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Appendix 1: A Note on Terminology

Mental Health

There are recognised difficulties in defining the problems that affect children and young people. The approach taken in Together We Stand (17) offers a consistent and widely agreed language and fits with the survey conducted by the Office for National Statistics (18) as follows:

'Mental health problems may be reflected in difficulties and/or disabilities in the realm of personal relationships, psychological development, the capacity for play and learning and in distress and maladaptive behaviour. They are relatively common, and may or may not be persistent.'

When these problems (conforming to the International Classification of Diseases (ICD) (19) criteria) are persistent, severe and affect functioning on a day-to-day basis they are defined as mental health disorders. In a small proportion of mental disorders, the term mental or psychiatric illness is used, to describe the very severe cases, for example, of depressive illness, psychotic disorders and anorexia nervosa. The Audit Commission report Children in Mind (20) found that many children presented to CAMHS with more than one condition, and up to five presenting complaints. It is common to find the presence of co-morbidity (more than one mental health disorder present, e.g. attention deficit hyperactivity disorder (ADHD) and depression, or ADHD and conduct disorder) which increases the challenge and 1 complexity of the care and treatment required for children and young people in the community.

What is CAMHS?

The term CAMHS (Child and Adolescent Mental Health Services) is used in two different ways. One is a broad concept embracing all services that contribute to the mental health care of children and young people, whether provided by health, education, social services or other agencies. Hence it includes those services whose primary function is not mental health care e.g. general practice or schools, referred to as Tier 1 or universal  services ( see 'The Four Tier Strategic Framework'). The other applies specifically to specialist child and adolescent mental health services at Tiers 2, 3 and 4, and also including specialist social care, educational, voluntary and independent provision for children and young people with mental health problems. For these services, the provision of mental health care to children and young people is their primary function. They are mainly composed of a multidisciplinary workforce with specialist training in child and adolescent mental health. In this National Service Framework, the term CAMHS is used to refer to the broader service concept, and specialist CAMHS to refer to the latter.

CAMHS cover all types of provision and intervention from mental health promotion and primary prevention, specialist community-based services through to very specialist care as provided by in-patient units for young people with mental illness (Tiers 1-4). Interventions may be indirect (e.g. consultative advice to another agency) or direct (e.g. direct therapeutic work with an individual child or family). Services for children, young people and their families in Tier 1, will focus on the initial assessment and identification of difficulties and may include advice or the provision of therapeutic help that does not require intensive specialist training or onward referral. The nature, severity, complexity and specificity of the child's mental health problem will help determine where the child is best seen and by which service. Specialist services may be offered in a range of  settings according to need and availability, often in partnership with other agencies, including in community locations, out-patient clinics, day and in-patient units and the family's home. Specialist CAMHS will provide a range of assessment and treatment options singly or in combination, utilising the skills of multi-disciplinary teams. Where the problems are uncommon or particularly complex, the child or young person may require referral on to highly specialist Tier 4 services.

The Four Tier Strategic Framework

In 1995, the NHS Health Advisory Service published a thematic review of CAMHS (17), which described a four-tier framework (see Box 4 for an example of how the framework can be described). Later work on CAMHS carried out by the Audit Commission (20) took the four-tier strategic approach as its baseline and its report confirmed the applicability of this approach to future planning. Although there is some variation in the way in which the tiered strategic framework has been developed and applied across the UK it has created a common language for describing and commissioning services.

Where services are described in this NSF, references have been made to the four-tier framework. But it is important to stress, that whilst the framework is a useful conceptual tool, it should not be seen as something constraining or limiting. Neither services nor people will fall neatly into tiers and nor should they. Similarly, there is a misconception that a child or young person will move up through the tiers as their condition is  recognised as more complex. In reality, there will be some children and young people that may require services from a number, or even all of the tiers, at the same time.

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