Mental Health Tribunal, 'Guidance for Tribunal Members on CAMHS cases' (April 2015)
Tribunal CAMHS guidance This document contains information under the following headings: (1) Introduction; (2) Service issues that impact on tribunal work; (3) Symptoms and presentation of illness in young people; (4) Legal aspects; (5) Tips for the Tribunal Doctor to facilitate the preliminary examination; (6) Advice for tribunal panel; (7) References.
- 1 Thanks
- 2 Child and Adolescent Mental Health (CAMHS)
Thanks to Dr Joan Rutherford (Chief Medical Officer, MHT) for providing this guidance document.
Child and Adolescent Mental Health (CAMHS)
CAMHS patients are 18 years and under.
Hearings for CAMHS patients represent 3% of the FTT-mental health workload.
CAMHS cases should have at least one CAMHS panel member – the member is indicated on the booking information.
The CAMHS panel consists of members experienced in CAMHS issues and trained in tribunal work.
2. Service issues that impact on tribunal work
There are re-organisations within services which have an impact on clinical team’s ability to manage risk and thus patients are detained rather than being maintained in the community. For instance, the reduction in Early Intervention teams means that patients transfer to adult community teams which may be less able to meet a young person’s needs.
Private sector services may be financially driven to admit patients, and child patients may be in the same accommodation as adults. There are increased numbers of private facilities which may be at a distance from the young person’s family, ‘home team’ and social services or education services. Private services may operate at a higher level of security than equivalent NHS services
In addition there is reduced availability of CAMHS secure care.
3. Symptoms and presentation of illness in young people
Symptoms are not always as clear as in adults. Depression in young people often presents as anger, excessive sleep/appetite as well as by more usual signs (poor sleep/appetite, weight loss, reduced contact with friends.)
In anorexia, the young person may agree to voluntary admission but then struggles to accept help and weight gain, and so MHA is necessary.
Hallucinations may be the result of PTSD or an attachment disorder rather than psychosis.
Young people with self-harm and suicide risks are more likely to be admitted. Self-harm can escalate with approaching discharge requiring teams and tribunal panel to consider short term and long term risk. The risk of inpatient admission and dependence has to be balanced against risk.
Features of borderline/emotionally unstable personality disorder can be present from a young age though often the diagnosis is not made till age 18. Some behaviours are normal features of adolescence; rebellion, anxiety, preoccupation with sex/self-image, experimentation with drugs, wild ideas, tantrums/outbursts, and some may be related to relationship and family difficulties.
4. Legal aspects
There is no minimum age for detention under the Mental Health Act.
Whether the MHA or the Children’s Act 1989 is used depends on the purpose of the detention. If the purpose is for medical assessment and treatment in hospital, then MHA applies. If the purpose is care and control because of unmanageable disturbed behaviour, then secure accommodation using the children’s Act may be appropriate.
The Mental Capacity Act has a presumption of capacity in over 16 years of age.
A 16 year old with capacity refusing treatment, when the treatment requires hospital admission for a mental disorder, should be under the Mental Health Act framework.
Deprivation of Liberty safeguards start at age 18.
Appropriate facilities must be provided (Code of Practice) subject to the young person’s needs.
There is no lower limit for Community Treatment Order but if under 18 and a referral there cannot be a CTO paper review.
S117 and CPA apply to CAMHS cases.
The Code of Practice recommends transition planning to start at least 6 months before the young person is due to leave CAMHS services (Chapter 19 para 119).
5. Tips for the Tribunal Doctor to facilitate the preliminary examination
- Approach confidently
- Be pleasant and approachable
- Explain carefully your role and that of the tribunal
- Explain the limits of confidentiality
- Listen actively
- Take time to summarise and check back
- Reflect on how the young person seems especially if angry or agitated
- Do have a professional who is known to the patient at the PHE, or an IMHA if the patient requests or the staff recommend
- If the young person doesn’t want to stay in the interview, try:
- ‘when and then’: when I’ve asked 5 more questions then you can go
- Offer choice in a ‘no choice’ situation. ‘Shall we have a 5 minute break now or carry on?
6. Advice for tribunal panel
- Young people may have a short attention span: they should be offered and encouraged to speak first.
- The Judge and Specialist Lay Member could introduce themselves outside the hearing room.
- The Tribunal judge should explain the process and ask the legal representative if young person wants parent(s) present at all/in part/not they speak
- Offer breaks especially if things are difficult
- Keep focussed on issues
- Be aware that the panel may be subject to family anger, because of parents’ conflict with hospital / their own absence re problems / the fact that the hospital isn’t including them.
- Do give reasons when giving decision; just a ‘no’ is insufficient. Do be clear, both with decision and what is positive.
The Senior Presidents Practice Direction (October 2013) gives guidance for Detaining Authority about reports for patients under the age of 18 in Section E.
ii. NICE guidance
There is a large range of guidance on the management of disorders in children and young people
iii. Code of Practice Chapter 19 concerns particular issues for Children and Young People
Original information: from training session Dr Mary Mitchell 2012 (Updated April 2015)