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Guidance for GPs on Referral of Children & Young People with Emotional Wellbeing Issues, Neurodevelopment Issues and Neurodisabilities Referrals to Universal Services, Routine CAMHS and Urgent CAMHS referrals *denotes facility for self-referral #SAFEGUARDING – for all of the presenting issues below, GPs should show curiosity and enquiry into the child’s home environment and association with behaviour(s), as well as parenting capabilities with regards to mental health, substance misuse and domestic abuse. Please consider with EVERY issue if there are any safeguarding concerns. If so, whether TAC and CAF are required and liaise with the child’s Health Visitor/School Nurse to progress the matter further. Where there are emergency safeguarding concerns please contact Child Protection, R&R: 01302 736636 or 01302 737777 Issue Symptoms/presenting problems Point of contact: Behavioural Difficulties# Poor behaviour at home only (including anger outburst, tantrums, etc.) *Family Support Evidence Based Interventions visit: http://www.doncasterchildre nandfamilies.info/ifss.htm click on the map at the bottom of the page to identify who to talk to about making a referral. *Health Visitor (0-4 years) or School Nurse (5+ years) (see School Nurse Pyramid or HV directory for contact details) School Nurses can also be contacted by (non-secure) email: CYP&[email protected] hs.uk *Local Children’s Centre: 01302 862 116 Other information: Doncaster Family Information Service http://www.doncasterchildre nandfamilies.info/ Poor behaviour at school only *School Learning Mentor directly or via School Nurse (see School Nurse Pyramid or HV directory for contact details) School Nurses can also be contacted by (nonsecure) email: CYP&[email protected] hs.uk DMBC Educational Psychology Service Referrals in writing or over the phone. Address: Educational Psychology Service Doncaster Council Civic Office Waterdale Doncaster DN1 3BU Phone: 01302 737291 Severe behaviour in both home & school Community Paediatrician (SPOA - use new referral form) *Family Support Evidence Based Interventions visit: http://www.doncasterchildre nandfamilies.info/ifss.htm click on the map at the bottom of the page to identify who to talk to about making a referral. *Local Children’s Centre: 01302 862 116 Eating Disorders# Low level eating issues – will only eat certain foods Monitoring of BMI by GP or School Nurse (see School Nurse Pyramid or HV directory for contact details). School Nurses can also be contacted by (non-secure) email: CYP&[email protected] hs.uk Public Health Dieticians Nutrition and Dietetic Department Doncaster Royal Infirmary Armthorpe Road Doncaster DN2 5LT Phone: 01302 366666 ext. 4110 Low level eating issues and physically unwell also Acute paediatrics via Choose & Book or by letter to Booking Team via email: [email protected] or fax: 01302 647073 – encourage open referrals (rather than to a named Dr) for all general (Acute) paediatric clinics. Anorexia Nervosa: • Weight loss, or lack of weight gain, leading to weight at least 15% below expected • Weight loss is self-induced by avoidance of “fattening foods” • Self-perception of being too fat, with fear of fatness • Endocrine changes (e.g., amenorrhoea) Bulimia: Persistent binge & purge behaviour CAMHS (Routine). If in doubt about urgency of referral contact our duty team who are available until 5pm. After 5pm refer to A&E who will refer to CAMHS out of hours. Body Mass Index 18.5 – 25 (normal) Body mass percentage less than 85% of that what it should be A constant focus on food, dieting and exercise. Insistence on having meals separate from the family. Feeling stressed when unable to exercise. Increasing social withdrawal, frequent weighing and frequent trips to the toilet immediately after meals. For both: A normal Body Mass Index (BMI) of between 18.5 – 25: BMI = weight (kg)/height (m) 2 A Body Mass Percentage of less than 85% is a concern (this measurement is preferred over BMI): Body Mass Percentage = Actual BMI x 100/Median BMI (for age and height) Suggested tests to be taken prior to referral: i. Height, weight, blood pressure (lying and standing). ii. Blood test investigations. (Findings suggestive of a suspected eating disorder.) Full Blood Count (Mild leucopenia or thrombocytopenia from malnutrition; Anaemia from malnutrition or gastrointestinal losses) Urea and electrolytes# (Hyponatraemia from excess water intake; Hypokalcaemia from vomiting; Metabolic alkalosis from vomiting) Random blood glucose (Rarely low) Calcium, phosphate and magnesium (Hypocalcaemia, hypomagnesia and hypophosphataemia – uncommon) Liver Function Tests (Slight elevation from malnutrition, albumin normal unless very chronic) Follicle stimulating hormone (FSH) leutinising hormone (LH) and oestradiol (Suppressed FSH and LH-oestradiol usually low) Vitamin D (Low from malnutrition) Haematinics-iron studies, B12 and folate (If indicated-low from malnutrition) # May also be raised due to dehydration. BMI below 18.5 Acute paediatrics via Choose & Book or by letter to Booking Team via email: [email protected] or fax: 01302 647073 – encourage open referrals (rather than to a named Dr) for all general (Acute) paediatric clinics. Anxiety /Disorders# If any other concerns about physical health status Worrying about specific situations e.g., separation anxiety anxiety around exams moving schools etc. CAMHS (Urgent) - If after 5pm send to A&E who will refer to CAMHS out of hours. * Learning Mentor or equivalent role in school directly or via School Nurse (see School Nurse Pyramid or HV directory for contact details) School Nurses can also be contacted by (non-secure) email: CYP&[email protected] hs.uk Jigsaw (Age 11-19). Referral form on request, please contact: 07786198675 or 07917031899 or email: [email protected] or [email protected] If you are a System one user you will find a copy of it on the system and can task it to a member of the team. Severe, persistent anxiety Panic attacks Attachment disorders (If diagnosed) Severe and disabling phobias (Social and specific phobias) CAMHS (Routine) GPs should absolutely not prescribe anti-depressants to patients before they have been assessed by CAMHS. There are clear processes and guidelines that CAMHS follow when prescribing, all young people need to have – A mental health assessment Brief intervention High Risk Assessment team meeting for a request for Psychiatric Assessment Psychiatric Assessment to decide whether medication is indicated-or CBT without medication Trial of medication if young person and family agree Titration of medication to therapeutic levels as per Maudsley Prescribing Guidelines, with particular care to be taken during the titrating of Fluoxetine (first line choice for young people) Mood Disorder or Depression# Low mood, not impacting on daily life and no risk evident (no suicidal thoughts or self-harm). *Learning Mentor or equivalent role in school directly or via School Nurse (see School Nurse Pyramid or HV directory for contact details). School Nurses can also be contacted by (nonsecure) email: CYP&[email protected] hs.uk Jigsaw (Age 11-19). Referral form on request, please contact: 07786198675 or 07917031899 or email: [email protected] or [email protected] If you are a System one user you will find a copy of it on the system and can task it to a member of the team. Persistent low mood. (Only refer if symptoms present for at least 2 weeks) Physical symptoms – poor sleep (or early wakening) or loss of appetite and weight. (Only refer if symptoms present for at least 2 weeks) Cognitive symptoms inc. pervasive negative thoughts (Only refer if symptoms present for at least 2 weeks). Loss of interest/Social isolation/withdrawal seen at home and school. (Only refer if symptoms present for at least 2 weeks) Suicidal thoughts without planned intent (discuss urgency of referral with team) Post-Traumatic Stress Disorder# Deliberate Self Harm# Suicidal thoughts with planned intent REFER URGENTLY. Suicidal thoughts without planned intent (discuss urgency of referral with team) Previous attempts to end life Symptoms following an event extremely traumatic to the individual, continuing longer than three months following event. Avoidance of reminders of the traumatic event. Persistent anxiety. Repeated enactment of reminders of the traumatic event. Intrusive thoughts and memories – e.g. nightmares. Sleep disturbance. Hypervigilance. Presenting with maladaptive coping strategies but less severe/frequent/recent. Always discuss case with duty team to help guide urgency Presenting with maladaptive coping strategies (e.g. self-cutting and where recent occurrence). Obsessive Compulsive Disorder (OCD)# Relationship Difficulties# Repetitive, intrusive thoughts, images or behaviour affecting daily life & activity. Obsessions/compulsions causing functional impairment (not if diagnosed with ASD) General relationship difficulties CAMHS (Routine) CAMHS (Urgent) if after 5pm refer to A&E who will then refer to CAMHS out of hours CAMHS (Routine) CAMHS (Routine) CAMHS (Urgent) CAMHS (Routine) *Learning Mentor or equivalent role in school directly or via School Nurse (see School Nurse Pyramid or HV directory for contact details) School Nurses can also be contacted by (nonsecure) email: CYP&[email protected] hs.uk Jigsaw (Age 11-19). Referral form on request, please contact: 07786198675 or 07917031899 or email: [email protected] or [email protected] If you are a System one user you will find a copy of it on the system and can task it to a member of the team. Persistent patterns of abnormal functioning in interpersonal relationships. *Family Support Evidence Based Interventions visit: http://www.doncasterchildre nandfamilies.info/ifss.htm click on the map at the bottom of the page to identify who to talk to about making a referral. *Anti-bullying Officer directly or via School Nurse (see School Nurse Pyramid for correct contact details) Suspected Autism Spectrum Disorder (ASD)# Where family dynamics are fractured and conflicts unresolved. CAMHS (Routine) If requesting an ASD assessment or concerns following diagnosis Community Paediatrician (SPOA - use new referral form) If diagnosed with ASD and where there is an underpinning concern about a mental health problem CAMHS (Routine) Other information: Autism Spectrum Information Centre, phone: 01302 737 493 or Email: autisminformation@doncast er.gov.uk Aiming High for Disabled Children, phone: 01302 862 332 or email: aiminghighbusinessunit@don caster.gov.uk Suspected Attention Deficit Hyperactivity Disorder (ADHD)# For children suspected of ADHD and under 7 years of age or concerns following diagnosis. Community Paediatrician (SPOA - use new referral form) Psychosis or suspected psychosis# Criteria for Routine / Urgent referrals – Always discuss with duty team to assist decision making re urgency. Active symptoms inc. paranoia, delusional beliefs & abnormal perceptions, (hearing voices & other hallucinations). Fixed, unusual ideas. Negative symptoms inc. deterioration in self-care & social & family functioning. CAMHS (Routine)/CAMHS (Urgent) If child over 16 refer to early intervention in psychosis team. *Early Intervention in Psychosis Team. Referrals in writing or over the phone. Address: Jade Centre Askern Road Bentley Doncaster DN5 0JR Phone: 01302 821410 Conduct Disorder# Very severe and persistent behavioural problems, at home, school and in the community, and unresponsive to parent training. If school related – preferable for school/ Educational Psychologist to make referral with relevant background information. CAMHS (Routine) Gender Identity Disorder# Initial exploration of issues *School Nurse (see School Nurse Pyramid or HV directory for contact details). School Nurses can also be contacted by (non-secure) email: CYP&[email protected] hs.uk Strong, persistent cross-gender identification. Persistent discomfort in gender role. Above causing impairment in social, family and school functioning. CAMHS (Routine) Refer to Community Paediatrician in first instance. Community Paediatrician (SPOA - use new referral form) Excessive fatigue Unexplained medical symptoms CAMHS (Routine) Chronic Fatigue/ Somatisation Disorder# Bereavement response# Within three months of bereavement If child is experiencing significant distress following death that has occurred within traumatic circumstances e.g., suicide. *Cruse Bereavement Care Referrals in writing or over the phone. Address: 109 Thorne Rd Doncaster South Yorkshire DN2 5BE Phone: 01302 814 647 After three months of bereavement If child is experiencing significant distress following death that has occurred within traumatic circumstances e.g., suicide. CAMHS (Routine) Enuresis or complex soiling# Moderate Mild to Severe *Health Visitor (0-4 years) or School Nurse (5+ years) (see School Nurse Pyramid or HV directory for correct contact details). School Nurses can also be contacted by (nonsecure) email: CYP&[email protected] hs.uk *Community Clinics for Children with Constipation, Soiling , Nocturnal Enuresis by self-referral – Sandringham Road Health Centre; Fridays weekly, 09.00am-12.00 Bentley Children's Centre; Tuesday fortnightly, 9.00am-12.00 Denaby Springwell Centre; Wednesday fortnightly, 13.30-17.15 Orchard Centre Moorends; Tuesday fortnightly, 13.3017.15 Overdose# Refer to Tier 3 CAMHS service CAMHS (Urgent) Substance Misuse# excluding alcohol Refer to Young People’s Drug and Alcohol Service *Better Deal Referrals in writing or over the phone. Address: New Beginnings Marshall Avenue Balby Doncaster DN4 0QP Secure fax: 01302 571261 Phone: 01302 571260 Teen pregnancy# Tier 1 support as part of Family Nurse Programme *Family Nurse Partnership Referrals in writing or over the phone. Address: Sprotbrough Clinic Melton Road Sprotbrough DN5 75B Phone: 01302 786 982 Sexual abuse People who have been sexually abused or raped can have different feelings or reactions to their situation: Having bad dreams or nightmares Imagining that everyone knows what has happened Feeling ugly or dirty Having problems concentrating Trying or wanting to hurt yourself Feeling like running away Feeling ashamed *Doncaster Rape and Sexual Abuse Counselling Service (DRASACS) Referrals in writing or over the phone. Address: DRASACS PO Box 470 Doncaster DN1 3XW Cerebral Palsy# Thinking it is your fault Concerns from parents e.g., visual problems, hearing problems, feeding problems, epilepsy etc. Urgent medical needs Phone: 01302 360421 Referral required to Child Protection – R&R Phone: 01302 736636 or 01302 737777 Community Paediatrician (SPOA - use new referral form) Acute paediatrics via Choose & Book or by letter to Booking Team via email: [email protected] or fax: 01302 647073 – encourage open referrals (rather than to a named Dr) for all general (Acute) paediatric clinics. Downs Syndrome# Any physical issues e.g., cardiovascular problems hearing problems visual problems etc. Check practice notes – all children with Downs Syndrome should be under surveillance by a community paediatrician. If not then refer to Community Paediatrician (SPOA - use new referral form) Motor & Language Issues# Any concerns from parents/ Health Visitors /Nursery staff around delays e.g., not walking by 18 months not babbling by 12 months (check hearing first) regression etc. Community Paediatrician (SPOA - use new referral form) Physical disabilities# E.g., Community Paediatrician (SPOA - use new referral form) Achondroplasia Neurofibromatosis any concerns following an accident or meningitis Process to be followed for CAMHS referral:1. In order to effectively triage a referral, please provide the contact telephone number for the patient. 2. Referrals will be acknowledged within 5 working days, with the aim to have an initial appointment within 28 working days of receipt of referral. Urgent referrals are seen within 24 hours. If available, a copy of the Common Assessment Framework (CAF) should also be provided and parent/carer/patient permission demonstrated. 3. Following Initial Assessment – Needs are identified & where appropriate a management plan communicated to the referrer. Where appropriate, referrals may be signposted to other services but only where patient contact details and consent is provided with the referral. CAMHS Referrals should be sent with the patient and/or family’s consent and using the agreed CAMHS referral form, or provide the required referral information in your letter (see ‘CAMHS Referral Checklist’) to:- The Duty Team, Doncaster Child & Young People’s Mental Health Service, Unit 3, Balby Court, Carr Hill, Balby, Doncaster DN4 8DE. Tel: 01302 304070 Fax: 01302 304077 DO NOT REFER Do not refer if not stated in the above list. If in doubt please discuss with the CAMHS Duty Team (available until 5pm). Out of Hours CAMHS clinician criteria: Access to CAMHS clinicians outside of office hours (i.e., Mon- Fri, 9am-5pm) will be considered using the current criteria for ‘urgent’ assessments during office hours, i.e.: • Children and young people expressing suicidal thoughts • Self harm- which may have required minimal medical intervention, but not requiring admission to a paediatric ward • Rapid weight loss and a low BMI • Symptoms of psychosis (hallucinations, delusions etc) causing distress o If a child or young person presents to Accident and Emergency having taken an overdose/ self-harm which requires medical attention anyone under the age of 16 years of age should be admitted to the paediatric ward as per NICE guidelines Access to CAMHS clinician: Young people below the age of 16 years: Access to the CAYPMHS clinician will be made via the locality crisis team and assessments will be completed within the local hospital environment. The member of staff undertaking the assessment will be responsible for informing the appropriate CAMHS team of each case and transfer information to ensure on-going care delivery as needed. The CAMHS clinician will be encouraged to discuss the case and assessment with the medical director or other consultant psychiatrist on their return work. 16-18 year olds: Crisis and Home treatment teams would provide assessments and support to young people aged 16-18 years out-of-hours via the same access route as adult services currently have in place per locality. The CAYPMH team would provide assessment for people under the age of 16 years and complete joint assessments with people aged 16-18 years with more complex presentations. The criteria for joint assessments for 16-18 yr olds is to be developed between CAYPMHS and Crisis teams • Dual diagnosis- mental health and ASD/ ADHD/ LD • Complex safeguarding issues • Looked after children with complex social situation Lead Consultants Lead GP Date Approved: Review Date: