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Children and young people with mental health problems are crying out for help. One in 10 has a mental health problem severe enough to need professional input yet fewer than one in five receive a service. The result is that many families are left struggling to cope while their children experience what can be severe mental health crises.

Because of the acute shortage of services, many children and young people are ending up being treated in inappropriate settings including adult psychiatric wards. Unpublished research for the Department of Health carried out by Professor Peter Hill, consultant child and adolescent psychiatrist at Great Ormond Street Hospital for children, reveals that 25 per cent of young people with severe mental illness are being inappropriately placed in either adult psychiatric wards or paediatric wards. According to the last report of the Mental Health Act Commission, the percentage of older adolescents being inappropriately placed is higher.

Since the early 1990s, 20 per cent of in-patient child and adolescent mental health beds have been lost. Hill argues that the number needs to be increased by one-third to cope with demand.

But it is not only in in-patient services for acute difficulties where the shortages lie. Children and young people are waiting for up to a year to see a child psychiatrist for an assessment. "If they put the waiting lists for child and adolescent mental health services [CAMHS] into the national statistics, they would be completely skewed," says Jane Held, co-chairperson of the Association of Directors of Social Services' children and families committee. CAMHSare the four-tiered services ranging from non-mental health specialists to highly specialised forensic units.

The government defines mental health problems in children and young people as "abnormalities of emotions, behaviour or social relationships sufficiently marked or prolonged to cause suffering or risk to optimal development in the child or distress or disturbance in the family or community". Using this definition, the statistics are stark. One in five children and adolescents has a mental health problem.¹ Some will cope with their problems for part, or all, of the time and will not need professional intervention in their lives. But even if they can cope, the experience of mental illness cannot but have a negative impact on their families and communities. Many, however, are not able to cope.

Some children and young people develop mental health disorders, a term used to describe those whose mental health problems are more severe, and mental illness such as psychosis, schizophrenia, and manic depression. One in 10 children aged between five and 15 has a mental disorder, according to the most comprehensive study conducted for the Office for National Statistics.² Of the older age group - 11-15 year olds - mental disorders were found in 13 per cent of boys and 10 per cent of girls.

Up to 2.5 per cent of children will suffer from major depression in mid-childhood; up to 8 per cent in mid-adolescence. Less common disorders, such as eating disorders, tics and autistic disorders, were attributed to 0.5 per cent of the age group. A total of 273 per 100,000 of 15 to 19 year olds will attempt suicide and 5 per cent will succeed - and the rate is rising in young men.³ The Royal College of Psychiatrists estimates that about one in every 200 children under the age of 12 and two to three in every 100 teenagers will suffer from some form of depression at any one time. Adolescents who experience a depressive episode are at high risk from other mental health disorders - up to half will have recurrent depression and up to one-third are at risk of substance misuse.

There is a strong link between poverty, social class, and the risk of childhood mental health problems.⁴ Children who live in disadvantaged circumstances are at higher risk. Studies have also found that having more than one disorder is common.

Conduct disorders are the most common reason for referral of young children to mental health services. In the ONS study, of the 10.4 per cent of children in the UK with a mental disorder, the majority had conduct disorders. Yet conditions such as conduct disorder, obsessive compulsive disorder, and other behavioural problems are often dismissed as "normal teenage behaviour" and the young people often receive little or no treatment or support.

Yet research has proven the link between adolescent mental disorder and antisocial behaviour in later life. Work by child psychiatrist Stephen Scott at the Maudsley Hospital in London suggests that four out of five children who show behavioural problems by the age of five go on to develop more antisocial behaviour. Approximately 40-50 per cent of children with conduct disorders may develop antisocial personality disorder as adults. The estimated annual cost per child if conduct disorder is left untreated is £15,270.⁵ But the community-based services specifically targeted at adolescents who are hard to engage in psychiatric services are almost impossible to find.⁶

Specific groups of young people are at higher risk from mental health disorders. One is children in the care system. Research in Oxfordshire in 1998 found 67 per cent of those in the care system have a mental disorder - rising to 96 per cent of those in children's homes and secure units.⁷

The other is group is young offenders. The link between mental health problems and youth crime is undeniable. According to a Cambridgeshire study in 1995, 90 per cent of recidivist juvenile offenders had a conduct disorder at age seven.⁸

Disabled children and those with learning difficulties are more likely to have mental health problems. Disabled children and adolescents are twice as likely to have emotional and behavioural difficulties. If they have a life-threatening disorder, the ratio rises to one in six.

It is estimated that up to half of all children who are sexually or physically abused have post-traumatic stress disorder. Often, those who have been sexually abused do not receive counselling or therapy for fear this will prejudice any criminal trials. The result is that young people develop mental health problems, including symptoms of psychosis, as a means of coping with the abuse they have suffered.

There are high and enduring long-term costs associated with childhood mental health problems. Research shows links with teenage pregnancy and bullying. Poor mental health is a factor in substance misuse, low academic achievement, and truancy.⁹ The cost to the state which has to pick up the pieces is high as the young people who are denied treatment become adults who cannot work and cannot contribute to society.

Yet many children and young people are denied specialist treatment simply because there is very little available. An audit of services in 1999 found that over one-third of health trusts could not respond effectively to a young person in crisis; only half had an agreement for emergency and 24-hour cover; and 10 per cent could not offer a non-urgent appointment within six months.¹⁰ Over the years, in-patient units have been forced to close, primarily because of the inability to staff them.

CAMHS vary dramatically across the country. In some areas there are no specialist services at all. Expenditure per health authority in the 1999 audit varied by 7:1. The mix of staff was also very variable. And almost one-third limited their services to children under 16. Yet many experts argue that the period between older adolescence up to 21 and even 25 is crucial, as young people enter work and form new families.

The specialist CAMHS (tier 4) is besieged and cannot cope with increasing demand, according to those on the front line. "There is not enough of a service," says Peter Hill. His research found one group of three health authorities were wasting enough money on independent health care provisions to build and staff three in-patient units. "Health authorities are spending on independent health care provision but are not investing in their own services which could be bought more cheaply. They are not building their own units."

For many health authorities and trusts, it is the impact of continual government initiatives to target different aspects of health care that has left CAMHS adrift, maintains Hill. Health authorities are still closing in-patient units - a unit in Surrey is about to shut its doors. Hill's own unit at Great Ormond Street cannot be staffed fully and has lost teachers and psychiatrists.

There are severe staff shortages throughout CAMHS. The Royal College of Psychiatrists aims for a ratio of 1.5 child psychiatrists per 100,000 - in Finland it is 6 or 7 - and estimates that about 50 per cent of CAMHS are running with fewer. There are areas where there are no child and adolescent psychiatric consultants at all, which means children are referred up to a higher tier service which is often unnecessary. Sometimes child and adolescent psychiatrists have to cover two geographical areas, placing them under even greater pressure. There is a false assumption that tier 3 services - multi-disciplinary and multi-agency teams offering assessments and treatment usually from a community base - are larger than they are. In one area, users estimated there were 50 full-time professionals working in this part of their local service - the true number was 17.5.

Hand in hand with recruitment problems comes low morale. The Royal College of Psychiatrists points to high levels of stress and early retirements among child psychiatrists. They complain there is no time to carry out proper needs assessments.

Neil Hemstock, senior clinical nurse at Oakhan House adolescent in-patient unit in Leicester, and chairperson of the Association of Professionals in Services for Adolescents, agrees that staff across the board are under increasing pressure. "Over the past two to three years on my own unit we are seeing more children with a psychiatric diagnosis of mental illness. We are seeing more children who self-harm. It's highly stressful, emotionally charged work." He describes the current crisis response as a postcode lottery. "In some places there is no emergency call-out system so a child in crisis at night could be left in casualty or put in paediatrics, where the staff don't know how to deal with them."

Meanwhile, in the community, because of the shortages of CAMHS, other professional groups are being forced to fill in the gaps. Approved social workers are being asked to carry out mental health assessments on 15 and 16 year-olds. The Community Psychiatric Nurses Association reports that its members are coming into contact with young people with mental health problems through their work with parents. According to Jane Held, the extreme variation in CAMHS is down to teams creating their own terms on what they will or will not deal with.

While children and young people are left grappling with mental health crises without treatment, their families are left struggling to support them (see below). The emotional cost is colossal. Wayne Thomas, a social worker with the Talking Point project run by Thamesmead Family Services Unit in east London, sums up the frustration of those working with families who are left waiting. "Families are at crisis point but there's nothing we can do - a lot are on the verge of breaking down. We are seeing a lot of families where there has not been a diagnosis though they have had contact with CAMHS. It's frustrating, as we cannot move forward. CAMHS are overwhelmed."

Thomas says CAMHS need better organisation and a system to contact families promptly rather than leave them waiting with no idea of when an assessment will take place. He also wants family support organisations to have better access to the services. "This should be on the priority list because for a lot of these kids, their condition will get worse. A lot of them will fall through the net and develop mental health disorders which will be far worse as adults."

Professionals in the field have known for years that child and adolescent mental health services have been neglected. But it was not until the Health Advisory Service report Together We Stand in 1995 that pressure for change began to build. The report revealed that only 20 per cent of young people with mental health problems were receiving a service. The health select committee confirmed the gaps in services in a 1997 report and the government's national priorities guidance, first set in 1998, included a target to improve liaison between primary care, specialised child and adolescent psychiatric services, social services, and other agencies.

The next year, the government ploughed more money into CAMHS through a new modernisation fund. To obtain a slice of the three-year grant, education, health, social services and voluntary groups had to demonstrate joint working. A total of £85m was announced in February 1999, and another £5m was injected into in-patient beds in August 2001. Part of the first pot was to be spent on new primary mental health workers, which are slowly coming on stream. However, the final tranche - £10m - for 2001-2 was not ring-fenced and instead included in health authority baseline budgets.

The government's spending review last month claimed there would be investment in new and improved child and adolescent mental health services as part of a cross-cutting government commitment to improved support for children at risk and their families. But the money is coming from the 6 per cent increase for social services, which directors are already complaining will all be used in sorting out the bed-blocking crisis.

Whether or not CAMHS does see additional investment, there is a serious shortfall to make up. The YoungMinds charity estimates that only about 5 per cent of the total mental health budget is spent on children and young people.

But it is not only about resources - it is about political and agency will. CAMHS must compete for priority with the endless directives on the health service. Concerns have been expressed that primary care trusts are not up to, and are not large enough, to commission CAMHS. Al Aynsley-Green, the national clinical director for children, voiced his apprehension at a Young Minds conference last month. "PCTs are struggling and will need help from us not least because of the importance of CAMHS and child protection."

According to Bruce Irvine, who runs the Young Minds consultancy service, what's lacking is a strategic framework for comprehensive CAMHS. Multi-agency boards and partnership boards both work but very few CAMHS have gone down this road. "The government's CAMHS strategy is supposed to be run by multi-agency partnerships but it is not. They have been thrown together. There is a major problem with delivery because education, social services and health do not see the same outcomes."

The balance between treatment and prevention is wrong. Irvine argues that CAMHS is seen as specialist rather than comprehensive, with the focus on the in-patient units instead of concentrating on ways in which the first and second tier services - GPs, health visitors, social workers - can prevent the need for specialist treatment. With adults, 60 per cent of mental health problems could be dealt with at tier 1 and although there are no statistics for young people, it is assumed that the percentage is similar. To do this will need a shift in perceptions among a range of professionals and agencies.

"The way forward is to make CAMHS part of a strategy group or children's services planning process," says Irvine. "We are talking about a sea change of cultures." But there is a long way to go. The bunker mentality between agencies is so bad that money is not being spent because of inter-agency rows, he claims.

Many local authorities have withdrawn their social workers from CAMHS teams. However, that drift has been halted somewhat by additional Quality Protects money for CAMHS. According to Jane Held, social services are now saying they want to invest in CAMHS. But the funding via QP is still a drop in the ocean, she says. "If you put it in perspective in terms of the investment in adult mental health services, it's tiny."

There is a need for both specialised and community-based services to treat, help and support children and young people with mental health problems. Increased, ring-fenced resources, focused workforce planning, sustained training, and improved work on the ground are all necessary. Held argues for a more flexible service, where specialists, such as psychiatrists and psychologists, provide advice and consultancy to professionals working in the community.

She wants compulsory child development training for everyone who works with children, and for staff to receive basic education in CAMHS as part of their continued professional development. "We also need an increase in the amount of tier 1 services. Tier 3 should be a continuum and Tier 4 professionals should move out into the community. For example, we could see child and adolescent psychiatrists working in schools." She is most concerned about the children without a formal diagnosis. "The most difficult are the young people who bounce around the system with no proper diagnosis. They are very high risk, very high worry."

The children's taskforce is drawing up a national service framework for children - due to be released in spring 2003. It has an external working group examining children's mental health. But its remit only covers young people up to the age of 19 and those working in the field argue that young people who are forced to leave the CAMHS framework often lose contact with services altogether or end up poorly served by adult services which fail to meet their specific needs. That's why a national strategy which covers people going through the transition to adulthood, which can take them up to 25, must be put in place.

Peter Hill wants to see a national framework. "We need a politician to see it through and, within health authorities and trusts, people to champion CAMHS and ensure it is funded and expands. What is needed is political will - we do not need much more money." He is cautious about the NSF. "We do not know if it is going to be sufficient - we have to wait and see."

Al Aynsley-Green, who heads the task force, is confident about the future. "We have a chance here," he told last month's conference. "CAMHS is certainly on the radar screen. How can we work together to make sure politicians are listening?"

The question is whether we are willing to put the investment in. Unless there is major improvement and expansion of the current system, children and young people and their families are going to continue to struggle to cope with mental health problems, running the risk of more serious mental health problems in later life. Is this the future we want?

“I’m on edge all the time”

There are no carpets in Jewett Bartholomew’s house. She had to remove them because her nine-year-old son Nathanael set fire to them. “Nathanael is very aggressive,” she says. “He wrecks the place. He set fire to the labels on his clothes while wearing them. He is always lashing out at other children. He kicks and punches his 12-year-old sister Esther in her face.”

Two years ago, when Jewett separated from her former partner, the children lived with their father for six months. When they returned to live with their mother two years ago, Jewett heard tales which shocked her, including how Nathanael’s father hung him by the ankles over the balcony of a multi-storey car park. Nathanael began demonstrating inappropriate sexual behaviour towards children at school, was exposing himself, and was eventually excluded. Jewett suspects his behaviour was due to his exposure to pornography before his father left the family home and while he lived away. “He’s angry,” she says. “His father tells him that all he wants is to get back to being a family. Nat keeps thinking we could be a family.” Jewett also speculates that some of Nathanael’s anger could be due to her condition - she has multiple sclerosis.

Last autumn Jewett contacted social services for help. “I just wanted them to help and support me - there was nobody.” In May, social services referred Nathanael to the local CAMHS team. However, the assessment has still not taken place. “Nat needs some specialist help. There’s something there that needs to be investigated. My main concern is Nat but I want help for both of them. Esther needs help too. She withdraws into her own little world and it is hard to draw her back. They are very angry towards each other. I’m not sure I understand that.”

The pressure of waiting for someone to help the family is taking its toll on Jewett. “My nerves are running on. I feel filled with nerves waiting at home. It affects my health. I get very down - I’m on edge all the time. My muscles are not flexing so I am in pain.”
One of Nathanael’s teachers now acts as a mentor and things have improved slightly - Nathanael has not demonstrated any sexualised behaviour. Three months ago, help came in the form of a support worker from Family Service Units, who comes once a week to see Nathanael. “I’m calmer since they came,” says Jewett. “I ring him at times when I feel I cannot cope. It’s just getting someone to help.”

“I didn’t know i had a baby”

When Becky (not her real name) was 16, she gave birth to a baby boy. She was living at home with her mum. Her partner was on remand in prison and days after the birth, he was sentenced to six years.

She suffered a postnatal psychotic episode 11 days after the birth. She has hidden the details of what happened deep inside but recalls seeing things. “I got a bit crazy.” Her mum phoned her GP who came to the house but refused to see Becky after she said she did not want to see him. Her aunt then rang the local hospital, who told her there was nothing they could do and to ring the police.
The police arrived immediately and Becky was taken to a police station. They asked her if she had been taking drugs. After a couple of hours, she was taken to an adult psychiatric hospital and placed in a padded cell. “For the first week at the hospital I did not know I had a baby. They kept giving me drugs - I slept for two whole days.” She refused to take the drugs after the first week. Becky was in a large mixed ward, where most of the patients were between 50 and 70 years of age. They had severe mental illness and kept asking her who she was visiting. “Horrible,” is how she describes it. “I was scared, shocked. Every time I saw the child psychiatrist, he would say that I was not ready to leave yet.”

After a fortnight, she was moved to a mother and baby unit at another psychiatric hospital and her baby joined her two days later. “It was a lot better because I wasn’t locked up. The mother and baby unit was separate from the rest of the hospital. I was not drugged. The staff were lovely.”

When she left, she continued seeing the psychiatrist for a few weeks. Social services put her in touch with Barnardo’s, who placed her in a supported housing project for young people.

Becky believes that if the GP has seen her when she initially became ill, she would never had ended up in the psychiatric system. She feels stigmatised by it - she says everyone in her locality knows she was once in a psychiatric hospital.

¹ Bright Futures, Mental Health Foundation, 1999, quoting M Target, P Fonagy, What Works for Whom: Implications and Limitations of the Research Literature, Guildford Press, 1996.

² Office for National Statistics, The Mental Health of Children and Adolescents in Great Britain, 2000. Main research is Meltzer et al,The Mental Health of Children and Adolescents in Great Britain

³ SA Wallace, JM Crown, AD Cox, M Berger, Child and Adolescent Mental Health: Health Care Needs and Assessment, Radcliffe Medical Press, 1997

⁴ Whose Crisis? Meeting the needs of children and young people with serious mental health problems, YoungMinds, 2000

⁵ Parent-training Programmes for the Management of Young Children with Conduct Disorders, Findings from Research, Royal College of Psychiatrists, 2002

⁶ Turned Upside Down, Mental Health Foundation, 2001

⁷ J McCann, Prevalence of Psychiatric Problems among Young People in the Care System, 1998

⁸ D Farrington, "The development of offending and antisocial behaviour from childhood: key findings from the Cambridgeshire study in delinquent development", Journal of Child Psychology and Psychiatry, 1995

⁹ Child and Adolescent Mental Health: Its importance and how to commission a comprehensive service, YoungMinds, 2001

¹⁰ Children in Mind, Audit Commission, 1999

Resources

- YoungMinds runs a confidential information and advice service for parents of children and young people with mental health problems on 0800 0182138. YoungMinds: 020 7336 8445 www.youngminds.org.uk

- The Royal College of Psychiatrist's Focus project is a dissemination project for professionals working in this field: www.focusproject.org.uk and 020 7227 0822.

- Mental Health Foundation: 020 7802 0302 and www.mentalhealth.org.uk  

- Rethink plus a helpline for young people on www.at-ease.rethink.org.uk