How Does a Specialized Mental Health Service Help Troubled Youth in Wales?

What you need to know

• The Forensic Adolescent Consultation and Treatment Service (FACTS) in Wales provides specialized mental health support for youth with complex needs beyond standard services.
• Nearly all youth referred to FACTS had experienced childhood trauma, but post-traumatic stress disorder was rarely diagnosed, suggesting a need for greater focus on trauma.
• Sexual behavior problems were very common among referred youth, indicating a need for more specialized services in this area.

Background and Purpose

When young people face serious mental health challenges that put themselves or others at risk, they often require specialized care beyond what standard child and adolescent mental health services can provide. To address this need, Wales established the Forensic Adolescent Consultation and Treatment Service (FACTS) in 2009. FACTS is unique in that it operates purely as a consultation service, working alongside other agencies rather than taking over cases directly.

This study aimed to examine the characteristics and outcomes of youth referred to FACTS over a 5-year period. By analyzing this data, the researchers hoped to gain insights into the complex needs of these young people and evaluate how well the FACTS model is working to support them.

Who Was Studied and How

The study looked at all new referrals to FACTS between 2013-2017 who had completed their episode of care by June 2018. This included a total of 80 young people.

The researchers reviewed the clinical records for each case, collecting information on:

• Demographics
• Reasons for referral
• Family and home life
• Adverse childhood experiences
• Education
• Prior involvement with health and other services
• Mental health symptoms and diagnoses
• Behaviors that put self or others at risk
• FACTS interventions and outcomes

They then analyzed this data using statistical techniques to identify patterns and relationships between different factors.

Key Findings

Complex Needs Beyond Standard Services

The youth referred to FACTS had extremely complex needs that went beyond what standard child and adolescent mental health services (CAMHS) could manage alone:

• The average age was 15.4 years old
• 81% were male
• Two-thirds had 3 or more reasons for referral
• All posed some risk of harm to others
• Half were also at risk of harming themselves
• Half engaged in sexually harmful behaviors
• Only about half were involved with the criminal justice system

This highlights the value of having a specialized service like FACTS to support these challenging cases.

High Rates of Childhood Trauma

Nearly all of the young people (91%) had experienced at least one adverse childhood experience (ACE), such as abuse, neglect, or family dysfunction. Over half (54%) had experienced four or more ACEs.

Common ACEs included:

• Domestic violence (51%)
• Physical abuse (49%)
• Parental separation (49%)
• Emotional neglect (40%)
• Household mental illness (39%)

This extremely high rate of trauma exposure is concerning and has important implications for treatment.

Mental Health Diagnoses

Interestingly, despite the high rates of trauma, post-traumatic stress disorder (PTSD) was rarely diagnosed (only 9% of cases). The most common diagnoses were:

• Attention deficit hyperactivity disorder (ADHD) - 44%
• Autism spectrum disorder (ASD) - 26%

Over a quarter (29%) had no formal diagnosis recorded. This may reflect the complex, overlapping nature of these young people’s difficulties that don’t fit neatly into diagnostic categories.

Sexual Behavior Problems

One of the most striking findings was that over half of the youth (51%) were engaging in sexually harmful behaviors. This was much higher than expected and suggests a major unmet need for specialized services in this area.

Treatment Outcomes

FACTS was involved with these cases for an average of nearly a year (309 days). Key outcomes included:

• Most youth (90%) were able to remain living in the community
• There was little change in living circumstances for most
• No new offenses were recorded during FACTS involvement
• No deaths occurred

Given the high-risk nature of these cases, maintaining stability and avoiding negative outcomes is a positive result. However, the lack of more substantial positive changes highlights the challenges of working with this population.

Implications for Care

This study provides several key insights that can help improve care for youth with complex mental health and behavioral needs:

1. Trauma-informed care is critical. The extremely high rates of childhood trauma exposure mean that all services working with these youth should be trauma-informed, even if PTSD is not formally diagnosed.

2. More specialized services are needed for problematic sexual behaviors in youth. The high prevalence of these issues suggests this is a major unmet need.

3. Diagnosis-driven approaches may be inadequate. The complexity of these cases often defies simple diagnostic labels. A more holistic, needs-based approach may be beneficial.

4. Maintaining stability is a worthwhile goal. For such high-risk youth, avoiding negative outcomes and maintaining community placement is a positive result, even if dramatic improvements are not seen.

5. Consultation-liaison models like FACTS can effectively support complex cases. By providing specialized expertise to existing services, this approach helps youth receive appropriate care without creating parallel systems.

Conclusions

• The FACTS consultation-liaison model provides valuable support for youth with mental health needs beyond standard services.
• Extremely high rates of childhood trauma highlight the need for trauma-informed approaches across all services working with at-risk youth.
• There is a major unmet need for specialized services addressing problematic sexual behaviors in youth.
• For complex cases, maintaining stability and avoiding negative outcomes may be a more realistic goal than dramatic positive changes.

While this study demonstrates the value of the FACTS model, it also reveals opportunities to further develop services for this high-need population. In particular, greater focus on trauma and sexual behavior problems could help improve outcomes. Overall, the findings underscore the importance of specialized, collaborative approaches to support youth with the most complex mental health and behavioral needs.