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  • Online publication date: February 2017

28 - Tier 4 options


‘Two roads diverged in a wood, and I–

I took the one less travelled by,

And that has made all the difference.’

Robert Frost (1874–1963)


Tier 4 CAMHS aim to meet the needs of children and young people with the most complex, severe or persistent mental health problems. Tier 4 services include in-patient care (see Chapter 29), as well as a range of day care and intensive community home-based and outreach services for specific groups of children and young people.

Day services

Early descriptions of child and adolescent mental health day units emphasised 5-day ‘milieu’ provision with a strong emphasis on education and behaviour management (Brown, 1996), whereas now they frequently provide daily focused activities to which children and families are invited, depending on their needs. Currently, about half of UK day services are linked to in-patient units, and many in-patient units have a day programme (Green & Jacobs, 1998). It is impossible to classify day services owing to the enormous range in milieu and interventions provided (Green & Worrall- Davies, 2008). However, day services broadly offer:

• support and transition to community services following in-patient admission;

• intensive 5 days per week treatment packages for children and their families;

• treatment of disruptive behaviour, using multimodal treatment strategies with a combination of individual, family and psychopharmacological interventions;

• specialist management and programmes of care for younger children with developmental disorders such as autism, speech and language disorders or neuropsychiatric disorders;

• intensive intervention aimed at improving family functioning in situations of family breakdown or child maltreatment.

Provision and organisation

Day units can offer assessment and therapeutic services that are more specialised, complex and intensive than out-patient services, although they are still community-based and less disruptive than in-patient admission. Most also have the benefit of educational input. Close liaison with specialised education and Social Services is central to their work. There is general acceptance of the central importance of maintaining attachments and working with whole systems if the complex needs of children are to be met. Day units can work with children and young people individually and in groups, as well as with their families, while keeping the focus of concern within the community and avoiding the ‘out of sight, out of mind’ dilemma of in-patient services.