A stretched service

Stressed, suicidal and likely to self-harm. These were the key findings of a survey of 1,000 young people that made the newspaper headlines in November and laid bare the truth about the state of children’s and young people’s mental health.

The survey, commissioned by the independent mental health service provider the Priory Group, reveals that young people are highly stressed about  schoolwork, money and sex, with peer pressure another contributing factor.

More than 900,000 adolescents have felt so miserable they have considered suicide, the research found, and more than one million adolescents have wanted to self-harm, including almost a quarter of girls aged between 15 and 19. More than 800,000 have actually self-harmed.

“An unacceptably high proportion of British youngsters suffer from a wide range of mental health issues that adversely affect family life, friendships, developments and academic achievement,” the Priory Group concluded.

But, while shocking, the story behind these findings is not new. In 1999, offi cial fi gures revealed that 10% of boys and 6% of girls aged between 5 and 10, and 13% of boys and 10% of girls
aged between 11 and 15, had some sort of mental disorder. The corresponding statistics collected in 2004 tell an almost identical tale, meaning that for at least the last six years we have known that one in 10 children in England, Scotland and Wales aged 5 to 15 has a clinically recognisable mental disorder.

Alarmed by these figures, the government has made efforts in recent years to raise the political profile of child and adolescent mental health (CAMH) services, extending the services’ remit
to cover 16- and 17-year-olds, investing more resources, and setting a range of new targets and performance indicators.

In 2002, this led to an undertaking by the Department of Health to achieve “year on year improvements” in access to CAMH services for children with mental health problems between 2003
and 2006. More recently, the DH agreed to maintain these levels of service up to 2008.

As part of this improvement drive, by the end of 2006 all CAMH services are expected to provide a “comprehensive service”. This means each locality must be able to clearly show how they will meet the full range of users’ needs in their area.

In terms of investment, according to the annual mapping exercise of CAMH services, £353m was spent in 2003-4 compared with a predicted spend of £416m in 2004-5. More than 80% of this money was reported to come from primary care trusts. The CAMH services grant to local authorities, which accounts for the rest of the spending, rose from £51m in 2003-4 to £90.5m a year from 2005-6 to 2007-8.

The impact of this extra investment speaks for itself. The 2004 mapping revealed that 99 of the 989 teams in the 139 CAMH services that returned data were newly resourced teams set up during the previous 12 months. The result was a 14.6% growth in the CAMH services workforce over this period.

However, there is still a long way to go. Although half of all new cases referred to CAMH services teams in 2004 waited less than a month for treatment, 11% waited between three and six months, and 8% waited for more than six months. At the end of the 2004 data collection period, there were 30,716 cases still waiting.

The 2004 mapping also revealed that only just over half of CAMH services had an on-call provision, and 13% offered neither an on-call service nor emergency next day response by CAMH services staff.

Services for 16- and 17-year-olds are another area of weakness. The age break between CAMH services and adult mental health (AMH) services in England can still vary between 16, 17 and 18 as CAMH services move towards providing services up to 18. As yet unpublished results of a survey of primary care organisations in England and Scotland last summer reveal that only 9% of CAMH services commissioners and 6% of AMH services commissioners who responded had specific policies in place to improve access and services for young adults. The survey was
conducted as part of the Stressed Out and Struggling project by children’s mental health charity YoungMinds to raise awareness of the mental health needs of 16- to 25-year-olds
and improve access for this group to mental health services.

A shortage of adolescent beds also means some young people continue to be cared for inappropriately in adult psychiatric beds. In addition, children and young people who are psychotic
or who have complex, persistent and severe behaviour disorders and who fi rst present in accident and emergency departments may then be admitted inappropriately to paediatric wards.

“There are definitely more mental health services for children and young people today than there were before the CAMH services grant started,” says YoungMinds director Barbara Herts. “But there is still a gap, particularly for the teenage age group. The issue about it is that, although there are some really good initiatives, it is still very patchy across the country. Mental health  historically has been under-funded in the NHS and it’s even more of a concern with the current NHS funding freeze. CAMH services could be particularly vulnerable.”

Although the government estimates that about 1.1 million children and young people under the age of 18 would benefi t from specialist mental health services, in 2004 around 40% were not receiving any specialist service at all.

Around 45,000 children and young people with less serious mental health problems are also estimated to need help, and in most cases responsibility for providing this falls to services in primary health care, social care, education, early years, and the voluntary sector.

Yet in July 2005, education watchdog Ofsted reported that only a very small minority of schools were working towards or had met the criteria for providing for pupils’ emotional health and
well-being set out in the 1999 National Healthy Schools Standards. One barrier was the low level of awareness of the importance of the issue, and Ofsted concluded that training for staff on mental health difficulties was needed in three quarters of the schools inspected.

Meanwhile in primary care, the Office for National Statistics reported in 2004 what many suspected: that GPs varied widely in their recognition of child psychiatric disorders.

“Teachers and GPs are just not trained very well in mental health so don’t spot it until it bites them on the nose,” explains Tamsin Ford, child psychiatrist and senior lecturer at the Institute of
Child Psychiatry, Kings College, London.

“GP and teacher training needs to change. They  need to be able to recognise severe mental health difficulties and to learn how to deal with milder ones or know who to refer them to. We can’t deal with everyone.”

It comes as no surprise, then, that Standard 9 of the National Service Framework on children, young people and maternity services recommends that all staff who work directly with children and young people have suffi cient knowledge, training and support to promote the psychological wellbeing of children, young people and their families and to identify early indicators of difficulty (see Guaranteed service access, below).

This is especially important given that certain groups of children and young people known to other agencies are particularly vulnerable in terms of their mental health. Looked after children, for
example, are fi ve times more likely than their peers to have a mental health disorder. Children and young people with signifi cant learning difficulties are three to four times more likely to have a mental disorder, and at least 40% of young offenders have been found to have a diagnosable mental health disorder.

Children with mental disorders are also much more likely than other children to have had time off school and to have poorer general health than other children.

Other factors that increase a child’s chances of developing mental health problems – including social class, the educational qualifications of parents, the number of siblings, and a family’s
household income and employment situation (see Prevalence of mental disorders, beliow bottom) – are also factors that might equally bring them to the attention of other agencies outside CAMH services.

On the joint-working front, there are signs that some progress is being made. In 2003-4, for example, 30% of newly resourced provision was in dedicated CAMH services staff working in non-specialist CAMH services teams, such as youth offending teams and behavioural and educational support teams.

But there is undeniably more to be done – and there is hope that the multi-agency and shared service delivery programme that underpins the Every Child Matters agenda could help.

“We can’t possibly meet the demand out there, so what we have got to do is mobilise and train up people like school nurses and health visitors, and look at teacher training,” explains Herts.

“There is this hidden army of people who could, with some training, work out what is naughty behaviour and what is a substantial mental health problem. YoungMinds has already done a lot of
training with Sure Start workers, for example.

“I’m positive about children’s trusts and extended schools. This is a really good opportunity to integrate things at the frontline. I think that’s the way forward: to pool the budgets with education and health, and get the schools on board.”

What is clear from all the evidence, then, is that although the continued improvement and growth of CAMH services is critical, real progress in addressing children’s and young people’s mental health needs is just as dependent on the commitment, input and investment of every other agency working with children too.

As child psychologist Tamsin Ford puts it: “Mental health really is everybody’s business.”

NSF from www.dh.gov.uk/assetRoot/04/09/05/60/04090560.pdf 
YoungMinds at www.youngminds.org.uk

Guaranteed service access
Standard 9 of the National Service Framework for Children, Young People and Maternity Services states: All children and young people, from birth to their eighteenth birthday, who have mental
health problems and disorders have access to timely, integrated, high quality, multi-disciplinary mental health services to ensure effective assessment, treatment and support, for them and their families.

Prevalence of mental disorders
16% of children in lone parent families
8% of children in two-parent families
14% of children in reconstituted families
9% of children in families with no stepchildren
20% of children in unemployed households
8% of children whose parents both work
16% of children in families with a gross weekly household income of less than £100
5% of children in families with a gross weekly household income of £600 or more
17% of children living in social housing
7% of children whose parents are home-owners

Source: ONS survey, Great Britain, 2004