1. Catherine Swaile Senior Commissioning Manager
Re-commissioning of Mental Health and Challenging Behaviour Services for CYP with Learning Disabilities/Autistic Spectrum Disorder
Catherine Swaile
Senior Commissioning Manager

2. Introduction
Hertfordshire Community Trust in collaboration with Barnet Enfield and Haringey Mental Health NHS Trust and ADD-Vance won the recent bid for mental health and challenging behaviour services for children and young people with Autistic Spectrum Disorder/Learning Disabilities.
Hertfordshire Community Trust will be the main provider and will recruit the majority of staff with support from BEH to provide psychiatry and medical supervision.
BEH currently operate a similar service called SCAN and HCT currently provide the Challenging Behaviour Psychology Service.
ADD-Vance will be co-facilitating workshops for parents on a range of related topics.

3. PALMS MODEL Positive behaviour Autism Learning disability
Mental Health
Service

4. Multi-disciplinary Team (MDT)
The MDT will include:
A Consultant Psychiatrist
Clinical Psychologists
A Speech and Language Therapist
Occupational Therapist
Media Therapist
Learning Disability Nursing
Specialist Positive Behaviour Practitioners
Systemic Therapist
Positive Behaviour Support Workers

5. Pathway
Referrals, triaged within one week on a weekly rotation basis by clinical staff. PALMS will employ highly skilled clinicians for triage to enable accurate identification of need, assessment of risk, ensure timely access and an effective use of resources.
The pathway shows a number of outcomes from triage with the CYP being guided to:
• Second opinion (1),
• Standard pathway (2)
• Priority pathway (3)
PALMS approach can be stepped up or stepped down according to need. CYP not meeting the remit of PALMS will be signposted to other services as appropriate.

6. 1. Second Opinion
The multi-disciplinary team, particularly the Consultant Psychiatrist, Clinical Psychologists and Speech and Language Therapist will offer expert advice and close working with regards to second opinions and complex presentations in relation to ASD diagnosis to colleagues including Community Paediatricians.
PALMS will utilise and develop the expertise of clinicians in differentiating between:
what is a mental health concern
what is challenging behaviour
what is understood in the context of ASD/LD

7. 2. Standard Pathway of Support
Initial Assessment Appointment (IAA)
The aims of the IAA will be to identify:
• Strengths
• Needs
• Primary and secondary goals
• The most appropriate support
• A clear collaborative plan

8. Standard Pathway of Support
An IAA will be offered within 28 days, the service hub will hold bookable slots for IAAs with a choice of days, times and locations.
An IAA factsheet and social story will be provided alongside photographs of the clinician(s) and location.
IAAs will be undertaken by PALMS’ clinicians at Band 5 and above who will be trained to ensure consistency of approach.
Criteria will also be developed to support staff to make the appropriate decision about which model of intervention is appropriate for families.

9. Standard Pathway of Support
Joint assessments with other services such as the local CAMHS clinic and Community Paediatricians would be considered at this stage.
A flexible approach will be taken determining the best way to engage the CYP.
This could include an appointment at a clinic location, through social stories, visuals, joining them in a preferred activity and at a preferred location.
The CYP and their families will also chose who they wish to bring to the IAA including other professionals currently working with the CYP.

10. Treatment
All interventions will be tailored to need, with the multi-disciplinary team able to draw on a breadth of therapeutic models including: behavioural, systemic and narrative and a wealth of methodology including visuals, modelling and video feedback.
A range of locations will be available for interventions, matching the appropriateness of timing and the family’s resilience, alongside what can feasibly and safely offered.
Joint working within PALMS and with relevant partners will be key to ensuring a holistic approach that does not overwhelm the CYP/family.

11. Access to Tier 4
At any stage of treatment, access to out of county Tier 4 Mental Health Services may be identified by the PALMS clinician working with the family or requested by the family and/or other agencies.
To ascertain the need for this referral there will be:
A comprehensive assessment
Liaison with all relevant professionals
A Review by the multi-disciplinary team in consultation with commissioners

12. Treatment: Workshops
All families on the standard pathway will attend a one off workshop unless the Initial Assessment Appointment identifies that this would not be appropriate, some of these will be co-facilitated with ADD-Vance.
Example workshops:
Understanding ASD/LD,
Explaining ASD/LD to all family members
Supporting parents to put themselves in their child’s shoes and walk alongside their child and alongside ASD/LD
The role of communication, understanding and expression.

13. Groups
A range of groups will be offered to CYP, siblings and parent/carers.
It is anticipated that for a number of presenting concerns such as toileting and sleeping, a group approach will be appropriate.
However, individualised and tailored approaches will always be considered, such as a Sleep Scotland approach.
All groups will be facilitated by one lead professional with other professionals within and external to PALMS and/or parent/carers co-facilitating specific sessions. For example, OT with regards to a sensory diet and/or a Communications Disorder Team professional with regards to home and school consistency.

14. Groups Possible groups to include:
Understanding of and adjustment to diagnosis
Toileting, feeding and sleeping
Understanding and managing challenging behaviour
Understanding and managing mental health
Sexual education
Developing resilience
Managing your emotions

15. Parent/Carer as Therapist (PAT)
Experience and the evidence base for both challenging behaviour and mental health, demonstrate the need to work within the world of the Child/Young Person to effect change. This approach means a lot of time will be spent working with the parent/carer rather than the Child/Young Person.
PAT could be the intervention of choice when:
There is difficulty in applying group work
Individual support to view how different strategies fit in their family life
Adjustment to diagnosis
Strategies have not been successful
Reactive strategies currently used
Difficult experience/difficulty engaging with services in the past

16. Individual Interventions with CYP
The role of individual interventions is recognised for those CYP with combined challenging behaviour and mental health issues and will be offered within PALMS by a range of clinicians.
Individual intervention might be entertained when:
Need for the child’s voice to be heard and their world to be explored
Recognised as an appropriate intervention for the assessed concern(s) such as OCD, low mood
Supporting CYP to find alternative strategies
Understanding and adjustment to their diagnosis

17. Individual Interventions with CYP
Individual intervention approaches offered will include:
Positive Behaviour support
Intensive interaction
Externalising, for example, Sneaky Poo
Play therapy
CBT
AIM principles (for sexualised behaviours)
Medication will be carefully considered in consultation with the Child/Young Person and family, The multi-disciplinary team, the wider network including the GP and Community Paediatrician. Clinically the use of medication will be led by the Consultant Psychiatrist and monitored/audited with the Service Lead.

18. 3. Priority Pathway of Support
A priority pathway is appropriate when:
Suicidal statements with intent.
Family at immediate risk of break down
Child at immediate risk of care placement
Child or others in home at immediate risk of harm or exclusion
High frequency, duration and intensity of behaviours and their impact will also be considered
This will involve an assessment of a CYP’s emotional wellbeing to identify any mental health concerns, level of risk and appropriate support required both immediate and longer term. As a result of this the CYP and their family may move in to the standard pathway of support or on to the PALMS Crisis Team.

19. PALMS Crisis Team
It is anticipated that a small number of families will receive an intensive and responsive bespoke package of PALMS’ support which could include:
Extended assessment, which may include a functional behavioural assessment and/or a detailed assessment of mental health/emotional well-being.
Assessment of communication functioning
Assessment of sensory needs
Preference assessments
Community observations including in the home, school, respite and leisure activities before, during and after interventions

20. PALMS Crisis Team Also included: Behavioural recordings
Intense psycho-education for parents/carers/siblings
Individual Therapy
Frequent PAT sessions
In home support involving adaptation of approach and modelling
Partnership working with all relevant agencies including Integrated Services for Learning, Social Care and KCLP

21. Consultation and training
Links with all relevant agencies through the PALMS Local Implementation Group and establishment of regular meetings with key partners including Mental Health Leads and ASD/LD Leads in Community Paediatrics, GPs, Education, A&E and the police will enable opportunities for sharing, learning, building partnerships, clarifying pathways and addressing barriers.
PALMS will provide training, consultation and support to partner agencies including universal health services, education, social care and the police.

22. Outcome Monitoring
Measurement and review of clinical outcomes will be an integral part of practice, in turn leading to improved service quality and effectiveness.
Core pre- and post-measures as well as individually chosen outcome measures will monitor the CYP’s journey throughout PALMS, identify change, progress and continuing needs and also inform the wider system regarding the service’s effectiveness.
This will be reviewed in the Integrated Local Implementation Group and will also be shared with commissioners.

23. Signposting, Transition and Discharge
One of the aims of PALMS will be to ensure that no CYP should ‘slip through the net’ and this principle will be equally considered at the end of their journey with PALMS.
When transition is required a clear action plan will be created so that people understand their roles and responsibilities.
Discharge will be agreed collaboratively with a clear tailored plan, summary of input, and when appropriate a relapse prevention plan.
Families will be able to access PALMS follow up consultation over the phone for 6 months after discharge. The website will have a specific ‘after discharge’ section and a blog will be considered in the development of PALMS.

24. Access
The service will be located using core hubs, semi-hubs and spokes in accessible community locations. Additionally sessions will be available within the home and school setting.
This will be agreed on an individual basis, assuring the most therapeutically relevant location.
It is anticipated that a significant proportion of input will be provided in the home. Particularly for those requiring an extended assessment from the PALMS crisis team and where it is identified that in-home modelling and support is required.
PALMS will provide assessments and interventions in the evenings and weekends as it can be difficult for parents/carers or both parents/carers to attend sessions if they are in employment and/or due to the many other appointments they have to attend.
PALMS hopes that by offering evening and weekend sessions parents will be able to attend out of their working hours and when they have fewer commitments.