“Call the Doctor…Quick!” Assessing Children under the Mental Health Act
By Sarah Redmond
When I receive a request to undertake an assessment on a child, the first thing I do is mentally run through the list of available Section 12 CAMHS doctors and start dialling them almost immediately (as the list is fairly short, it’s a pretty straightforward task!). Am I embracing this task with such enthusiasm because the Code of Practice says that I should? I can tell myself this (and others if they ask) but the truth of the matter is that assessing children and young people is often filled with so much complexity, dilemma, resource battles and uncertainty that I am filled with the overwhelming desire to have the “right people” at the “right time” in the “right place”. A task that is so much easier said than done.
This feeling is not unusual in AMHP work but as the numbers of referrals for assessments on children steadily but slowly increase year on year, I am left wondering why these feelings continue to pervade and do not start to diminish with my increased levels of experience. If you are nodding away in agreement with some of my sentiments, then for full disclosure I should probably tell you that I am actually a social worker that comes from an eighteen year career in Children’s Services and only stumbled into AMHP work through a job on the Emergency Duty Service for my local authority eleven years ago. While I remain very grateful for the opportunities that doing my AMHP training has opened up to me (and I am a much better practitioner for completing it), I knew straight away that I was fairly unique at university having a very limited knowledge of mental health but oodles of safeguarding children experience (not brilliantly helpful on that AMHP portfolio!!)
My background in Children’s Services has been both a blessing and a curse, from the start I was often called upon to undertake high profile assessments on children as myself (and colleagues on the Emergency Duty Service) were considered to be the “experts”. Within my first six months of being an AMHP I was asked to complete an assessment on a child in a secured environment from a Section 2 to a Section 3. The risks were significant at the point of admission (both to themselves and others). Despite extensive information being available from the secure unit, there was nothing to support me in trying to establish what the actual risks were right now, in that moment. The young person was being monitored on a 2:1 basis night and day. There were minimal risks as every possible means had been eliminated by the extensive restrictions on their liberty. Do I depend on the risks that existed a month ago to inform the application despite many changes in the highly influential external circumstances or did I try and suppose what the risks might be outside of this environment if an application was not made? Also, there was also no definitive treatment plan as the young person had not been diagnosed with a ‘formal’ mental disorder.
This brings me to the first major difficulty in these particular assessments - the legal framework is not that helpful. 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 and Section 3 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” (19.5). This does not really assist where there is no defined or diagnosed mental disorder, more usually a cluster of behaviour patterns that are sometimes more 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.
So what can we do? – Remember that this life stage for the child is often characterised by increased desire for autonomous decision making, leading to impulsive and sometimes irrational behaviours and this is an understandable and natural progression. Consultation is key – establish patterns of behaviours and/or presentations; triggers and responses; stressors and positive associations/actions. Consult with as many people as practicable - professionals, family, carers but most importantly the expert – the child – preferably before the formal assessment even begins.
Even this seemingly straightforward suggestion should not be taken without caution though. Having recently assessed a child on a S136, who had been placed in a residential unit outside of their own local authority, I could sense that my consultation with the police and the residential workers had a very specific agenda. I am sure that I don’t need describe the detail but it is safe to say that there was a keenness for me to put pressure on the placing authority for a swift resolution outside of our county.
This neatly brings me onto the next level of complexity and that is the expectations of others both professionals and those personally linked to the child. These assessments are often preoccupied by discussions around risk to the child or young person. It is understandable that the age of the child heightens professional (including our own) and parent/carer anxiety. These assessments come with a sense of responsibility and it is easy to see how the balance could easily be tipped in favour of more restrictive interventions for protective reasons.
So what can we do with this? Try to separate out the actual risk from perceived risks, my experience tells me that often too much weight is put on what might happen and this is an unhelpful narrative to put around a child. We know that a child will say things or behave in a way to elicit a response and trying to take the time to understand motivating factors for them will sometimes help to reframe the risk and formulate a plan. I will also challenge, where necessary, the concept of risk elimination which often becomes the ultimate aim of these assessments. Also, these discussions should never shy away from the risks that a child may encounter coming into hospital – I find it useful to have frank discussions with both children (if their age and understanding allows) and their parents about what this looks like. This can be difficult and I speak with experience after a recent protracted and hostile discussion with a parent of a young person who really wanted them admitting to hospital.
Talking of coming into hospital, this brings to me to my final reflection. The question of accessibility. Hear the ultimate AMHP sigh as we tentatively mutter the word “resources” under our breath - whether that is in relation to beds, community-based interventions, crisis provision or support in admission arrangements, it is generally agreed that there is a “lack of”. In addition to this, these assessments can escalate dramatically particularly where a decision for admission is made. The 24 page referral form for NHS England (the bed managers) is merely the starting point for the avalanche of bureaucracy that can follow these assessments. Ranging from “pushback” from said bed managers such as requests for further assessments to extensive delay while a bed is identified means the path of admission rarely runs smoothly. For many AMHPs the focus of their attention is negotiating the logistical details of admission and combating the challenge that seems to arise from every angle in trying to secure a bed. This is not to diminish the role of the doctors involved in these assessments as it is often the case that they are equally engaged in navigating these challenges. However, the reality is that where there is delay, it is the AMHP that remains the pivotal point of contact for the many agencies circulating on the periphery awaiting outcomes.
So what can we do about this? – Focus on the child - I would argue that these distractions can make it increasingly difficult for the AMHP to focus on the child at the centre of the assessment and prioritise their experience. Sadly, when the focus is lost, we can be left feeling uncomfortable and dissatisfied. I think that we, as AMHPs carry these feelings which can be difficult to articulate and perhaps add to that sense of trepidation that we experience the next time the phone rings with an assessment on a child.
Let’s end on a positive – Despite the challenges, I would suggest that these assessments often exemplify the brilliance of AMHPs who rely on their own personal and professional knowledge to engage children; utilise their own access to resources to achieve the least restrictive option for them and adapt their skills in creative and innovative ways to protect and promote their mental and emotional wellbeing – great work all round!
If you have any views in relation to this area of practice – please get in touch: