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Children & Adolescent Mental Health

Introduction

Social and emotional wellbeing refers equally to:

  • Emotional wellbeing (e.g. feeling happy and confident)
  • Psychological wellbeing (e.g. feeling in control of one's life, being resilient, and displaying assertiveness)
  • Social wellbeing (e.g. the ability to have good relationships with family and friends)

Children's social and emotional wellbeing is not only important in its own right, but also a contributor to good physical health and as a factor in determining how well they do at school (National Institute for Health and Care Excellence, 2008)

The importance of social and emotional wellbeing in the early years of a child's life in relation to a healthy development is described in 'Supporting Families in the foundation years' (Department for Education and Department of Health, 2011). The social and emotional wellbeing of older children, particularly during the transition from adolescence to adulthood, is of equal importance to future wellbeing. However, the challenges occurring during adolescence are often less acknowledged and understood than those occurring during the early years (Pona, Royston, Bracey, & Gibbs, 2015).

Although anyone can have poor social and emotional wellbeing, it is well evidenced that certain population groups are more likely to suffer from poor wellbeing and have mental health problems. Those children who do develop mental health problems will need additional timely treatment from the appropriate mental health service, supported by the wider services around the child. There is now an increasing emphasis on the need to support the social and emotional wellbeing of the wider population of children and young people, and the need for a clearer distinction between mental health treatment and emotional wellbeing support (Wolpert, et al., 2014).

The report of the government's Children and Young People's Mental Health Taskforce, "Future in mind - promoting, protecting and improving our children and young people's mental health and wellbeing"  (DoH, 2015) was launched in March, 2015. It provides a broad set of recommendations across comprehensive CAMHS that, if implemented, would facilitate greater access and standards for CAMHS services, promote positive mental health and wellbeing for children and young people, greater system co-ordination and a significant improvement in meeting the mental health needs of children and young people from vulnerable backgrounds.

What do we know?

Statistics about mental health are published by Young Minds, a charity committed to improving the emotional wellbeing and mental health of children and young people. These illustrate why ensuring early support is essential.

There has also been an increased emphasis place on the importance of Public Mental Health which involves the assessment of the local need and the delivery of mental health promotion, prevention, and early intervention initiatives. There is good evidence for a number of public mental health interventions which are shown to provide significant economic savings (Joint Commissioning Panel for Mental Health, 2013).

Table 1: Savings for every £1 invested in Public Mental Health services

Savings (£s)

Intervention

84

School-based social and emotional learning programmes

18

Early intervention for psychosis

14

School-based interventions to reduce bullying

10

Early intervention for pre-psychosis

8

Early interventions for parents of children with conduct disorder

(Joint Commissioning Panel for Mental Health, 2013)

Facts, Figures, Trends

Data relating to Child and Adolescent Mental Health are available from a range of sources. The Child and Maternal Health Intelligence Network (ChiMat) publishes estimates of the numbers of children with different mental health conditions in Local Authority areas. These are calculated by applying estimated prevalence to local population size and therefore acknowledged to be approximations only. Public Health England (PHE) has a profiling tool that provides a range of information linked to Children's and Young People's Mental Health and Wellbeing. As with ChiMat, caution should be used as some of the data are estimates and maybe not as robust as we would like.            

Figures show that:

  • In 2013, 1,902 (9.1%) children aged 5-16 living in Reading are estimated to have a mental health disorder. This is higher than the average in the South East (8.5%) but lower and the England average (9.6%). Conditions will include emotional, conduct, hyperkinetic, attachment and eating disorders, as well as substance misuse problems.
  • In 2012/13 there were 762 referrals received by the local mental health trust, of which, 586 were appropriate to a response from Reading CAMHS tier 3 and 4 services. The majority (66%) of these referrals came from primary health care. 22% of referrals were waiting over 18 weeks for a first appointment. 9% of cases did not attend their appointment.
  • In 2013/14 the number of 5 to 19 year olds in treatment with mental health disorder in Berkshire increased by 17.5% to 4,214.
  • In 2013/14 the total number of Deliberate Self Harm cases (DSH) increased by 52% to 76

Table 2 below shows more information on the prevalence of mental health issues for Reading compared to the South East and England averages.

Table 2: Current mental health prevalence

Indicator

Reading

South East

England

Year

Perinatal mental health: Estimated number of women requiring support during pregnancy or postnatal period

326

N/A

N/A

2012

Estimated prevalence of any mental health disorder: % population aged 5-16

9.0%

8.5%

9.3%

2014

Estimated prevalence of emotional disorders: % population aged 5-16

3.5%

3.3%

3.6%

2014

Estimated prevalence of conduct disorders: % population aged 5-16

5.5%

5.1%

5.6%

2014

Estimated prevalence of hyperkinetic disorders: % population aged 5-16

1.5%

1.4%

1.5%

2014

Prevalence of potential eating disorders among young people: Estimated number of 16 - 24 year olds

3,000

126,533

N/A

2013

Prevalence of ADHD among young people: Estimated number of 16 - 24 year olds

3,134

134,099

N/A

2013

Fixed period exclusion due to persistent disruptive behaviour: % of school pupils

1.1%

1.2%

1.0%

2011/12

Fixed period exclusion due to drugs/alcohol use: % of school pupils

0.08%

0.13%

0.10%

2011/12

 Children who require Tier 3 CAMHS: estimated number of children <17

635

N/A

N/A

2012

 Children who require Tier 4 CAMHS: estimated number of children <17

30

N/A

N/A

2012

Source: Public Health England

The following data all relates to the ADHD, ASD, Anxiety and Depression, Specialist Community, CAMHS Common Point of Entry and Urgent Care services commissioned by the four west of Berkshire CCGs, including North & West and South Reading CCGs, between April 2014 and March 2015.

The total caseload for the year was 4,003. The majority were aged between 10 and 15 years of age. 302 were aged less than 5 and 10 were over the age of 18. The majority of the caseload were male. 59 cases were subject to a child protection order and 87 were looked after children. Table 3 below shows the number of referrals and caseload by CCG.

Table 3: Prevalence of mental health problems in children and young people (numbers of individuals)

 CCG

NHS NEWBURY AND DISTRICT

NHS NORTH & WEST READING

NHS

SOUTH READING

NHS

WOKINGHAM

 

Referrals

Patients

Referrals

Patients

Referrals

Patients

Referrals

Patients

Apr 2014

45

44

58

57

46

45

98

0

May 2014

49

48

57

56

62

61

86

80

Jun 2014

53

52

45

45

76

73

64

64

Jul 2014

80

73

46

44

75

73

88

85

Aug 2014

29

29

29

28

41

41

51

50

Sept 2014

54

51

40

39

46

44

87

85

Oct 2014

73

72

44

42

63

63

87

83

Nov 2014

67

64

48

46

62

61

70

69

Dec 2014

44

44

48

47

62

61

86

82

Jan 2015

52

52

67

63

66

66

87

83

Feb 2015

51

51

57

55

59

59

84

84

Mar 2015

71

70

67

66

64

63

71

69

Source: Berkshire Healthcare Foundation Trust

Reading's Primary Mental Health Service (PMHS), operated by the council, assessed 163 children in 2014/15. 52% of these children were passed on by the Common Point of Entry service that Berkshire Healthcare Foundation Trust (BHFT) operates as the front door to CAMHS services, with the remainder being referred from local Reading services, e.g. schools, social workers, GPs. Of the 163 children that were assessed by a PMHW, 41% received a direct therapeutic intervention by the PMHW service. The remainder were signposted to alternative community services, such as: Tier 3 CAMHS, parenting, youth work, youth counselling, etc.

Reading Educational Psychology service are often the first professional service that Schools, Children's Centres and other settings will take their concerns to about children's emotional health and wellbeing issues. Importantly, the service also has a key role to play in the statutory assessment of Special Educational Needs for Education, Health and Care Plan (EHC Plans). In Reading Autistic-Spectrum Disorder (ASD) is a growing primary reason for active statements and EHC Plans. In 2014 there were 216 cases with a statement for ASD, a rise of 30 from 2013. For Behavioural, Social and Emotional Development, as the primary reason of active statements, there were 586 cases in 2014, a slight rise from 2013, when there were 579 cases (DfE, 2016). In recognition of the impact of mental health on children's education, the new Code of Practice (Children and Family Act 2014) now refers to Social, Emotional and Mental Health Difficulties.

National & Local Strategies (Current best practices)

The Department of Health's (2015) national policy, Future in Mind, aims to improve mental health services provision for young people by delivering on 5 key themes:

1-    Promoting resilience, prevention and early intervention

2-     Improving access to effective support - a system without tiers

3-    Care for the most vulnerable

4-    Accountability and transparency

5-    Developing the workforce

The national policy direction is shown in the Department of Health's (2013) report Mental Health Service Reform and intends to make mental health services more effective and accessible. This includes reviewing health visiting and school nursing services, checking that staff have the right training to identify and help parents, children and young people with mental health problems.

The Government strategy for mental health implementation framework; No Health without Mental Health: Implementation framework focuses attention at a local level and advocates that tackling mental health is everyone's business.

The National Institute of Health and Care Excellence (NICE) have also published a briefing document, pathways, guidelines and quality standards for commissioning of services developing children's social and emotional well-being.

The National Children's Bureau's Guidance for Schools has published, 'What Works in promoting social and emotional well-being and responding to mental health problems in schools?' to provide up-to-date and evidence informed advice and guidance for schools on 'what works' in promoting emotional well-being and mental health in schools.

The Department for Education (DfE, 2015) has published guidance for schools to identify and respond to pupil's mental health needs, in 'Mental Health and Behaviour in schools'.

Local strategies:

A Common Point of Entry for Berkshire Healthcare trust was set up in 2013 and this includes specialist pathways for ASD, ADHD and A&D. There is a 20% increase in referrals and the waiting time for the specialist clinics is increasing.

Reading Youth Cabinet have undertaken a survey of young people, on issues to do with Mental Health and presented findings at 'Health for Youth' conference in November 2012.         

Healthwatch Reading have conducted local surveys and produced reports about local services and support for children and young people with mental health conditions; Children and Adolescent Mental Health Services in Reading (2013) and Exploring the role of Specialist Schools Nurses to Support the Mental Health of Young People in Secondary Schools (2014).

What is this telling us?

Mental health problems in children and young people are common and poor mental health in childhood is associated with:

  • Poorer health
  • Poorer social skills
  • Lower education attainment
  • Higher risk of self-harm and suicide
  • Higher risk of risky behaviours such as substance misuses
  • Higher rates of antisocial behaviour and offending
  • Higher levels of future unemployment
  • Higher risk of future crime and violence
  • Higher risk of adult mental disorder

The importance of children's social and emotional wellbeing is being increasingly emphasised. In particular, there is a need to support the social and emotional wellbeing of the wider population of children and young people.

We know that children and young people want:

  • To grow up confident and resilient
  • To know how to find help easily
  • Choice about where to get advice and support
  • To have the opportunity to shape the services they receive
  • To only tell their story once
  • Not have to wait until they are unwell to get help (NHS England, 2015)

What are the key inequalities?

One in ten children will need support or treatment for a mental health condition, yet only a quarter of children and young people with a diagnosable mental health problem receive treatment. Work needs to be done to ensure that as many young people who may need support are identified.

Children and young people who are living in more deprived areas, are disadvantaged, have vulnerable backgrounds or maybe living a chaotic lifestyle are more likely to have mental health issues.

Looked after children (LAC) have a higher risk of mental health problems. Continued use of the SDQ assessment tool for LAC is essential to identify and plan appropriate support for young people who need it.

What are the unmet needs / service gaps?

There is good evidence for a number of public mental health interventions which are shown to provide significant economic savings and these need to be further utilised by local areas.

In July 2015, a Children's Trust workshop suggested the need to:

  • Engineer a new model of delivery that tackles access and prevents young people being lost in the system.
  • Invest in our staff and workforce, strengthening the working culture and level of support at all levels of service delivery, but in schools in particular.
  • Build a stronger Early Intervention offer that builds the resilience in children and young people and providing support as early as possible.
  • Include families in the support process as well as include peers and friends in supporting the delivery of services, particularly to help young people feel and think differently about mental health issues, achieving less fear, stigma and discrimination.

The following are also in place to promote and address children and young people's mental health in Reading:

  • Berkshire Autism Society run various activities for children and young that include; trampolining sessions, swimming sessions, Lego clubs, a games club and visits to Thames Valley Adventure playground.

  • Reading's Children's Trust are looking at emotional wellbeing as a partnership priority area of work.

  • Perinatal mental health services.

  • Oxford Parent Infant Project (OXPIP)

  • ADHD clinics in Whitley Park School

  • Strengths and Difficulties Questionnaire project and Young Peoples Mental Health

  • Reading Borough Council financially supported youth counselling service (Adviza).

  • CCG funded voluntary sector services via their grants scheme

  • Educational Psychologists (EP) therapeutic work in schools

  • Specialist parenting programmes for children and young people whose parents have Social Emotional & Mental Health Difficulties (SEMHD) which affect parenting: 'Just What we Need', 'Mellow Parenting'; Voluntary sector (Special Parenting) run specialist parenting and support groups for ADHD and with ASD are run by voluntary sector.

  • Mental Health training in schools includes:  Psychological First Aid training

  • Public Health funded a Help line following leaflets on Mental Health been distributed in schools.

  • Community eating disorders services are being expanded by BHFT.

Primary Mental Health Worker Recommendations

  • In line with the 'Future in Mind' government document (DoH, 2015), in order to make effective changes happen local services need to:

    • Place the emphasis on building resilience, promoting good mental health, prevention and early intervention.

    • Simplify structures and improve access: by dismantling artificial barriers between services by making sure that those bodies that plan and pay for services work together, and ensuring that children and young people have easy access to the right support from the right service.

    • Deliver a clear joined up approach: linking services so care pathways are easier to navigate for all children and young people, including those who are most vulnerable, so people do not fall between gaps.

    • Harness the power of information: to drive improvements in the delivery of care, and standards of performance, and ensure we have a much better understanding of how to get the best outcomes for children, young people and families/carers and value from our investment.

    • Sustain a culture of continuous evidence-based service improvement delivered by a workforce with the right mix of skills, competencies and experience

    • Make the right investments: to be clear about how resources are being used in each area, what is being spent, and to equip all those who plan and pay for services for their local population with the evidence they need to make good investment decisions in partnerships with children and young people, their families and professionals. Such an approach will also enable better judgements to be made about the overall adequacy of investment

  • RBC should have a Mental Health Strategy. Primary Mental Health Workers and Educational Psychologists are central to the emotional and well-being work that goes on in Reading, Educational Psychologists therefore they are ideally suited to contribute to the development of a coherent strategy. We recommend, therefore, that they are represented at any discussion of this nature.

  • Encourage positive mental health in our schools and colleges. Resilience training across Reading Borough Council linked to preventative work on how to be emotionally well. This could be put together as a strategy across RBC, which would use existing services to provide a substantive and planned preventative work. This would reduce the need for crisis work further down the line. EPs are working with PMHW colleagues in the development of a resilience programme which can be reported back on and developed as needed across Reading schools/colleges. This links to 'Future in mind: promoting and improving our children and young people's mental health and wellbeing' (DoH, 2015).

  • 'To build a stronger awareness in Reading's secondary schools around understanding, identifying and talking about emotional health and well-being issues, covering areas such as attachment difficulties, bullying and self-harm'. It is recommended that:

    • There is expansion of a tiered package of Emotional First Aid training in schools to raise awareness and confidence of staff working in schools to recognise and respond to children and young people with MH issues. PMHW and EPs to all be trained in EFA to improve delivery to schools.

    • Joint 'surgeries' are held in schools by EPs and PMHWs to allow staff and pupils to access an information and advice on MH, and to provide a safe reflective space for staff to think about how best to support CYP with MH issues in their classes.

  • The earlier interventions happen the more likely it is that people can be resilient at difficult points in their lives. Early intervention is happening in children's centres e.g. OXPIP and family support. This can be further developed and improved through increased recognition of these services and data analysis of the effectiveness, alongside increased communication between services. We would like to see other MH professionals working out of Children's Centres and schools in order to allow a greater access of service to parents with young children, and to further reduce the stigma associated with MH. Further evidence based programmes of intervention to support attachment between parent and child to avoid trauma and build resilience and improve behaviour. With additional funding this can be delivered in Children's Centres by existing maternal, perinatal and early years health services and parenting programmes.

  • Create MH hubs in schools - training package offered by PMHW and EPs in schools to all staff and parents. Offer parenting information sessions in schools on MH e.g. coffee morning in schools with parents on MH and resilience. Voluntary sector involvement; other practitioners could attend for clinics in the schools. These could be seen as one-stop shops to make MH services visible and accessible to CYP and families.

  • Agree a standard of CYP being seen within 6 weeks for IAPT (as Adults standard)

  • Specialist services for CYP who have experienced trauma and in particular sexual abuse. PMHWs are trained for this work but are under-resourced both in terms of their own team and the team around them. The suggestion is that SA work should have a virtual team that can work with the individual and their family system.

This section links to the following sections in the JSNA:

Mental health

Social & Environmental Context

Long Term Conditions in Children & Young People

Carers

Safeguarding children

School life

Young Offenders

Gypsies & Travellers

References

Department for Education and Department of Health. (2011). Supporting families in the foundation years. Available at: https://www.gov.uk/government/publications/supporting-families-in-the-foundation-years

Department of Health (2015). Future in Mind - promoting, protecting and improving our children and young people's mental health and wellbeing. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf

Joint Commissioning Panel for Mental Health. (2013, July). Guidance for commissioning public mental health services. Available at: http://www.jcpmh.info/wp-content/uploads/jcpmh-publicmentalhealth-guide.pdf

National Institute for Health and Care Excellence. (2008). Social and emotional wellbeing in primary education (PH12). Available at: https://www.nice.org.uk/guidance/ph12

NHS England. (2015). Guidance to support the introduction of access and waiting times for mental health services in 2015/16. Available at:: http://www.england.nhs.uk/wp-content/uploads/2015/02/mh-access-wait-time-guid.pdf

Pona, I., Royston, S., Bracey, C., & Gibbs, A. (2015). Seriously Awkward: How vulnerable 16-17 year olds are falling through the cracks. Available at: http://www.childrenssociety.org.uk/what-we-do/resources-and-publications/seriously-awkward-how-vulnerable-16-and-17-year-olds-are

Wolpert, M., Harris, R., Jones, M., Hodges, S., Fuggle, P., James, R., et al. (2014). THRIVE. 

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