Your views: mental health

We know that one in ten children aged between 5 and 16 years has a clinically diagnosable mental health problem. Half of those with lifetime mental health problems first experience symptoms by the age of 14, and three-quarters before their mid-20s. For that reason, the cross government mental health strategy No Health Without Mental Health takes a life course approach to improving mental health outcomes and includes a strong focus on improving public mental health and prioritising early and effective evidence-based intervention.

We also know there is still some way to go in developing the whole system approach needed to integrate high quality evidence-based services around the child and their family and across the whole care pathway including health, education and social care to drive the sustained improvement in children’s mental health outcomes we all want to see.

There is activity under way including:

  • an ambitious programme of service transformation  through the CYP Increasing Access to Psychological Therapies project
  • the development of Payment by Results currencies for child and adolescent mental health services
  • an implementation framework to test and support delivery of the ambition of the mental health strategy and the outcome based objectives it sets out.

The development of Children and Young People’s Health Outcomes Strategy offers a real opportunity to drive further improvements. To help us do this, we would like your views on the following questions as they relate to mental health:

  • Where is the health service falling short for children and young people – what is our weakest link and what can we do to improve things to make sure it makes a real difference to the lives of children and young people?
  • With so many different parts of the health system in place, what do they need to focus on and improve to make sure they each work together to deliver the best possible health service for children and young people?
  • The NHS and Public Health Outcomes Frameworks propose key areas of focus: making sure everyone lives healthy lives for longer, addressing inequalities, enhancing quality of life for people with long term conditions, helping people recover from ill health or following an injury, ensuring people have a positive experience of care, treating and caring for people in a safe environment and protecting them from harm – are these the right priority areas in relation to children and young people’s health outcomes? Is there anything missing?
    See outcomes specific to children and young people in these frameworks
  • What should key health outcomes for children and young people include?

The Forum’s work on mental health is led by Lisa Christensen and Margaret Murphy.

In Children and Young People’s Health Outcomes Forum | Tagged ,

23 Responses to Your views: mental health

  1. Sarah Stewart-Brown says:

    it is important to include a measure of mental wellbeing in children. This measure should like the Warwick Edinburgh Mental Wellbeing Scale for adults focus on the positive aspects of mental health and be worded positively
    Stirling Council have just produced such a measure for 8-13 year olds which has evaluated well in Stirling. Here is the report http://www.friendsforlifescotland.org/site/SCWBS%20Report.pdf
    A small amount of validation in England would be necessary before adoption but this does not have to be costly .
    It is equally important to meaure the positive mental health of infants up to 7 years and such a measure should be commissioned. Because it needs to be developmentally sensitive this would be a larger project

  2. Lynn Aulich, Specialist Art Therapist says:

    The Improving Access to Psychological Therapies refers to ‘talking therapies’. This omits all the Art therapists, Music therapists Dance Movement therapists and and Dramatherapists registered by the HPC. This is making it very difficult for us working with young people in mental health services, CAMHS Forensic Mental Health and prison healthcare to defend our services from cuts at a time when there should be increased access to the arts therapies in particular as they are a form of therapy that people who have difficulty in expressing themselves verbally in ‘talking therapies’find very helpful. I would like to see an increase in access to arts therapies in young peoples services.

    • Hannah West says:

      I very much agree. There is currently a heavy bias towards CBT to the detriment of access to the creative therapies. Creative approaches are often more suited to people, particularly younger children and people who are emotionally ‘young’, who express themselves impulsively through ‘doing’, and are perhaps not developmentally ready for cognative approaches.

      Also, creative therapies are traditionally more common in tiers three and four of mental health treatment, but I and many others have found that using brief models with creative therapeutic approaches much earlier on is effective, such as in Primary Care and in schools with pupils who do not reach the criteria for a core CAMHS service.

      Hannah West, Art Psychotherapist

  3. Sheena Crankson says:

    I agree with Lynn Aulich,I tried to access Art Therapy for my son who has ASD and ADHD and finds expressing himself verbally virtually impossible.The waiting list was long and the therapist wanted my son to talk to her ? DUH ? My son is very creative but never put pen to paper after 2 appointments ! He finds it difficult to connect with strangers and took an instant dislike to this woman ! He prefers Males !
    We need many more Psychological Therapies who really know how to connect to our children !

  4. Dr Somnath Banerjee says:

    Children are tomorrow’s future. They have every right to access the services, available in the present day society. A Child or adolescent should not be waiting for months for an ADHD assessment. But unfortunately this has become a routine practice now. ADHD is a recognized neuro-developmental disorder, which is ackowledged by the scientists. Atleast NICE has tried to address some issues in the management of ADHD. No drug can cure an illness. A drug in ADHD should be used in combination with other interventions such as behaviour therapy, family therapy, educational modification etc.

  5. Simon Richardson says:

    We agree with the comments above, however we feel that two key components appear to be missing from the Goverment’s strategy. Firstly, prevention. Whilst it is essential that children and young people have access to treatment and support services it is equally essential that preventative approaches are taken within schools, community groups and vitally at home. There needs to be a greater dialogue around mental health, ways to build reslience and general self esteem issues. Unfortunately the Government seems a little dismissive of this – I would highlight their failure to make PSHEe a statutory subject and the ‘down grading’ of the Healthy Schools programme as evidence of this. The second missed opportunity is around the early identification of mental health problems within young people. Resilience can fail, building resilience it is only ever going to be half the solution. The pressures and burdens that many young people face will sadly result in some form of mental health or emotional difficulty. Perhaps these difficulties will involve substance misuse, early and inappropriate sexual behaviour or a multitude of other risk taking behaviours as they struggle with their emotional distress. Early identification of these issues is essential. People caring for young people need to be given training around recognising mental health problems and supported in developing the skills to know what to do in a mental health first aid situation. Funding for this would be well recieved by schools, colleges and other organisations as well as community groups and parents. I am in no way suggesting that it should be an either or approach. the system is sorely underfunded along the whole continuum of mental health. I just wish this Government would be more proactive than reactive and perhaps if we can be more proactive we can prevent the distress that many young people will suffer as a result of having a mental health problem. More information on Mental Health First Aid is available at http://www.emotionalhealthwellbeing.co.uk but also further information on supporting the emotional health of children, young people and adults through laughter yoga can be found at http://www.totallylaughteryoga.co.uk

  6. Sebastian Kraemer says:

    I want to make a special plea for multidisciplinary mental health in paediatric settings, particularly hospitals. This is very different from CAMHS in that children and parents are not usually asking for or expecting mental health care at all.

    Yet when we work closely with paediatricians and their colleagues we can make significant changes to the course of chronic disease such as brittle asthma and diabetes, and of medically unexplained symptoms such as infant regulatory disorders (feeding/sleeping/crying/attachment), elimination problems (soiling/severe enuresis) or difficult to diagnose pains, fatigue, seizures etc

    In addition of course psychiatrists need to be in attendance to see acute psychiatric disorders and deliberate self harm/overdose that do present to paediatricians via A&E.

    Also children traumatised in accidents, after major surgery or burns, will require psychotherapeutic care. Finally the children of seriously ill/dying patients are frequently neglected in hospitals.

    see http://bit.ly/GGwngJ

  7. Dr Dickon Bevington says:

    Attention to the problem of COMPLEXITY and the CO-OCURRENCE of multiple disorders or risk factors needs much greater attention, as this is how to target the young people most at risk of chronic difficulties – who are also those most at risk of struggling to parent the next generation of children effectively.

    Multiple studies over the past 20 years have shown that some of the most burdensome difficulties (in terms of suffering by the young person, incidental suffering of people around them, and economic costs) such as substance use disorders, conduct disorders and emerging personality disorders are the ones most likely to be determined by multiple causes. Measures of complexity, and co-morbidity that include factors such as poverty, family dysfunction, educational exclusion, enmeshment in anti-social peergroups, exploitation/abuse, and use of substances alongside more “mainstream” measures of mental wellbeing/mental health problems are required.

    This could drive the development of more effective integrated and integrative interventions for this “hard to reach” population (hard to reach, that is, by conventional clinic-based and “uni-modal” services that operate from within separate agencies, with separate budgets, separate and often frankly contradictory organisational aims, and which may now increasingly also be competing with each other for short-term contract tenders; this arrangement risks swamping young people and families with multiple well-intentioned but poorly-coordinated workers – what might be referred to as “dis-integrated interventions”.)

    There are few robustly evidence-based interventions for this group, but there are the beginnings of such an evidence base, and there are multiple instances of excellent locally-derived projects both in the voluntary and statutory sectors. The sharing of best practice in this field risks being hampered by an increasingly competitive “market” in which agencies tender against each other for contracts, whilst at the same time being exhorted to collaborate for the benefit of clients.

    Attempts to measure, identify and intervene for these extremely vulnerable youth may be hampered if they have multiple risk factors/co-ocurring problems but are referred to a single agency which focuses on one area of difficulty without having the expertise to identify others. Alternatively, clinical experience suggests that many suffer under a crushing cumulative burden of multiple problems, whilst individually these problems may not fit the “caseness criteria” to justify the involvement of relevant specialist services. Their “problem” in these cases is often the very complexity, as much as it is the specifics of their self-injury, gang-enmeshment, depression, family-breakdown, substance use, etc.

    An “open source” and “deployment-focused” approach to the systematic development of more effective and integrated practice for such young people is being developed by the Anna Freud Centre charity, supported by Comic Relief. It aims to provide a platform that supports (a) the marriage of “evidence-based practice” with “practice-based evidence” and (b) the efficient sharing of locally-derived best practice. Its materials and methods (which include local teams “blogging” their own local adaptations and innovations in their own local wiki [website] over a shared core of theory and practice) are all freely available following links for AMBIT via the signposting website http://www.tiddlymanuals.com.

  8. Paul McArdle says:

    Often children’s mental health is not seen in context. Many children destined to be not in education, employment or training have mental health problems, certainly. However, they also will have failed in school and schools tend to blame parents (see Sir Michael Wilshaw’s recent speech to heads) without looking at the developmental problems these children have – learning difficulties, autism, problems with concentration and frank learning disabilities. When these are pointed out, they sometimes are unwilling to understand. OFSTED seems determined not to support these children or to modify curriculums so that they can thrive. They do make up 10-15% of the male population and if they are not to be left behind and grow into alienated young men, how to support them requires serious consideration, not wishful thinking or scapegoating of parents

  9. Sue Topalian says:

    Our comments on the questions posed (repeated below before each answer):

    Where is the health service falling short for children and young people – what is our weakest link and what can we do to improve things to make sure it makes a real difference to the lives of children and young people?
    In terms of mental health?

    1. Identify the children and young people most at risk of mental ill health- ie those whose parents form poor attachments with them in the first two years, those who are living with domestic violence, those are living with substance misusing or mentally ill parents, those who are being/ have been abused or neglected, and design services to meet their mental health needs. The current NHS clinic-based appointment system, which depends on organised, reliable, consistent parents, militates against the children at highest risk of the greatest levels of mental ill health receiving a service. (It is also designed largely for those who have verbal skill and feel comfortable in clinic settings.)
    2. For children and young people, improving their mental health will usually require therapeutic work with the parents to improve family relationships. So it is important that services are seen as addressing the therapeutic needs of the family rather than just the child.

    With so many different parts of the health system in place, what do they need to focus on and improve to make sure they each work together to deliver the best possible health service for children and young people?

    In terms of mental health,
    1. Focus on training staff to view and assessing a child’s needs not just in mental health terms, but holistically.
    2. Focus on employing staff who care about children, and want to improve their lives
    3. Focus on finding out what children/ young people / parents with mental health needs what they think of services and then design services that really help.
    4. Focus on working together not just with each other, but with education and social care services,

    The NHS and Public Health Outcomes Frameworks propose key areas of focus: making sure everyone lives healthy lives for longer, addressing inequalities, enhancing quality of life for people with long term conditions, helping people recover from ill health or following an injury, ensuring people have a positive experience of care, treating and caring for people in a safe environment and protecting them from harm – are these the right priority areas in relation to children and young people’s health outcomes? Is there anything missing?

    1. The priority for children’s mental health is very early intervention to prevent later ill health. We know from adult service users and neuroscience that poor attachment to parents, and living in an environment of domestic violence and/or abuse and neglect is hugely damaging to mental health. We also know that poor mental health leads to reduced life expectancy, inequalities, poorer physical health and quality of life, and greater risk of harm (all key areas of focus). It also leads to harm for others, as some children externalise ( rather than internalise) their mental health problems in violence, substance misuse and crime. The key outcome for children needs to be: ‘Ensuring that parents who are identified as having difficulties are enabled to build positive relationships with their children’. This is the one thing that would make a huge difference to children’s health and happiness.

    What should key health outcomes for children and young people include?

    In terms of mental health,
    1. It is key to start tackling the roots of mental ill health early in a persons life.The outcomes framework does not address the early identification of infants with poor attachment to parents, and early therapeutic work with families which is essential for this.
    2. The outcomes framework does not address the actual impact of mental health intervention on health. ‘Payment by results’ seems likely to mean ‘payment by activity’ again…
    3. Poor emotional health and wellbeing is linked to poor attainment, poor attendance at school, school exclusion, designation as having Behavioural, Emotional and Social Difficulties, increased substance misuse, crime, and unwanted pregnancy.Therefore,in Bristol, we have used the following outcomes to try to measure children’s mental health across the city:
    NI 50 Emotional Health and Wellbeing- children and young people user perception
    NI 112 Under 18 conception rate
    NI 115 Reduce the proportion of young people frequently using illicit drugs, alcohol or volatile substances
    NI 69 Percentage of children who have experienced bullying
    NI 111 Reduce the number of first time entrants to the Criminal Justice System
    NI 72 Achievement of at least 72 points across the Early Years Foundation Stage with at least 6 in each of the scales in Personal, Social and Emotional Development and Communication, Language and Literacy.
    NI 73-75 Achievement in English and maths at Key Stages 2 and 3 and GCSE.
    NI 87 Secondary school persistent absence rate
    NI 58 Emotional and behavioural health of looked after children
    NI 86 Secondary schools judged as having good or outstanding standards of behaviour
    NI 114 Rate of permanent exclusions from school
    NI19 Rate of proven reoffending by young offenders
    We are also establishing a good return rate for the CORC measures in NHS CAMHS. The outcomes data they provide will be used to improve the service.

    Sue Topalian
    Bristol CAMHS Commissioners
    (NHS Bristol and Bristol City Council)

  10. Cherie Hinchliffe says:

    There is a general lack of awareness in schools and amongst health care professionals about the rise in eating disorders amounts our children. The earlier an eating disorder is diagnosed the better the outcome/response to treatement. The general public are not aware that eating disorders are a mental illness and that eating disorder sufferers have the highest suicide rate of ALL mental illnesses 1:5.

    It is not acceptable that our children are being sent away to in-patient units for treatment – often 40+ miles away from their home. Alot of the inpatient treatment is provided by “private hospitals” and to be honest they have jumped on the bandwagon – knowing that there is shortage of inpatient treatment facilities for eating disorders and they provide sub-standard care for the children they are being paid a small fortune each week to look after.

    ANY healthcare professional, bank staff, CPN should have eating disorder training or have personal experience of dealing with a child who has an eating disorder. IF you have not had experience then you are not qualified to look after them – they are not the run of the mill children that “bank staff” can just look after. EVERY NHS trust should have an outpatients service available to treat eating disorder patients , where you can take your child each day and bring them home. Sending them away makes them institutionalised and reduces the chances of recovery. Also PHSE lessons should include eating disorders and not just obesity.

    Early detection is vital, early treatment is essential – as it takes on average 6 years for an eating disorder sufferer to recover fully (if they are one of the lucky ones who do recover 4-10 never recover) Eating disorders lead to depression, selfharm and OCD’s and more must be done for the children who suffer from them and to help the carers of them.

  11. Jeff Thomas says:

    We agree with all of the comments, especially those relating to prevention and the use of creative arts therapies. We request that play therapy is added to the list of interventions substantiated by Play Therapy UK’s research based on over 8000 cases. This shows that between 74% and 83% of children receiving this intervention show a positive change using the Goodman SDq as a measure.

    Jeff Thomas – Research Director Play Therapy UK

  12. Liv Kleve says:

    Our experience is that referrers are frustrated by CAMHS being a tier 3 service and that children with miilder mental health problems are not prioritised. We would in fact be delighted to see milder conditions as well, but either funding needs to be increased to accommodate this or tier 1 services need to be much better coordinated and skilled up to deliver effective services to this group (not only addressed thorugh short term funding like TAMHS)

    Services for emerging personality disorders also need strenghthening as well as psychological interventions for children with physical health problems.

    A last point concerns the way in which services will be commissioned for the future. It is all very well to have “four year plans” and consider “best value for money” but it is also vital to ensure that our knowledge of how to motivate the work force to deliver good care and how innovative practice can be fostered is not lost. There is a concern that frequent changes in priority , short term commissioning as well as short term funding for specific conditions followed by cuts (as has been experienced recently) may take up too much unnecessary energy.

  13. Elaine Boulton says:

    Please do not forget children and young people with severe learning disabilities and mental health problems, including severe challenging behaviour. As there is evidence to show that indentifying these children pre-school and providing specific specialist early intervention can improve outcomes fand prevent many children needing residential schools or units.

    Elaine Boulton – Learning Disability Nurse Multi Agency Support Team (MAST) for children with severe learning disability and challenging behaviour

  14. Mark Simmonds says:

    The TaMHS project was a real pointer for how childrens mental health services should be targetting really early onset of mental health problems. It also allowed workers to address the issues of parents/carers too and this is important as they will affect their children aswell. It is very important that the whole family is worked with if the outcomes are going to be effective and long lasting, otherwise we will have the revolving door syndrome and that is not ok just because the waiting times have now been reduced (maybe)!

    I feel it is unhelpful within mental health to have a payment by results approach as it is extreemly difficult to say what therapeutic approach will always benefit a person, CBT is not the great panacea the Government seems to think it is! Some people can be helped in a reasonably short time period, for others it is much longer. With the pressure on CAMHS to target those on tier three it is going to be much harder for them to give the results commissioners and the Governmnet want because the target group is much more complex and so generally require more input over a longer period of time.

  15. B Manning says:

    The availability of children’s clinical mental health support in areas of profound multiple deprivation and high need is a major worry to many secondary schools. CAMHS (and previously TaMHS) is great up to a point but when issues arise an immediate response is required. I have experience as a school leader of referring and referrals for childen who’ve attempted serious self harm being rejected as “not meeting Tier 3″. As a school we did not buy into Tier 2 PEIS due to budgetary constraints and our children were penalised. The referral process takes at least days if not weeks and the supply doesn’t meet the demand. CAMHS counselling is just not effective enough because there’s not enough of it and it’s not able to be intensively implemented. The training is great but it doesn’t make school staff mental health experts. A little knowledge……Some schools in very challenging IMD type contexts need on-site Mental Health Nurse type provision as part of integrated frontline delivery of services and to also implement early identification and support planning strategies within total family settings.The EP service is saturated and straining at the seams. I’d love to see a wholly community (school) based Child Mental Health strategy being commissioned jointly by education and health that actually responds to symptoms but also the tackles root causes of the problems.A huge amount of poor behaviour is mental health driven and educators have neither the skills nor the capacity to lead on this. If the school I work in was offered a pilot for this, we’d jump at it.

  16. Simon Eedle says:

    The majority of comments posted relate directly to mental health services for children and young people. A major gap in support for children at risk of mental health issues is the lack of adult mantal health services for parents, particularly those parents who are looked after by their children (young carers). The tendency of adult mental health services to see their service user in isolation and the high entry criteria for services means many young people are having to provide levels of care that impact negatively on their own mental wellbeing. When assessing support for the adult the additional needs of parenting and impact on family members is not taken into consideration i.e. a patient may be assessed on their ability to survive in the community without professional support but the needs of their children/family and their ability to parent are not considered and the thresholds for service access are not adjusted accordingly leaving young people vulnerable and more likely to succumb to their own mental health issues. As with so many issues the importance of seeing the service user in the context of family/environment is key to good practice and effective prevention.

    Simon Eedle
    Children’s Services Manager
    Barnardo’s Young Carers, Newcastle

  17. Bronach Hughes says:

    Bronach Hughes, Emotional Health and Wellbeing Co-ordinator at ContinYou

    As other respondents have mentioned, there is a need for much more early identification and intervention to support children, and the most obvious place for that to happen is in schools (as most children attend one). However, there are several factors that mitigate against schools providing suitable early intervention services including lack of time in the curriculum, the downgrading of PSHE/ECM/Healthy Schools which specifically encouraged staff and children to talk about these issues, and, crucially, lack of willingness and/or skills in school staff to tackle these issues.

    The TaMHS programme successfully brought together statutory and voluntary sector providers to pilot interventions that could be offered through schools, whether during the school day or as after-school activities. The health service should be looking at the work that has already been done across England through TaMHS to see what works and could be rolled out more widely.

    We do too much reinventing of wheels in this country – there are lots of interventions around that we know work because they have been evaluated to death (nurture groups, Pyramid clubs, play therapy, parenting support) yet we go back to square one each time! Could we not build on these known interventions and fund the organisations that can support them, rather than putting in place yet more expensive structures? The voluntary sector has supported children and families experiencing a range of the health problems identified above for a very long time, and yet is on the verge of disappearing because of changes in commissioning arrangements in local authorities. The health service needs to look beyond clinical settings and providers to bring in suitable early interventions to support children as early in the life of their problem as possible, and as close to home as possible. Research consistently shows that investing in early intervention systematically will reduce the numbers of children and young people needing specialist services to support their mental health in time. Government says it believes this, but has yet to fund it in any meaningful way – could we do it right this time?

  18. Dr Mike Shaw says:

    Prevention and early intervention with child abuse and neglect presents a clear opportunity to improve lifetime mental health. Child abuse and neglect affect a substantial number of children. Abuse and neglect have an immediate impact on mental health and wellbeing, however they are also important because of the long-lasting effects on adult mental health, drug and alcohol misuse, obesity, and criminal behaviour. For example in women there is a particularly strong link between penetrative sexual abuse in childhood and adult mental health disorders including psychosis. Child and Adolescent Mental Health Services make an important contribution to the assessment and treatment of child abuse and neglect, however the provision is patchy. A large proportion of abused and neglected children have a psychiatric disorder, including diagnoses (ADHD, PTSD, depression, anxiety, conduct disorder) for which the evidence base developed in the CAMHS clinic population is applicable. The Family Drug & Alcohol Court (FDAC) is an example of highly coordinated interagency working to improve health outcomes for children http://www.brunel.ac.uk/shssc/research/ccyr/research-projects/fdac.

  19. Holly Millerchip says:

    I think there should be more support available the parents and the child of one who has tried to commit suicide.
    Parents should have a general explanation of how a child is feeling and what they can do to support their child.
    For the child/adolescent I think it is VERY useful for them to talk to someone who has been in the same situation as them (i.e. who has previously tried to commit suicide) but has managed to overcome there difficulties and now enjoys their life and so can now instill some inspiration into the child.
    Both the parent and child should have treatment options available to them and explained why it is not as easy as taking a pill.
    Also it should be explained why some people cannot cope with daily stresses for example they may have a biochemical inbalance in the brain.

    I am a 21 year old who volunteers on a Childrens Assessment Ward and have previously tried to commit suicide and have been sectioned before, but now I love my life and am looking forward to studying childrens nursing soon and being able to revive some peoples confidence in life.

  20. Sue Topalian says:

    I am sure that those working on the outcomes strategy are aware of the useful work done in Scotland on outcomes indicators for children mental health. For others who may be interested, see
    http://www.healthscotland.com/documents/5589.aspx

  21. joe squash says:

    My experience of CAMHS has been a disappointment from start to finish. I was referred there because of my depression and found the whole process made my depression worse! I was seen, assessed and offered therapy by a social worker who had no qualifications in mental heath or therapy!
    I will NEVER go back – until CAMHS have qualified staff treating patients I fail to see how it can ever work!!

    • Rod Whiteley says:

      It’s not just in CAMHS that this happens. Many NHS staff play at being amateur psychotherapists when their only qualifications are in something else. IAPT was supposed to fix this by providing more trained therapists, but many IAPT staff are still only PWPs, not fully qualified psychotherapists. NHS commissioners and providers haven’t all understood that it takes properly qualified staff to deliver effective treatments, and that using unqualified staff wastes NHS resources as well as providing a shoddy service. You could have your social worker disciplined for dabbling in psychotherapy, but it wouldn’t solve the wider problem.

Leave a Reply

Leave a comment

*