No one to turn to

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 Unpublished research for the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