questionnaire submissions
A4.1.2 (i) Clinician questionnaire submission results – overview
A4.1.2 (ii) Family questionnaire submission results – overview
A4.1.3 Interviews with clinicians
A4.1.4 Interviews with families/carers

A4.2 Demographic information on patients included in study
A4.2.1 Ethnic group
A4.2.2 Gender
A4.2.3 Age
A4.2.4 Looked-after children

A4.3 Diagnoses
A4.3.1 Level of Learning Disability
A4.3.2 Autism spectrum disorder diagnosis
A4.3.3 Additional psychiatric diagnoses
A4.3.4 Physical health diagnoses

A4.4 Presenting behaviours and admission characteristics
A4.4.1 Presenting behaviours
A4.4.2 Police involvement at any stage
A4.4.3 Year of admission
A4.4.4 Reasons for admission
A4.4.5 Detention under Mental Health Act
A4.4.6 Staff: patient ratio required during admission

A4.5 Pre-admission issues
A4.5.1 Time taken from identification of need for admission to admission
A4.5.2 Positive pre-admission experiences
A4.5.3 Pre-admission issues where existing 'generic' CAMHS in-patient unit required
A4.5.4 Pre-admission issues where specialist LD CAMHS inpatient unit required
A4.5.5 Trying to avoid admission and managing while waiting for a bed
A4.5.5 (i) Response from out-patient teams
A4.5.5 (ii) Intensive community treatment services
A4.5.5 (iii) Pediatric and social care services
A4.5.6 Looked after children and out of area placements
A4.5.7 Impact of pre-admission difficulties on children, young people and their families

A4.6 Admissions to different types of ward - overview
A4.6.1 Type of ward admitted to for all admissions
A4.6.2 Profile of patients admitted to different types of ward
A4.6.2 (i) Level of learning disability
A4.6.2 (ii) Age at admission
A4.6.2 (iii) Autism spectrum disorder diagnosis
A4.6.3 Summary of issues and outcomes to currently available Scottish units

A4.7 Admissions to Adult Learning Disability (ALD) wards
A4.7.1 Positive aspects of care
A4.7.2 Patient safety
A4.7.3 Lack of age-appropriate environment and interventions
A4.7.4 Parental concerns and relationship with services
A4.7.5 Complex/severe presentations and staff expertise
A4.7.6 The physical ward environment

A4.8 Admissions to regional young people's units (YPUs)
A4.8.1 Positive aspects of care
A4.8.2 Patient groups with less access to YPUs
A4.8.3 Parental concerns/relationships with services
A4.8.4 Staff expertise and experience
A4.8.5 The physical ward environment

A4.9 Admissions to National Child Psychiatry Inpatient Unit
A4.9.1 Parental concerns/relationships with services
A4.9.2 Staff expertise and experience

A4.10 Admissions to Adult Mental Health (AMH) wards, including intensive psychiatric care units (IPCUs)
A4.10.1 Patient safety
A4.10.2 Parental concerns/relationships with services
A4.10.3 Lack of age-appropriate environment and interventions
A4.10.4 Staff expertise and experience
A4.10.5 The physical ward environment

A4.11 Admissions to Pediatric wards

A4.12 Admissions to specialist mental health inpatient units in England
A4.12.1 Pre-admission issues
A4.12.2 Cross-border transfers and the Mental Health Act
A4.12.3 Benefits of specialist LD CAMH inpatient units
A4.12.4 Distance and its impact
A4.12.5 Discharge planning
A4.12.6 Other issues and concerns

A4.13 Not admitted to hospital when it was required
A4.13.1 Profile and presentations of those not admitted to hospital when required
A4.13.2 Reasons admissions were required
A4.13.3 Reasons for not being admitted
A4.13.4 Interventions during time when admission required
A4.13.4 (i) Health interventions
A4.13.4 (ii) Social work and education interventions
A4.13.5 Impact on patient and family
A4.13.6 Patient safety

A4.14 Patient pathways
A4.14.1 Length of admission
A4.14.2 Transfers between inpatient units within an admission
A4.14.3 Repeat admissions by individual patients
A4.14.4 Pathways for patients requiring specific types of units

A4.15 Discharge

A4.16 Community context
A4.16.1 Local provision and access to specialist knowledge
A4.16.2 Intensive community LD CAMH services
A4.16.3 Individualised specialist environnments in the community
A4.16.4 Staff experience of learning disability and autism spectrum disorder
A4.16.5 Multiagency community services

A4.17 Concerns raised by families via interviews
A4.17.1 Managing the implications of diagnosis
A4.17.2 Communication and involvement
A4.17.3 Lack of written information about processes
A4.17.4 A non-holistic perspective of the young person
A4.17.5 A lack of therapeutic input and other interventions within settings

A4.18 Impacts on services, clinicians and their other patients
A4.18.1 Impact of pre-admission issues
A4.18.2 Impact of admissions to Scottish wards
A4.18.2 (i) Adult wards
A4.18.2 (ii) Age-appropriate admissions
A4.18.3 Admissions to English specialist units
A4.18.4 Patients not admitted when required

A4.19 Data on clinicians' opinions on type of hospital ideally required by their patients
A4.19.1 Actual admission destinations for those requiring specialist LD CAMH inpatient unitA4.19.2 Type of hospital ideally required by those with different levels of learning disability
A4.19.3 Profiles of those requiring different types of specialist units
A4.19.4 Profiles of those requiring LD CAMH specialist or 'mainstream' YPU provision
A4.19.4 (i) Level of learning disability
A4.19.4 (ii) Gender
A4.19.4 (iii) Age at first admission
A4.19.4 (iv) Reason for admission
A4.19.4 (v) Staff ratio required

A4.20 Clinicians' views on the potential advantages to their patients of specialist mental health inpatient provision in Scotland for children and young people with a learning disability
A4.20.1 Earlier, more effective treatment
A4.20.2 A safer, more appropriate physical environment
A4.20.3 Thorough assessment and treatment from a specialist multidisciplinary team
A4 20.4 Other advantages

A5: Experiences from working with families of children and young people with learning disability and/or autism spectrum disorder requiring inpatient mental health care (Kindred)