Mind the gaps

Spotting a mental health problem in a child is a job for a
specialist, isn’t it? Well, yes and no. For mental health problems
to be identified at an early stage when they are easier to work
with, professionals who have contact with children need to know the
signs to look for. Yet according to a survey by children’s mental
health charity YoungMinds,¹ while almost 90 per cent of
social workers, teachers, health visitors and other front-line
staff have had contact with children with mental health problems,
80 per cent have received no relevant training.

In the survey – an analysis of training needs carried out in one
part of England at the end of 2000 – three-quarters of staff
identified recognition of mental health problems, promotion of
mental well-being, managing emotional and behavioural difficulties,
and knowledge of local services as key areas of learning.

So why isn’t this happening?

The Diploma in Social Work is a generic qualification and there is
nothing specific in its curriculum outlining exactly what should be
taught about child mental health. Although students are introduced
to common mental health problems in adults and children, it is up
to the university or college to decide how much or how little
training is given on child development and the way in which adverse
conditions impact on development, health and well-being.

Most social workers specialise after qualifying, and child mental
health is an aspect of the Child Care Award qualification for
social workers. Whether the new social work degree will put a
greater emphasis on child mental health than the DipSW is still
unknown.

YoungMinds and other agencies offer training and there are a number
of post-graduate qualifications appearing. YoungMinds and London’s
City University launched a masters degree in child and adolescent
mental health this month, as has Leicester University.

But with a dearth of general training, it is unsurprising that most
front-line staff do not have the skills or tools at their
fingertips to assess a child’s mental health. Dinah Morley, deputy
director of YoungMinds, says: “This stems from a lack of
understanding of mental health problems. They think of the florid,
psychotic symptoms, which are rarely seen in children. But what we
do see are the other problems like depression, eating disorders and
conduct disorders.”

About 10 per cent of the general child population have mental
health problems, but this leaps to up to 90 per cent among children
who are in contact with social services. Conduct disorders, in
particular, are extremely common, says Morley, and need to be
identified early otherwise they can lead the child on a downward
spiral from truanting, to crime, to prison.

Social workers are understandably reluctant to label children as
mentally ill because of the stigma attached. But the reality is
that the problems that social workers spend most of their time
grappling with are largely outcomes of poor mental health, says
Morley.

The reason behind the findings of the YoungMinds survey dates back
to the change in the social worker’s role, Morley argues. About 20
years ago, training was focused on interpersonal relationships –
something that is now the role of the family therapist in a child
and adolescent mental health team. The jobbing social worker is
more focused on a tickbox approach of carrying out prescribed tasks
and the child has become an object rather than a person, she
says.

“It means that mental health is not considered in the depth that is
necessary to assess the sort of support that a child needs in a
particular circumstance,” adds Morley.

Judy Shuttleworth, former chairperson of the Association of Child
Psycho-therapists, agrees: “Something has gradually happened to
social work training following ‘genericisation’. Before, you felt
that there was a greater level of understanding about children’s
needs, but that seems to be disappearing as these people have left
the profession.”

This depletion of experience results in social workers spending
more money on commissioning services or using the private sector.
The knock-on effect is that they then lose control over what
happens to a child, says Shuttleworth, since children rarely return
to a CAMHS team.

“Then they end up buying back training from these services, which
doesn’t necessarily tie in well with what it means to be a local
authority social worker working with children with mental health
problems,” she adds. “A lot of money that could go into training
and support for social workers goes into this parallel world of
services.”

And how can someone commission services if they don’t properly
understand the problem in the first place? In order to act as
filters for other services, they need a good understanding of what
other people do.

Appropriate mental health training will help them function as
social workers, says Shuttleworth. It will help them use specialist
staff more effectively and give them a common language. It is
difficult to work productively without these in place.

The problems don’t just lie with social work training. There is a
severe shortage of specialist staff. Child psychiatrists, child
psychotherapists and child clinical psychologists, the staff who
work at the heavy end of child mental health and take a long time
to train, are all pretty thin on the ground. And there is a
particular lack of people trained in child mental health combined
with learning difficulties or drug and alcohol problems.

One explanation is that adult mental health is seen as the more
prestigious field, while child mental health is seen as the soft
option.

Funding issues are the historical reason behind the lack of child
psychotherapists. Now that the NHS funds training, there has been
an expansion in the numbers trained, but as this takes six years it
will be some time before this increase is felt on the ground.
Happily, unlike social work, once trained there is generally no
retention problem.

It doesn’t help that some child psychiatrists see this as their
medical domain, says Morley. “There is a split view, with some
thinking that children’s mental illness is their business and that
social workers deal with social problems. Whereas others think of a
comprehensive CAMHS team with them at the sharp end and other
professionals like social workers and teachers at the front end
where they will see the early manifestation of mental health
problems.”

Sue Bailey, chairperson of the Royal College of Psychiatrists’
faculty of child and adolescent psychiatry, in London, says it’s
something that she wouldn’t be precious about. “It’s not realistic
that psychiatrists can do it all, social workers have an important
part to play.”

But to play this part properly, there needs to be a stronger
developmental underpinning to training across all professions,
particularly social work, so that they understand normal and
abnormal development. “If you don’t have any understanding about
how children and families function and develop mentally, your risk
assessments are flawed from the beginning,” says Bailey.

Children often have mental health problems because their ordinary
needs were not met from the beginning. It takes a well trained
social worker to recognise the impact that situations in their life
could have on their mental health and to know whom to turn to if
they can’t deal with it. Without this training, any children they
come into contact with could already be at a disadvantage.

Unfortunately, a large proportion of the current workforce has a
gap in their training around child mental health, and it will take
time to repair. CC

¹ YoungMinds, press release, 12 March 2001. For
more information go to
www.youngminds.org.uk