The behaviour and family support team (BFST) is a specialist child and adult mental health service (CAMHS) service that focuses on the emotional, behavioural and mental health needs of children with moderate to severe learning disabilities and/or autistic spectrum disorders and aspergers Ssndrome. The BFST is a multidisciplinary service consisting of a full time consultant clinical psychologist/manager, two full time clinical psychologists, an assistant clinical psychologist, a part time speech and language therapist, occupational therapist, psychiatrist and office administrator. We see children aged 5- 18 years who live in Kensington and Chelsea. The BFST has an intervention focus, as opposed to a focus on diagnostic assessment.
The team provides intervention work across different settings, consultation, family support and counselling, practical advice strategies, direct CBT/emotional literacy work, social skills training and joint work with/referral to other services where appropriate.
Aims and objectives
The BFST was set up in 2005. It's aims are;
- To meet the gap identified by the children's National Service Framework (2004) regarding CAMHS services for children with disabilities by extending and improving access to CAMHS for these children and their families.
- To provide a borough wide service that builds on existing initiatives (including generic CAMHS and local Child Development Services) and offer a specialist service for children with disabilities who present with challenging behaviours.
- To improve, stabilise and help manage challenging behaviour by;
- sustaining educational placements
- preserving family and peer relationships
- minimising placements away from home
- contributing to multi-agency co-ordination of family support
- addressing transition issues (16/17 year olds).
- To contribute towards establishing an integrated service for disabled children in Kensington and Chelsea in line with the expectations and outcomes of Every Child Matters.
Reasons for implementing your project
Within Kensington and Chelsea, children with suspected moderate to severe learning disabilities and children on the autistic spectrum are assessed in the local CDC's, and/or generic CAMHS, dependent on age and concerns at referral. Subsequent access to therapeutic input for these children presenting with behavioural and/or emotional difficulties post diagnosis was felt to be variable and limited at the time the bid for a new service was made.
A local audit of CAMHS showed that families of children with disabilities were not routinely accessing help through existing generic CAHMS services, and a consultation process overseen by a multi-agency steering group including representation from Health, Social Services and Education as well as user group involvement, highlighted the need for a specialist intervention service which could offer a more accessible, flexible, intensive, outreach, and timely approach.
As the BFST was filling an identified gap in services, the expectation was that families who had not previously accessed mental health services would be able to do so, and that families that may have been seen by generic CAHMS, would be referred to the team, reducing the pressures on the local CAMHS services. It is difficult to tease out to what extent the BFST saves costs, as the impact of the work we do can only be effective alongside the other agencies involved with these families. A cost saving and risk reduction analysis conducted in March 2012 looking at cases open to the team suggested that BFST involvement had contributed to saving costs by for instance:
- Preventing children's school placements from breaking down (e.g. maintaining children in mainstream school who might otherwise have gone to specialist schools or maintaining children in special schools, who might otherwise have gone to residential schools.
- Facilitating children moving from specialist schools to mainstream school with support.
- Reducing risk of family breakdown and placement into foster care by supporting a family to care for the child at home or for a longer period of time than they would have otherwise been able to manage.
- Reducing the risk of inpatient admission.
How did you implement the project
As the BFST was a new initiative, setting up the team involved an in depth consultation process with key stake holders (including service users), as well as research into existing specialist CAMHS services. A steering group has met regularly since its inception, ensuring that the BFST continues to offer services that are helpful to families and the network, and continues to evolve.
The BFST was initially funded by a two year government grant, but since 2007, has joint funded by the Local Authority (75%) and what was previosuly the local Primary Care Trust (25%). As of 2013, the service cost approximately £294,000 per year.
An important consideration when establishing the service was where the BFST might be located (e.g. within an established generic CAMHS service or as a separate service), which required work to address some local resistance/concerns about a service. Joint posts were and continue to be helpful in this process, as was joint working of complex cases with other services.
This resulted in services understanding our model, how we differ from existing services and how/when we can be helpful. It was/is also important to secure support at all levels of the organisation (e.g. from managers) by for instance regular attendance at multi agency meetings and planning meetings.
The BFST has always evaluated the service and monitored outcomes. The service carried out an evaluation project at the end of the Department of Health funding period. The team managers host multi-agency steering group meetings which are a forum for updating members on issues faced by the team as well as for considering new initiatives. The team is represented at and contributes to various local inter-agency meetings that address service development and review for disabled children and their families. The service works at developing links with community and more specialist services locally to develop the range of support available to these children and their families.
In our day-to-day work, we use the Honos-LD as a formal standardised outcome measure which is completed pre and post intervention. This is supplemented by a locally devised individual goal/outcome form which is completed in collaboration with each parent and or child/adolescent were appropriate, and lists all of the initial difficulties raised by the family/system and then goals for intervention. At discharge, the family and clinician discuss to what extent the goals have been met. The team collects parent/carer/child/referrer views via in house satisfaction questionnaires and where appropriate has used child/LD friendly outcome measures which have been adapted to be more developmentally appropriate for our clients. The Developmental and Behaviour Checklist was piloted but is currently only used on specific cases. Until last year, our team completed the Paddington Complexity scale for each case, which enabled us to analyse the nature of our client group, and the issues they face. We stopped using this measure because it was not providing meaningful data.
Our trainee clinical psychologist and asssistant psychologist complete an annual audit of the service which has consistently shown that BFST intervention leads to improvement in behaviour problems and relationships with others as measured by the HONOS-LD and that the majority of goals set with parents are met (from the 2011-2012 audit: 75% of clients were felt to be doing "better" or "much better" at follow-up compared to initial assessment). Although many presenting problems in this client group are chronic and intractable, more indirect benefits have included: increased understanding of a child's difficulties, a coherent care plan amongst professionals, improved relationships with other agencies and improved relationships within the family.
Key learning points
- Setting up a specialist team takes considerable time in terms of securing funding and resources, recruitment and induction, agreeing team remit, procedures and protocols.
- A proactive parent/carer group, who were able to lobby for a specialist CAMHS service and their continued representation on the multi-agency steering group, helped keep the focus on the needs of children and their families.
- Have a collaborative approach with parents when developing/delivering all strands of services to disabled children (e.g. social work, respite, play services).
- An active steering group with representation from key services (Special Educational Needs, Social Services, Health) has been key in forming a shared vision and ownership of the service.
- Being positioned physically and strategically alongside our children with disabilities social work team within the Local Authority enabled shared management structures, joined up working and positive working relationships.
- It's important to take a multiagency approach at all levels of the service.
- A clearly defined focus on intervention enabled us to make the best use of our energies and skill set.
- A multidisciplinary staff mix enabled us to address difficulties with communication and sensory difficulties common in our clients.
- A flexible, creative 'can do' approach at all levels.
- It helped to have access to specialist music art and play therapies within the borough.
- Being well resourced included having a budget for training, a specialist library, practical equipment such as a camcorder, laminator, symbol soft ware, sensory equipment etc.
- It's important to have a good respite service offering a range of play and overnight options.
- Outcome measures may reflect small changes or benefits not limited to behaviour/symptom change.
- New services need to consider ways of demonstrating effectiveness to secure ongoing funding.