Referral guidance for Lincolnshire CAMHS

Our exclusion criteria

Children and young people will not be accepted

• Where an emergency response for an immediate physical or medical health emergency is required. In this case the emergency services should be contacted by the referring agent or the individual should be taken to an Accident and Emergency Department.
• Behavioural problems where no other interventions have been tried with parents/carers and school according to the ‘Collaborative Lincolnshire Behaviour Pathway’.
• For the assessment, diagnosis of, or review of medication for ADHD.
• For the diagnosis/treatment of Autism Spectrum Disorder (ASD), Tourette’s Syndrome, Dyslexia, Dyspraxia and other neurodevelopmental disorders of childhood. For clarity, these are not diagnosis of exclusion and a young person with a diagnosis of ADHD, ASD and other neurodevelopmental disorders of childhood who is referred to CAMHS with a clear secondary mental health need will be able to access a service for the period of treatment of the mental health problem.
• For the provision of purely physical health and/or sexual health in isolation of a mental health need.
• For treatment of a substance misuse problem. However if there are coexisting mental health problems, these should be discussed with CAMHS through the Here4You Line.

Who can refer?

Referrals will be accepted from:

• GPs
• Social workers
• Paediatricians
• Vulnerable Children’s Nurses
• 01-9 Service
• GP Surgery Nurse Practitioners
• Educational psychologists
• Special Educational Need & Disability Team
• Teachers / Educational staff
• SENCO's
• Youth Offending Team
• Barnardo’s (leaving care referrals)
• Parent/carer
• Self

How to refer

The young person’s GP, Paediatrician or Social Worker can refer directly to the service in writing or using a CAMHS referral form via a single point of access. This should be addressed to:

Lincolnshire CAMHS

LPFT Single Point of Access

Sycamore Assessment Unit

Beacon Lane

Grantham

NG31 9DF

All other referrers should first speak to the Here4You Line to confirm what interventions have already been tried with the young person and to receive guidance on the suitability of the referral. If it is agreed to be a suitable referral, the referrer should submit this using a CAMHS referral form and include copy of the Advice Form.

Once a referral has been confirmed as suitable, it should be submitted using a CAMHS referral form to the address above. Lincolnshire Here4You is available between 9.30am and 4.30pm Monday to Friday. Call 0800 234 6342.

Clinical guidance

Depression

Before referring to CAMHS

• There is an expectation that the GP has seen the child and carried out a period of ‘watchful waiting’. 
• There should also be evidence the young person has received support from professionals within universal services with regards to self-help strategies. For example, advice offered about benefits of regular exercise, sleep hygiene, anxiety management and nutrition. These must not have not helped to make an improvement.
• Consultation can be accessed via the Lincolnshire Here4You Line to support the above strategies.

Severity is often indicated by the degree to which the child can no longer achieve as well at school and mix with friends.

Thoughts and feelings may be linked to past significant traumas and events.

A referral to CAMHS should be made

• If the difficulties are not related to age appropriate mood variation and are a substantial change from previous behaviour.
• Where there is a significant impact on daily living. For example, sleeping, appetite, decrease in energy, poor concentration and decreased interest or pleasure in daily activities. Somatic symptoms may also be present.

And/or

• A change in the child’s behaviour indicating sustained sadness, irritability and anxiety, with subjective feelings of negativity, low self-worth and hopelessness.

Anxiety (general and social)

Before referring to CAMHS

• There is an expectation that the referrer has seen the child. There is evidence they have received support from professionals within universal services and this has not helped to make an improvement. This will include mental health promotion and advice.
• Consultation can be accessed via the Lincolnshire Here4You Line.

Bodily symptoms are common.

Younger children may not clearly voice subjective feelings of worry and dread but may be clingy, tearful and show regressed behaviour.

A referral to CAMHS should be made

• Where the anxiety is inappropriate for, and/or affecting, the child’s stage of development or level of functioning or resulting in substantial distress.
• If persistent anxiety has been present for more than four weeks and has not responded to appropriate support and intervention from universal services.
• Where the levels of anxiety experienced cause avoidance or isolation that interferes significantly with the child’s everyday life.
• Where there is a sudden change or deterioration in the child’s wellbeing.
• Where there is a damaging impact on family and other relationships.
• If there are generalised anxiety symptoms, anxiety linked to significant past traumas, life-restricting phobias, panic disorder, social phobia, and/or separation anxiety disorder. Separation anxiety may sometimes present as a particular pattern of non-school attendance.

Anxiety (OCD and BDD)

Before referring to CAMHS

• There is an expectation that the referrer has seen the child. There is evidence they have received support from professionals within universal services and this has not helped to make an improvement. This will include mental health promotion and advice.
• Consultation can be accessed via the Lincolnshire Here4You Line.

A referral to CAMHS should be made if the young person has been experiencing

• Intrusive repetitive thoughts (obsessions)

And/or

• Repetitive, ritualistic, unwanted actions (compulsions). These will be sufficiently distressing and impairing for the child to change their behaviour and cause disruption in the family.

Post Traumatic Stress Disorder (PTSD0 and trauma

Before referring to CAMHS

For PTSD sufferers presenting in primary care, GPs should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment.

Children, particularly those aged under eight years, may not complain directly of PTSD symptoms. These may include re-experiencing or avoidance. Instead, children may complain of sleeping problems. It is therefore vital that all opportunities for identifying PTSD in children should be taken.

When assessing a child or young person for PTSD, healthcare professionals should ensure that they separately and directly question the child or young person about the presence of PTSD symptoms. They should not rely solely on information from the parent or guardian in any assessment.

• When symptoms are mild and have been present for less than four weeks after the trauma, watchful waiting as a way of managing the difficulties presented by individual sufferers should be considered by primary healthcare professionals. Expected reaction to the event could include nightmares, bedwetting, clinginess and tearfulness.
• A follow up contact should be arranged within one month.

Or, if symptoms are already severe within a month, refer straight to CAMHS.

A referral to CAMHS should be made

• When symptoms have been severe after one month.
• Where symptoms have been present for more than three months after a trauma. These could include hyper-vigilance, avoidance, flashbacks, or a marked increase in unexplained temper tantrums or episodes of other distress.

As a result of a single trauma or familial or extra familial abuse, the child may display repetitive, intrusive memories, thoughts, images and emotions during wakefulness and trauma-related nightmares during sleep.

Complex presentations as a result of multiple or historical abuse may involve early life disruption and an unstable environment. The young person may exhibit re-experiencing, avoidance, numbing and/or increased arousal symptoms.

Bereavement (Complex and Unresolved Grief)

Before referring to CAMHS

The young person should have been given time to experience a normal grief reaction. They should then be offered counselling either through school or a recognised bereavement counselling service.

A referral to CAMHS should be made:

• Where there is a prolonged grief response or where the child or young person is experiencing significant distress following a death that has occurred in traumatic circumstances.

Self-harm

Before referring to CAMHS

• Children and young people who present to primary care with recent untreated current or imminent self-harm should be taken to A&E.
• Universal services should work with the young person to develop harm reduction strategies and reinforce existing coping strategies.
• Universal services can access the Lincolnshire Here4You Line for support.

A referral to CAMHS should be made

• Where there is no need for urgent care but evidence of persistent or severe self-harming behaviour, or persistent suicidal ideation.

Eating disorders

Before referring to CAMHS

• For young people with eating disorders presenting in primary care, GPs should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment.
• The GP should carry out baseline physical tests including height, weight, FBC, U&Es, and LFTs. These should be provided with the CAMHS referral.

A referral to CAMHS should be made if there is

• Significant weight loss or low weight.
• Eating habit problems.
• Body image problems that are leading to deterioration.
• Physical health issues. 
• Issues with daily functioning.

CAMHS will provide support to young people with anorexia nervosa, bulimia nervosa, binge eating disorder and atypical eating disorders.

Attachment Disorders

Before referring to CAMHS

Young people with low level attachment difficulties that do not impact significantly on their life, including home, education and peer relationships, should be addressed within universal services.

Mental health support can be accessed via the “Lincolnshire Here4You” telephone line. If the child or young person resides in a Lincolnshire County Council (LCC) residential placement, the allocated (dependant on locality) link worker in CAMHS should initially be contacted directly for advice.

A referral to CAMHS should be made 

• When significant attachment difficulties are identified that are in the borderline/clinical range of concern, these will be impacting significantly on all aspects of a child/ or young person’s life. For example, home, peer relationships and education. These referrals are most likely to be Looked After Children (LAC), young people adopted from care or at high risk of going into care.
• If the referral requires an initial assessment with CAMHS, then accept it as per the usual CAMHS screening process. Offer an initial assessment appointment for the child or young person and parents/carers to attend the relevant CAMHS hub.
• If the referral appears to be more suited for a consultation to the system (see clinician screening guidance), open the referral and offer a consultation appointment for the relevant CAMHS hub (admin). In this instance, invite the social worker (corporate parent; has PR) and indicate that the social worker should invite appropriate adults/professionals. For example, foster carer/s, education, and/or residential worker/s. A telephone consultation can be offered where more appropriate. For exmaple when the social worker is out of county and therefore travel to Lincolnshire is unrealistic.

Harmful sexualised behaviour

Before referring to CAMHS

CAMHS would not take on referrals for low level sexualised behaviours and concerns present in children and young people or for behaviours that could be expected for the child’s age and stage of development. Referrers are advised to use the Lincolnshire Here4You Line to help make the decision on whether to refer.

Universal services must ensure that appropriate safeguarding processes are followed prior to referral.

A referral to CAMHS should be made

When there is evidence that a child/young person’s sexualised behaviours are outside safe and healthy behaviour. They may be excessive, secretive, compulsive, degrading or threatening, and involve significant age, development or power differences. They may be of potential concern due to activity type, frequency, duration or the context in which they occur.

Behaviour Problems

Before referring to CAMHS

• There should be clear intervention from universal services following part one and two of the ‘Collaborative Lincolnshire Behaviour Pathway’.
• For young people with low level and sporadic need, at level one of the pathway, CAMHS will provide support to universal services via the Lincolnshire Here4You Line consultation and training.
• For young people with low level to moderate ongoing need at level two of the pathway, CAMHS will provide consultation and contribute to Multi Disciplinary Team (MDT) discussions.

A referral to CAMHS should be made

• When the young person has multiple, complex and consistent needs and a specialist and multi-disciplinary package of support is required.
• When the young person has highly complex needs with extreme behaviours and a highly specialist and clinically led package of support is required.

Psychosis

Before referring to CAMHS

GPs should consider if the presentation is a drug induced state.

Auditory and visual hallucinations in children are much more commonly associated with anxiety, conduct problems and trauma than psychosis.

An immediate referral to CAMHS should be made when

Young people are presenting with a progressive change in behaviour and loss of social functioning, with active odd or strange behaviour and social withdrawal that could include:

• Perceptual disturbances
• Hallucinations
• Delusions

Plus any of the following.

• Disinhibited behaviour, over activity, and risk taking with pressure of speech and agitation.
• Deterioration in self-care and daily personal, social and family function that is not related to age and stage of development.

Learning Disability

CAMHS provides a learning disability assessment and treatment service.

A referral to CAMHS should be made if

• The young person has mental health, emotional and behavioural problems along with moderate to severe learning disabilities.

And

• A known IQ of less than 50.
• Attends a school for children with severe learning disabilities. If the young person attends a school for children with moderate learning disabilities and the team feels aspecialist Learning Disability (LD) clinician may be appropriate, please discuss this with the Lincolnshire Here4You Line.

Substance misuse

Referrals for purely addressing substance misuse problems should be directly referred to ADDACTION.

However, if there are mental health concerns alongside the substance misuse issues, please consult with the Lincolnshire Here4You Line.

Crisis referrals

CAMHS operate a Crisis Enhanced Treatment Team 24 hours a day, 7 days a week.

Before referring to CAMHS

• Where an emergency response for an immediate physical or medical health emergency is required, emergency services should be contacted by the referring agent or the individual should be taken to an Accident and Emergency Department.

An immediate referral to CAMHS should be made when young people are 

• Actively displaying suicidal ideation or following suicide attempts that have received immediate physical health intervention.
• Showing severe symptoms of depression with suicidal ideation.
• Expressing/demonstrating life threatening harm to self or harm to others as a result of a mental health concern.

Or

• Presenting with acute psychotic symptoms.