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Around half of all lifetime mental health problems start by the mid-teens, and three-quarters by the mid-20s, although treatment typically does not start until a number of years later.[footnote 1] The most recent survey of the mental health of children and young people in England found that 12.5% of 5 to 19 year olds had at least one mental disorder when assessed (2017), and 5% met the criteria for 2 or more mental disorders. There also appears to be a slight increase over time in the prevalence of mental disorder in 5 to 15 year olds, rising from 9.7% (1999) to 10.1% (2004) to 11.2% (2017).[footnote 2]
Inequality underlies many risk factors for mental health problems in children and young people, and needs to be addressed through the wider determinants of health which are outlined in the ‘Mental health: environmental factors’ and ‘Mental health: population factors’ chapters of the knowledge guide.
There are opportunities to promote good mental health and wellbeing and to build resilience throughout childhood and youth. It’s important to take these opportunities both for the health and wellbeing of children and young people, and for people’s health and wellbeing throughout their life.
The following questions could form a useful basis for a Joint Strategic Needs Assessment (JSNA) that seeks to better understand and respond to children and young peoples’ mental health and wellbeing needs:
- what are the social, economic and other factors that promote good mental health and resilience in children and young people or make them more vulnerable to developing a mental health problem
- what are the community assets that help build children and young people’s resilience
- what is the local prevalence of different mental health conditions among children and young people; how does it compare with other similar areas
- is there evidence of local inequalities in rates of mental health conditions among children and young people
- what (if anything) is special about the local population that might require a different approach to local service provision for children and young people’s mental health
- what provision is available in schools, colleges and universities to support a whole system approach to promoting mental health and wellbeing
- are preventive interventions available and taken up by those who need them most
- what Children and Young People’s Mental Health Services (CYPMHS) are available locally; what does the profile of service users look like
- are there appropriate links between relevant services, particularly between universal and secondary healthcare services
Before planning for the provision of local mental health services, it is important to understand the national policy landscape regarding children’s mental health and wellbeing. There has been significant effort in recent years to make a difference for children, resulting in a range of ambitious policy guidance.
Most recently, the NHS Long Term Plan (2019) made the commitment that at least 345,000 more children and young people under 25 will have access to support through either NHS-funded mental health services or school/college mental health support teams by 2023 to 2024. It is part of a drive to offer a comprehensive model of care that covers children, young people and adults. It comes with the commitment to invest in new mental health support teams across 20% to 25% of schools and colleges nationwide and to ensure that crisis care is universally available 24/7 by 2023 to 2024. The NHS Mental Health Implementation Plan 2019 to 2020 to 2023 to 2024 relates to the long term plan, and provides details of a new framework to help achieve the mental health specific commitments.[footnote 3]
The Department for Education (DfE) are also introducing guidance for schools on relationships education, sex education and health education. As a part of this both mental health and internet use will be addressed, with targets for what children should understand by the end of primary and secondary school.[footnote 4] Schools are also a core avenue through which the Healthy Child Programme (5 to 19) is implemented, in which building resilience and emotional wellbeing are key objectives.[footnote 5]
In 2017 ‘Transforming children and young people’s mental health: a green paper’ was jointly published by the Department for Health and Social Care (DHSC) and the DfE. It proposed designated mental health leads in all schools, new mental health support teams working with children experiencing mild to moderate mental health problems and trialling reduced waiting times for specialist mental health services.[footnote 6]
All of this has built on ‘The Five Year Forward View for Mental Health’ (2016), which made a push for parity of esteem between mental and physical health for people of all ages. It argued that this should be supported by a workforce ambition to train 3,400 existing staff members in evidence-based treatment and recruit a further 1,700 staff in CYPMHS.[footnote 7]
It also all builds on ‘Future in Mind’ (2015), which emphasised resilience and the importance of prevention, early identification, coordinated support and the promotion of good mental health among children and young people.[footnote 8]
2. Children under 5
For the first time, we have large survey data on the mental health of children aged 2 to 4. This is experimental data, to be used cautiously. The results suggest that 5.5% (1 in 18) of preschool children may have a mental disorder. The rate was higher in boys (6.8%) than in girls (4.2%).[footnote 9]
As outlined in a report for NHS Health Scotland, a young child’s attachment to, security given by, and positive stimulation from their main carers has a major impact on their social and emotional wellbeing. This provides the foundation for healthy behaviours and educational attainment. Children who have been neglected are more likely to experience mental health problems including depression, post-traumatic stress disorder and attention deficit and hyperactivity disorder. In later life, they may also find it difficult to maintain healthy social relationships, including with their own children.[footnote 10]
Parenting styles, interpersonal relationships and family functioning are all associated with a child’s mental wellbeing. Loving and trusting relationships, feeling supported and having a sense of connection have a positive association. Whereas maternal mental health problems, family discord, hostility and breakup, are negatively associated with child mental wellbeing.[footnote 10]
The Universal Health Visiting Service, part of the Healthy Child Programme, is a home visiting service focused on assessing the needs of the family, and providing early intervention where required. [footnote 11] The universal health review at age 2 to 2.5 years uses the Ages and Stages Questionnaire (ASQ) to assess child development outcomes which include:
- problem solving
- social-emotional development
- aspects of physical development
Development delays identified at this stage are associated with poorer long term outcomes including mental health and general wellbeing. The ‘new birth visits’ and ‘6 to 8 week reviews’ are also important components of this health visiting service.
Although these services are available in all areas, there can be some geographical variation in access and uptake. For example, 2017 to 18 data indicates that 90.2% of children aged between 2 and 2.5 received the reviews, but at the regional level this ranged from 75.8% to 96%. As with all services, there is benefit in assessing local access and identifying local opportunities for service development.
2.1 Understanding local population: data sources
The Mental Health of Children and Young People in England, 2017 (preschool children) examines, for the first time, the prevalence of mental disorders in preschool children (2 to 4 years old).
The National Child and Maternal Health Intelligence Network: a wealth of information and data around children and young people in general. In particular, the ‘Early years’ domain of their Fingertips profile contains useful indicators.
- percentage of children at or above expected level of development in all five areas of development at 2 to 2.5 years (as well as a break down by areas of development)
- school readiness: the percentage of children achieving a good level of development at the end of reception
- percentage of children achieving at least an expected level of development across all learning goals in communication and language
- proportion of new birth visits (NBVs) completed within 14 days
- proportion of children who received a 2 to 2.5 year review
- proportion of children aged 2 to 2.5 years receiving ASQ-3 as part of the Healthy Child Programme or integrated review
Further consideration of prevention of mental health problems will require use of local knowledge and data. This is likely to include working with schools, primary care, third sector and community services which are providing targeted interventions and obtaining and analysing local data. Local knowledge and data analyses should be included in Local Children and Young People’s Mental Health Transformation Plans.
2.2 Evidence and further information
This update brings together evidence about ‘what works’ in:
- parental mental health
- alcohol/drug misuse
- intimate partner violence
- preparation and support for childbirth and the transition to parenthood
- parenting support
- unintentional injury in the home
- safety from abuse and neglect
- nutrition and obesity prevention
- speech, language and communication
A range of documents to support local authorities and providers in commissioning and delivering children’s public health services aged 0 to 19 years. The documents include health and wellbeing, resilience, maximising learning and achievement, supporting complex and additional health needs and transition to adulthood. An extensive list of links to relevant resources and tools is also given.
3. Children and young people aged 5 to 17
As outlined in the PHE report on Promoting children and young people’s emotional health and wellbeing, doing so will positively impact on their cognitive development, learning, physical health, mental health and social and economic prospects in adulthood.[footnote 12] Poor mental wellbeing in childhood and youth increases the likelihood in later life of:
- poor educational attainment
- antisocial behaviour
- drug and alcohol misuse
- teenage pregnancy
- involvement in criminal activity
- mental health problems[footnote 13]
Risk factors that may increase childhood vulnerability and reduce childhood mental wellbeing include:
- being in social care (looked after children)
- youth offending
- low household income
- family disharmony/parental breakup
- domestic violence and abuse
- parental substance misuse
- parental mental ill health and school absence and exclusions
There are also protective factors that may decrease vulnerability and increase mental wellbeing. These include:
- high self-esteem
- good education
- someone from the family being in work
- development of good oral language skills
- positive relationships with parents
- social/community inclusion
- sport and physical activity
A child’s resilience is also an important factor, referring to the child’s capacity to bounce back from adversity. The negative impact of the presence of risk factors on a child can be countered when a child is more resilient because he or she also has several protective factors, such as the presence of a supportive adult.
Within the context of vulnerable children and young people it is important to consider the impact of adverse childhood experiences (ACEs). These are a specific set of childhood experiences that have then been compared with outcomes in later life, detailed below.
ACEs directly relating to the child:
- psychological abuse
- physical abuse
- sexual abuse
ACEs relating to the child’s household:
- parental separation
- domestic violence
- mental illness
- alcohol abuse
- substance misuse
Compared to experiencing no childhood ACEs, an adult who experienced four or more during childhood was:
- 4 times more likely to be a high-risk drinker
- 6 times more likely to be a current smoker
- 6 times more likely to have had sex under 16 years of age
- 11 times more likely to have smoked cannabis
- 16 times more likely to have used heroin or crack cocaine. [footnote 8]
It is important to note that while using an ACE approach to target interventions towards the most vulnerable children can be effective, it does not address the full range of vulnerabilities.
Cyberbullying is an important emerging issue, with one survey reporting around 18% of 11 to 15 year olds experiencing some form of bullying via electronic communication over a two month period.[footnote 14] Use of the internet and social media may have an impact on the mental health of children and young people. The Royal Society for Public Health estimate that 91% of 16 to 24 year olds use the internet for social networking, and suggest that this is linked with increased rates of anxiety, depression and poor sleep.[footnote 15]
Quantifying these risk and protective factors allows localities to understand the needs of children in their area who are at higher risk of developing mental health problems. Commissioners can then plan and implement the appropriate prevention and early intervention services to meet those needs.
3.1 Understanding local population: data sources
The JSNA profile has a variety of metrics which cover risk and protective factors:
In risk factors:
- children in need due to abuse or neglect: rate per 10,000 children aged under 18 years (County & UA)
- Children in care (County & UA)
- School pupils with social, emotional and mental health needs: % of school pupils with social, emotional and mental health needs (County & UA)
- first time entrants to the youth justice system (County & UA)
- 16 to 17 year olds not in education, employment or training or whose activity is not known (County & UA)
- GCSEs achieved 5A* to C (ward)
- mean score of the 14 Warwick-Edinburgh Mental Wellbeing Scale statements at age 15 (county and UA)
- average Attainment 8 score (county and UA)
- average Attainment 8 score of children in care (county and UA)
Other data sources
The Children and Young People’s Mental Health and Wellbeing Profile includes other metrics which can be used to identify levels of risk and protective factors in children between the ages of 0 and 18. Indicators from the Department for Education, such as percentage of school pupils with special educational needs and school exclusions. It also includes indicators relating to the number of children in care (looked after) due to abuse or neglect.
The National Child and Maternal Health Intelligence Network provides a wealth of information and data around children and young people in general, in addition to Fingertips profiles.
Public Health England ROI tool provides assessment of the return on investment (ROI) for school-based social and emotional wellbeing programmes and programmes to address bullying of young people.
Local Health has a variety of indicators around poverty and education which are reported at geographies below local authority level.
Further consideration of prevention of mental health problems will require use of local knowledge and data. This is likely to include working with schools, primary care, third sector and community services which are providing targeted interventions and obtaining and analysing local data. Local knowledge and data analyses should be included in local children and young people’s mental health transformation plans.
3.2 Evidence and further information
Measuring and monitoring children and young people’s mental wellbeing: a tool kit for schools and colleges (produced in collaboration with the Evidence Based Practice Unit at University College London and the Anna Freud National Centre for Children and Families)
Early intervention foundation guidebook is an interactive tool to find evidence and guidance on how to deliver effective early intervention for the family and the home and positive child development.
The Child and Family Clinical Psychology Review issue ‘What good could look like in integrated psychological services for children, young people and their families’ by The British Psychological Society considers the challenges of providing services for children and young people in terms of capacity, demand and workforce development. It proposes integrated models of care to overcome these challenges.
Wellbeing of adolescent girls: an analysis of data from the health behaviour in school-aged children (HBSC) survey for England, 2014 summarises data on girls’ emotional health and wellbeing, informed by an analysis of data from this survey.
Cyberbullying: an analysis of data from the health behaviour in school-aged children (HBSC) survey for England, 2014 summarises data on cyberbullying informed by an analysis of data from this survey.
Intentional self-harm in adolescence: an analysis of data from the health behaviour in school-aged children (HBSC) survey for England, 2014 is a thematic analysis of survey data to explore the rising trend in poorer emotional wellbeing of young people.
4. Planning quality mental health and care services
Child and adolescent mental health services (CAMHS) are all services that work with children and young people who have difficulties with their emotional or behavioural wellbeing. These might be from the statutory, voluntary or school-based sectors, such as an NHS trust, local authority, school or charitable organisation.
Specialist CAMHS are NHS mental health services that focus on the needs of children and young people. They are multidisciplinary teams that often consist of:
- social workers
- support workers
- occupational therapists
- psychological therapists – this may include child psychotherapists, family psychotherapists, play therapists and creative art therapists
- primary mental health link workers
- specialist substance misuse workers
When planning service delivery, it is important to know if the care and interventions children and young people are receiving through health care, social services and education are having a positive effect.
It is also important to look at how the interventions available fit with the stated preferences of children and young people and parents/carers to shape provision increasingly around what matters to them.[footnote 8]
Some planning will focus on the system as a whole, but other planning may focus on specific conditions. This chapter includes some resources to help with both.
In order to plan user friendly services, it is important to understand how children and young people currently use mental health services:
66% of 5 to 19 year olds with a mental disorder have had contact with a professional service in the past year because of worries about mental health; teachers are the most common source of support (48.5%), followed by primary care professionals (33%), mental health specialists (25%) and educational support services (23%)
over 1 in 5 children with a disorder reported waiting more than 6 months for contact with a mental or physical health specialist (21%) or with educational support services (22%)
2.5% of 5 to 19 year olds take medication with the aim of improving their mental state, this equates to 16% of children with a disorder
over 35% of children with a disorder have recognised special education needs, but only half of children with recognised special education needs have an ‘Education, Health and Care Plan’ in place; 5 to 16 year olds with a mental disorder are 10 times more likely to have played truant from school or been excluded than children without a mental health disorder
Source: NHS Digital analysis.
CCGs, together with local partners across the NHS, public health, children’s social care, youth justice and education sectors are working to develop and deliver local transformation plans. These plans seek to implement the main principles from recent policy relating to children and young people’s mental health. Plans cover prevention, support and care for existing or emerging mental health problems, as well as transitions between services and addressing the needs of the most vulnerable.
‘You’re Welcome’ (refreshed in 2017) provides a framework to help commissioners and service providers improve the suitability, accessibility, quality and safety of health services for young people. The standards have been refreshed as part of a project supported by PHE, and are being tested across England.
4.2 Understanding local population: data sources
The JSNA profile includes prevalence metrics to aid estimation of need and has some metrics which cover activity and quality of care services.
- estimated prevalence of mental health disorders in children and young people (District & UA, County & UA)
- local spending on children and young people’s services excluding education (county and UA)
- hospital admissions for mental health conditions (county and UA, region)
- hospital admissions as a result of self-harm (10 to 24 years old) (county and UA)
There are 3 further children and young people’s mental health service indicators currently under development:
- number of referrals received by mental health services for children and young people aged under 18
- number of contacts made by children and young people with mental health services
- number of children and young people in contact with mental health services
Further indicators can be found in the children and young people’s mental health and wellbeing profile, which includes measures designed to help with identification of need, protective factors and prevention planning. As part of this (within the ‘primary prevention: vulnerability’ tab), it includes measures of the number of children in social care, special education needs, and school exclusions.
The Child and maternal health fingertips profile includes indicators covering the general health of children from birth to young adulthood. They also publish an annual snapshot 4 page report Child health profiles for each upper tier local council in England.
4.3 Other sources of data
Mental health of children and young people in England, 2017 survey series provides one of England’s best sources of data on trends in child mental health. Major surveys were carried out in 1999, 2004, and 2017. They applied consistent methods to assess for a range of different types of disorder.
The Millennium Cohort Study (MCS) is following the lives of around 19,000 young people born across England, Scotland, Wales and Northern Ireland in 2000 to 2001. The project has been asking both parents and children about mental health and wellbeing since the cohort turned 11 years old.
Since 2016, data on children and young people has been included in the Mental health services data set (MHSDS). NHS Digital produce a monthly report, providing an overview of access across all mental health services for children and young people. There is often a high-level summary of children and young people included in the ‘key facts’ box. The monthly data file includes different indicators in each column, and different geographies in each row. Indicators relating to children and young people are named with ‘CYP’ and a number. They are:
- CYP01 - people in contact with children and young people mental health services at the end of reporting period (RP)
- CYP21 - open ward stays in children and young people mental health services at the end of RP
- CYP23 - open referrals in children and young people mental health services at end of RP
One indicator which does not follow this trend is ‘MHS69 – CYP Access two contacts’. This is published in a separate excel sheet, and at the time of writing, was under further methodological review.
New metrics based on this data set are currently under development to be added to the JSNA and CYPMH&W profiles.
The Child Outcomes Research Consortium (CORC) support registered members to collect and improve the quality of data relating to children and young people’s mental health and wellbeing outcomes.
4.4 Local data
Commissioners will have access to further local data on outcomes and feedback from children, young people, parents and carers. Detailed assessment of local support services will require direct contact with providers (such as social care and NHS and private specialist mental health services). Local Health has indicators covering rates of hospital admissions for injuries in children at geographic areas below local authority level.
4.5 Evidence and further information (system planning)
The following documents and supporting materials are useful sources of further information on this topic.
Delivering with and delivering well (2014) sets out an overarching quality framework for the children and young people improving access to psychological therapies (IAPT) programme, and identifies the principle markers underpinning the values and qualities of the programme.
THRIVE Elaborated (2015) offers a set of principles and values to guide service implementation. It takes a whole system approach and focuses on building individual and community strengths and ensuring that children, young people and families are active decision makers in the process of choosing the right service approach. It also draws a clearer distinction between treatment and support. For the latest information about the i-THRIVE implementation please refer to the annual report (May 2017).
Choice and Partnership Approach (CAPA) is a clinical service transformation model that involves young people and their families, goal setting and regular review involving the young person. It addresses demand and capacity, skills and job planning.
Evidence Based Practice Unit: Anna Freud National Centre for Children and Families is a collection of booklets, leaflets and other publications on academic research and mental health practice, in support of children, young people and mental health practitioners. It Includes guides on using outcomes and feedback tools.
4.6 Evidence and further information (planning for specific conditions)
Sometimes it will be necessary to plan services with specific conditions in mind. In such circumstances, the following resources may be useful:
The PHE report The mental health of children and young people in England provides an overview of different mental health problems that are experienced and summarises the evidence of what works to improve children and young people’s mental health.
The 2017 survey of the mental health of children and young people in England categorises disorders into emotional, behavioural, hyperactivity and autism spectrum, eating, and other less common disorders. This is a useful categorisation to work from.
Joint Commissioning Panel for Mental Health’s Guidance for commissioners of eating disorder services is a guide to commissioning comprehensive mental health services for people with eating disorders.
NHS England’s access and waiting time standard for children and young people with an eating disorder commissioning guide provides guidance on establishing and maintaining a community eating disorder service.
NHS England: implementing the early intervention in psychosis access and waiting time standard provides support to local commissioners and providers in implementing the access and waiting time standard.
The National Institute for Health and Care Excellence offers clinical guidelines and quality standards for recognising, diagnosing and managing a wide range of specific mental health conditions in children and young people. Important examples include:
5. Transition to adult services
The point of transition from CYPMHS is potentially a time of upheaval for young people. Children and young people may find it difficult to navigate new service settings or to manage their mental health and wellbeing following discharge from CYPMHS, especially as the availability and type of support can change dramatically.[footnote 18],[footnote 19]
There are significant risks of young people disengaging or being lost in the transition process. This can result in young adults presenting again in crisis or with a greater severity of need later in life. Transitions for vulnerable groups, such as those within the criminal justice system, can be particularly problematic. They require careful management and close engagement with the young person and, where appropriate, their families/carers.
Future in Mind recommends joint working and shared practice between services to promote continuity of care during transition. The transition out of CYPMHS must be supported by a robust and coordinated multi-agency approach to transition planning, with the full involvement of the young person throughout.
CYP mental health local transformation plans have highlighted transition as a major area for development. NHS England included a financial incentive to improve transition planning under the national mandatory Commissioning for Quality and Innovation (CQUIN) scheme 2017 to 2019, but this was not repeated in 2019 to 20.
5.1 Understanding local population: data sources
The JSNA profile includes some indicators which may help you plan for managing the transition between children, adolescent and young people’s services and adult services.
- estimated prevalence of common mental disorders: % of population aged 16 and over (district and UA, county and UA, CCG and STP)
- long-term mental health problems (GP Patient Survey): % of respondents (aged 18+) (CCG)
- new cases of psychosis: estimated incidence rate per 100,000 population aged 16 to 64 (district and UA, county and UA, CCG and STP)
- contact with mental health or learning disability services: rate per 1,000 patients on GP practice list aged 18+ (CCG)
- entering IAPT treatment: rate (quarterly) per 100,000 population aged (18+ yrs) (CCG)
Further indicators can be found in the Children and Young People’s Mental Health and Wellbeing Profile, which includes measures of hospital admissions as a result of self-harm for 15 to 19 year olds as well as 20 to 24 year olds under the ‘identification of need’ tab. Under the ‘vulnerability’ tab, the measure of children leaving care may be particularly useful, as well as the percentage of 15 year olds with 3 or more risky behaviours, the percentage with a long term illness, disability or medical condition, and the percentage of 16 to 17 year olds not in education, employment or training.
5.2 Local data
Commissioners will have access to further local data on outcomes and feedback from children, young people, parents and carers. Detailed assessment of local transition services will require direct contact with providers (such as social care and NHS and private specialist mental health services). Local health has indicators covering rates of hospital admissions for injuries in 15 to 24 year olds and smoking prevalence in 15 year olds at geographic areas below local authority level.
5.3 Evidence and further information
The following documents and supporting materials are useful sources of further information on this topic.
Joint Commissioning Panel for Mental Health’s Guidance for commissioners of mental health services for young people making the transition from child and adolescent to adult services is a guide identifying the needs of young people with mental health problems in transition from child and adolescent mental health services to adult mental health and other services. It gives evidence-based guidance on what a good quality transitions service looks like and the reasons why a transitions service is important for commissioners of speciality mental health services.
NHS England’s Commissioning for Quality and Innovation National Scheme 2017 to 2019 sets out what is required of providers to improve the transition process, and how success is measured.
NHS England’s model service specification for transitions from child and adolescent mental health servicesis a sample service specification based on a range of quality standards and best practice.
NICE guidance Transition from children’s to adults’ services for young people using health or social care services gives advice to help young people and their carers to have a better experience of transition by improving the way it’s planned and carried out. It covers both health and social care.
Social Care Institute for Excellence guidance, research and case studies on moving from adolescent to adult mental health services.
YoungMinds: CAMHS transition guides on transition are available for young people, their parents and professionals.
The Anna Freud National Centre for Children and Families website has information about moving on from CAMHS.
Department of Health and Social Care and Department for Education. Government response to the consultation on Transforming Children and Young People’s Mental Health Provision: a green paper and next steps, (2018) ↩
Singh SP, Paul M, Ford T, Kramer T, Weaver T. Transitions of care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK Study): a study of protocols in Greater London. BMC Health Services Research (2008): 8 ↩
McLaren S, Belling R, Paul M, Ford T, Kramer T, Weaver T, Hovish K, Islam Z, White S, Singh SP. Talking a different language: an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services. BMC Health Services Research (2013) ↩