Mental health assessments of children – we must do better

Published by Professional Social Work magazine, 2 February, 2023

In the ten years I’ve worked as an AMHP I have seen a steady increase in requests for formal assessment of children and young people under the Mental Health Act.

Contributory factors include the pressures of social media, high levels of social isolation perpetuated by the pandemic, and limited access to health professionals and social workers (particularly for children who are living within the care system).

Access to care and support has been brought into sharp focus by the publication of a new report. Away from Hospital and into the Community by Look Ahead highlights concerns with provision of services and raises questions about the threshold for admission to hospital.

Inadequate resources are impacting on AMHPs and doctors ensuring that outcomes for children are least restrictive. For AMHPs there needs to be an open and transparent discussion about implications for practice and how it shapes and influences our decision-making.

In my experience assessments can be complex, challenging, and protracted and they are undoubtedly traumatic for the children and young people involved. I am often left concerned about the outcome and troubled by the long-term implications for the families involved, with children being isolated in a hospital a long way from home or living with the stigma of mental illness. I am left wondering why these assessments are so difficult when complexity is now intrinsic in many areas of AMHP practice.

So here are my reflections:

Training and Experience

The National Workforce Plan for Approved Mental Health Professionals (2019) found that the vast majority of AMHPs currently practising were situated within adult services with only three per cent in children’s services. While the plan encourages local authorities to train AMHPs across all services including children’s and recommends a strategy for recruitment and retention, there is clearly a long way to go.

The reality is that many AMHPs and Section 12 doctors feel ill-equipped to assess children, bringing into question the quality and depth of training. This is despite the expectation that assessments will be covered by the duty arrangements in place within their organisations.

To really enhance the training of AMHPs, direct contact with children and young people should be integral, either through placement settings, or fully embedded within the wider training programme.

Currently within AMHP training standards published by Social Work England there is no reference to the specific assessment of children and young people, only guidance on supporting candidates to “understand the needs of children and young people and their families, and the impact those needs have on AMHP practice.”

This does not sufficiently consider the complexity of these assessments, such as decision making within the scope of parental responsibility and the ambiguous nature of consent and capacity.

Without definition of the complexities involved, there is a risk of inconsistent interpretation, further compounded by a workforce heavily dominated by professionals whose expertise and knowledge lies within adult services.

Access to Resources

Research indicates that the majority of inpatient healthcare provision for under 18s is funded privately, although access to this provision remains in the hands of NHS England. The referral process and subsequent wait for allocation is complicated and protracted leaving the AMHP trying to manage high-risk situations while factors beyond their control cause anxiety, delay, frustration, and trauma to those being assessed and their families.

It is not unusual for assessments to conclude without adequate resolution while a bed is identified, and children are left in temporary and highly unsuitable arrangements such as paediatric wards or alternative places of safety. These decisions often carry a degree of discomfort and uncertainty for the assessing team and almost certainly intensify the trauma for the child.

The report completed by Look Ahead champions the use of targeted community support for children and finds that access to CAMHS provision had a significant impact on reducing hospital admission. For AMHPs, access to adequate community provision would enable consideration and planning to support the principles of the least restrictive actions within the assessment process

Assessment of risk

This is a key contributory factor to the heightened professional anxiety experienced by those completing assessments. The decision to make an application for admission to hospital carries great responsibility. Adolescence is a life stage characterised by a search for identity and is often associated with autonomous, impulsive and risk-taking behaviours, sometimes accompanied by degrees of emotional dysregulation.

The way in which emotional dysregulation manifests often leads to requests for Mental Health Act assessments and can leave doctors and AMHPs trying to define a degree of risk based on factors that quickly fluctuate or deteriorate given a particular context.

Relying purely on the legislative framework of the Mental Health Act and Code of Practice is often insufficient as the criteria for admission under Section 2 specifically states “[a patient] is suffering from mental disorder of a nature or degree which warrants the detention”.

The Code of Practice goes a little further and encourages AMHPs to consider the “developmental process from childhood to adulthood…in addition to the child and young person’s personal circumstances, when assessing whether a child or young person has a mental disorder”. But this does not really assist where in many assessments there is no defined or diagnosed mental disorder, more usually a cluster of behaviour patterns indicative of emotional distress.

In these circumstances, the second element of the criteria for admission, namely “[detention] in the interests of his own health or safety or with a view to the protection of other persons”, becomes the pivotal turning point of decision-making.

Working with children and young people who need Mental Health Act assessments is clearly an area of practice that requires specific levels of knowledge and expertise. Without it AMHPs are left to draw on personal and professional experiences not necessarily consistent with processes and practices associated with adult assessments.

Being stretched to our professional limits in this way is not conducive to meeting the principles outlined in the Mental Health Act Code of Practice. More importantly, it is not achieving the ultimate responsibility of ensuring that the best interests of the child are central to each assessment.

So, what can we do now? My advice would be to stop and take stock at the point of referral:

• Investigate: make connections with parents, carers, social workers, residential workers, nurses, CAMHS and even wider if necessary and appropriate. I often find these discussions start to identify and address areas of professional anxiety – including our own!
• Slow things down: use the opportunity to really engage the child in a way that feels safe to them. Accept that their feelings and emotional responses are subject to rapid change - their presenting behaviours may be a response to events that have led them to point of assessment.
• Form a realistic view: in some circumstances admission to hospital for their own safety may be appropriate even where a behavioural element to the presentation is evident. Emotional distress is not only a coping mechanism and underlying mental disorder or trauma may coexist that could be missed if an over-reliance is placed on presenting behaviours.
• Consider options: children and young person assessments rarely end neatly particularly where no admission is required. Options such Section 25 Welfare Orders (Children Act) or alternative accommodation arrangements are highly unlikely following conclusions of MHAs due to policies and procedures within local authorities. While this does not negate their responsibility, navigating further support and intervention is extremely complex.
• Be informed: outside of assessments there should be opportunities to undertake specific training in relation to CYP assessments and also use your experiences to inform others through AMHP peer support networks.