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This publication is available at https://www.gov.uk/government/publications/better-mental-health-jsna-toolkit/5-children-and-young-people
The last survey of the mental health of children and young people in Great Britain in 20041 found that 8% of 5 to 10 year olds and 12% of 11 to 16 year olds had a clinically diagnosed mental health condition. Up to 25% of children show signs of mental health problems with more than half continuing through into adulthood1.
Half of all mental health problems emerge before the age of 14 and three quarters by age 252. Inequality underlies many risk factors for mental health problems, and needs to be addressed through the wider determinants of health which are outlined in ‘Understanding place’ and ‘Understanding people’.
There are a number of opportunities across the life course to help promote positive mental health and wellbeing and to build resilience of children and young people.
The following questions could form a useful basis for a JSNA that seeks to better understand and respond to children and young peoples’ mental health needs:
- what are the social, economic and other factors that promote good mental health in children or make them more vulnerable to developing a mental health problem?
- what are the community assets which help build children and young people’s resilience?
- how do children and young people’s lifestyle/behaviour affect their mental health?
- what is the local prevalence of different mental health conditions among children and young people? How does it compare with other similar areas?
- 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?
- is there evidence of local inequalities in rates of mental health problems among children and young people?
- are preventive interventions available and taken up by those who need them most?
- what provision is available in schools, colleges and universities to support a whole system approach to promoting mental health and wellbeing?
- what children and young people’s mental health services 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?
2. Children under 5
A child’s attachment, security 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.
Parenting styles, interpersonal relationships and family functioning all have an influence on a child’s mental wellbeing. Loving and trusting relationships, feeling supported and having a sense of connection are aspects which positively influence wellbeing. Factors which harm wellbeing include maternal mental health problems, family discord, hostility and breakup3.
The universal health visiting service, part of the Healthy Child Programme4, is a home visiting service focussed on assessing the needs of the family, and providing early intervention where required. The universal health review at age 2 to 2.5 years uses the Ages and Stages Questionnaire 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 longer term outcomes including mental health and general wellbeing. The new birth visit and 6 to 8 week review are also important components of this health visiting service.
Although these services are available in all areas there can be some variation in access and uptake. For example, recent quarterly data identified that 78% (regional range 57 to 90%) of children aged between 2 and 2.5 years have received a review5. There may be benefit in assessing local access to the range of these services and identifying opportunities for service development.
2.1 Evidence and further information
The following documents are useful sources of further information on this topic:
This update brings together evidence about ‘what works’ in: parental mental health; smoking; alcohol/drug misuse; intimate partner violence; preparation and support for childbirth and the transition to parenthood; attachment; parenting support; unintentional injury in the home; safety from abuse and neglect; nutrition and obesity prevention; and 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. All age children and young people
Improving children and young peoples’ mental wellbeing will positively impact on their cognitive development, learning, physical health, mental health and social and economic prospects in adulthood6. Poor mental wellbeing increases the likelihood in later life of:
- poor educational attainment
- antisocial behaviour
- drug and alcohol misuse
- teenage pregnancy
- involvement in criminal activity
- mental health problems7.
Those with better mental wellbeing are likely to deal better with stressful events, recover more quickly from illness, and be less likely to engage in behaviours which may put their health at risk8. This topic is covered in detail in Understanding place.
3.2 Primary prevention and early intervention
Particular groups of children have significantly worse outcomes. A child’s gender, socioeconomic status, ethnicity, disability, sexual orientation and whether or not they are a looked after child or in the youth justice system all can have an impact on their development.
Childhood experiences can have a lasting impact upon a child’s mental health9. Adverse childhood events (ACEs) have a strong influence on the chances of developing mental health problems, including being the victim of:
- physical abuse
- sexual abuse
- domestic violence
- parental separation
- emotional neglect
- emotional abuse
- living with an alcoholic or drug abuser
- having a parent in prison
There is an increased risk if a child experiences multiple cumulative events. Events associated with chronic adversity and deprivation carry the greatest risk10. An increasing issue is that of cyberbullying with one survey reporting around 18% of 11 to 15 year olds experiencing some form of bullying via electronic communication over a two month period11.
A child’s mental health is not the only aspect of their wellbeing which is influenced by adverse experiences. A strong relationship has been found between the experience of ACEs and risky behaviours during adulthood10. Compared to experiencing no childhood ACEs, an adult who experienced four or more during childhood was12:
- 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
Many of these behaviours can lead to physical ill health in adulthood and some of these behaviours have the potential to be repeated across generations.
Quantifying these factors allows localities to understand the needs of children in their area who are at higher risk of developing mental health problems. Commissioners should then plan and implement the appropriate prevention and early intervention services to meet those needs.
3.3 Data Sources
The JSNA profile has a number of metrics which cover risk and protective factors and some related spend on services:
In risk factors
- child poverty (County & UA, District & UA, CCG, GP, Ward)
- children in need due to abuse, neglect or family dysfunction (County & UA)
- looked after children (County & UA)
- pupils with behavioural, emotional and social support needs (County & UA)
- first time entrants to the youth justice system (County & UA)
- 16 to 18 year olds not in education, employment or training (County & UA)
- GCSEs achieved 5A*-C (County & UA, District & UA, Ward)
- spend on local authority children and young people’s services (excluding education) (County & UA)
Other key data sources include:
The Children and Young People’s Mental Health and Wellbeing Profile: has a number of other metrics which can be used to identify levels of risk and protective factors in children between the ages of 0 and 18 years.
The National Child and Maternal Health Intelligence Network: a wealth of information and data around children and young people in general, in addition to a number of profiles.
Public Health England ROI tool: provides assessment of the ROI for school-based social and emotional wellbeing programmes and programmes to address bullying of young people.
Local Health: has a number 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 local action. This is likely to include working with schools, primary care, 3rd sector and community services providing targeted interventions. Local analyses will be able to draw upon additional local data. These should be reflected in Local Children and Young People’s Mental Health Transformation Plans.
3.4 Evidence and further information
The following documents and supporting materials are useful sources of further information on this topic:
Early Intervention Foundation : Early Intervention Foundation Guidebook: interactive tool to find evidence and guidance on how to deliver effective early intervention for the family and the home and positive child development.
NICE: Social and emotional wellbeing in primary education & Social and emotional wellbeing in secondary education guidelines covering promoting social and emotional wellbeing in children in full time education. They include planning and delivering programmes and activities to help children develop social and emotional skills and wellbeing. They cover identifying signs of anxiety or social and emotional problems in children and how to address them.
PHE Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill Health includes sections on the effectiveness of school-based social and emotional wellbeing programmes and programmes to address bullying of young people.
PHE: Evidence Based Practice Unit UCL and Anna Freud National Centre for Children and Families: Measuring and monitoring children and young people’s mental wellbeing: A tool kit for schools and colleges: toolkit aiming to make schools and colleges aware of the range of validated instruments that can be used to measure and monitor student mental wellbeing. Included are examples from across the primary, secondary, special and college sectors, where validated tools have been used in practice.
PHE: Improving young people’s health and wellbeing: a framework for public health: gives practical support in addressing the specific health and wellbeing needs of children and young people aged 10 to 24 years. It takes an asset-based approach, focusing on wellbeing and resilience and placing young people at the centre of service design and delivery. It describes six core principles to promote an effective and integrated response to needs.
PHE: Measuring mental wellbeing in children and young people: provides signposting to evidence driven interventions and metrics to measure wellbeing and its risk and protective factors.
PHE: Promoting children and young people’s emotional health and wellbeing: a whole school and college approach: eight principles, informed by evidence and practitioner feedback, contribute towards helping protect and promote student emotional health and wellbeing. The document signposts to Ofsted inspection criteria, practice examples and resources to support implementation.
PHE: Supporting public health: children, young people and families: 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.
PHE: The mental health of children and young people in England: report describing the importance of mental health in CYP, presenting the case for investing in mental health, and summarising the evidence of what works to improve mental health in CYP.
The British Psychological Society: The Child & Family Clinical Psychology Review: What good could look like in integrated psychological services for children, young people and their families: 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: summarises data on girls’ emotional health and wellbeing, informed by an analysis of data from the health behaviour in school-aged children (HBSC) study for England, 2014.
PHE. 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 the Health Behaviour in School-aged Children.
Intentional self-harm in adolescence: An analysis of data from the Health Behaviour in School-aged Children (HBSC) survey for England, 2014: thematic analysis of the recent HBSC survey data to explore the rising trend in poorer emotional wellbeing of young people.
4. Planning quality mental health and care services
It is important to know if the care and interventions children and young people are receiving through health care, social services and education is resulting in positive outcomes. Not only in terms of addressing their mental health problems and promoting emotional and psychological wellbeing, but also in addressing individual needs and views of service users.
Providers must monitor, and commissioners must consider, the extent to which the interventions available fit with the stated preferences of children and young people and parents/carers so that provision can be shaped increasingly around what matters to them13.
Around 25% to 35% of young people who need support are not accessing services13 and around 60%-70% of children have not had appropriate interventions at a sufficiently early age14. When children and young people do access services, the average wait for the first routine appointment was 9 weeks in 2015/1615.
CCGs, working with local partners across the NHS, public health, children’s social care, youth justice and education sectors; are working together to lead and manage change in line with the key principles outlined in Future in Mind13. This is being done through the development of Local Transformation Plans16.
The plans cover prevention and support and care for existing or emerging mental health problems, as well as transitions between services and addressing the needs of the most vulnerable. Key elements of the plan should include commitments to transparency, service transformation and monitoring improvement.
The ‘You’re Welcome - Quality criteria for young people friendly health services17 sets out principles to help commissioners and service providers to improve the suitability of services for young people. The quality criteria are based on examples of effective local practice working with young people aged under 20 years. An updated version of ‘You’re welcome’ is planned for 2017 to 2018.
Implementing the Five Year Forward View for Mental Health18, makes the delivery commitment that by 2020 to 2021, mental health services will provide timely access to evidence-based, person-centred and outcome focused care.
This is backed by a commitment that 70,000 more children and young people will have access to timely and appropriate care each year by 2020 to 2021. Widened access is to 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 children and young people’s mental health services (CYPMHS).
There is a commitment that, by 2020, 95% of CYP with an eating disorder will receive treatment within 1 week if the need is urgent and 4 weeks if the need is non-urgent. There is also a commitment to improve crisis care for all ages, including investing in places of safety, and improved access to and use of inpatient care closer to the young person’s home, driving towards better integration with local community services to reduce the length of stay and bed usage.
NHS England will ensure that, by 2020 to 2021, the access and waiting time standard for early intervention in psychosis (EIP) services is being met. This standard requires that at least 60% of people experiencing first episode psychosis (aged 16 to 45) will start treatment with a NICE-recommended package of care with a specialist EIP service within two weeks of referral.
Commissioners and providers should ensure that children and young people benefit from the standard and put in place robust local arrangements between children and young people’s mental health services and EIP services so that specialist expertise in working with children and young people with psychosis is available.
4.2 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 (County & UA, District & UA)
- new children and young people receiving treatment (CCG, STP)
- children and young people’s mental health admissions to hospital (CCG, STP)
- hospital admissions for unintentional and deliberate injuries (age 0 to 24) (CCG, STP)
- children on adult wards (CCG, STP)
Estimates of prevalence of mental health disorders in children can be found in the CYPMH&W profile, these use national prevalence rates from the 2004 Survey of Mental Health of Children and Young People in Great Britain, they are age, sex and socio-economic group standardised and applied to local populations.
There are no nationally derived reliable estimates of psychosis during childhood and estimates of the prevalence of potential eating disorders in the CYPMH&W profile should be reviewed with caution. The results from the 2016 survey, due in 2018, will allow for an update of these prevalence rates.
There is little national data currently available which reports on mental health services for children and young people. This is being addressed through the Mental Health Services Dataset reporting, which incorporated CYPMH from January 2016.
The Mental Health Services Dataset produces a monthly report, published by NHS Digital, which provides an overview of access across all mental health services for CYP aged 0 to18. This data is still experimental so should be treated with caution. As the data quality and completeness improves and more data becomes available, new metrics will be reported in the JSNA and CYPMH&W profiles.
Commissioners will have access to further local data on outcomes and feedback from children, young people, parents and carers. 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.
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 geographies below local authority level.
4.3 Evidence and further information
The following documents and supporting materials are useful sources of further information on this topic:
Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing: report from the Children and Young People’s Mental Health and Wellbeing Taskforce brings together the core principles and requirements needed to create a system that can support the emotional wellbeing and mental health needs of children and young people.
Developed by young people, professionals, commissioners and academics this sets out the principles and markers of a good service. These markers are currently recognised in the existing quality assurance and quality process mechanisms and have been included in the CQC:
- Quality Network for Community CAMHS (QNCC)
- Youth Wellbeing Directory with ACE-V Quality Standards (ACE-Value)
- Choice and Partnership Approach (CAPA)
- Child Outcomes Research Consortium (CORC)
Example of service planning: THRIVE 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): example of service planning: CAPA is a clinical service transformation model that involves young people and their families, goal setting and regular review involving the young person and addressing demand and capacity and skills and job planning.
Evidence Based Practice Unit: Anna Freud National Centre for Children and Families: collection of booklets, leaflets and other publications on academic research and mental health practice, in support of children, young people and mental health practitioners. Including guides on using outcomes and feedback tools.
5. Specific and related conditions
Children and young people can experience a wide range of mental health problems. The PHE report ‘The mental health of children and young people in England’ describes the importance of mental health in CYP, provides an overview of mental health problems that CYP can experience and summarises the evidence of what works to improve mental health in CYP.
The Survey of mental health of children and young people in Great Britain 20041 includes typical behaviour patterns and characteristics of children and young people for a similar range of conditions, including autism, which is not included in the above.
5.2 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: Guidance for commissioners of eating disorder services: guide to commissioning comprehensive mental health services for people with eating disorders.
NHS England: Access and Waiting Time Standard for Children and Young People with an Eating Disorder Commissioning Guide: guidance on establishing and maintaining a community eating disorder service. This guidance is being extended to include episodes of care in day or inpatient settings (paediatric wards, general medical wards, inpatient CAMHS units) and will be published late in 2017.
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.
NICE: ADHD National guidance: guideline to diagnosing and managing attention deficit hyperactivity disorder (ADHD) in children over 3 years, young people and adults.
NICE: Antisocial behaviour and conduct disorders in children and young people: recognition and management guidance and quality standard: guideline and standard for recognising and managing antisocial behaviour and conduct disorders in children and young people.
NICE: Anxiety disorders (quality standard): identification and management of anxiety disorders in primary, secondary and community care for children, young people and adults.
NICE: Attention deficit hyperactivity disorder: diagnosis and management guidance and quality standard: diagnosing and management of ADHD in children over 3 years, young people and adults.
NICE: Autism national guidance and standards: wide range of NICE guidance available for the recognition, referral and diagnosis of autism which varies according to age. The interactive pathway is a useful way to access the full amount of information available.
NICE: Bipolar disorder, psychosis and schizophrenia in children and young people (quality standard): recognition, early intervention and management of bipolar disorder, psychosis and schizophrenia in children and young people.
NICE: Depression in children and young people (guidance): identifying and managing depression in children and young people aged between 5 and 18 years.
NICE: Depression in children and young people (quality standard): the diagnosis and management of depression in children and young people aged 5 up to their 18th birthday.
NICE: Eating disorders (guidance): recommendations for the identification, treatment and management of anorexia nervosa, bulimia nervosa and atypical eating disorders in primary, secondary and tertiary care.
NICE: Psychosis and schizophrenia in children and young people: recognition and management (guidance): recognising and managing psychosis and schizophrenia in children and young people, aiming to improve early identification so they are given the treatment and care they need.
NICE: Self-harm in over 8s: long-term management (guidance): longer-term psychological treatment and management of self-harm in people aged 8 years and over.
NICE: Self-harm (quality standard): short-term management of self-harm and the provision of longer-term support for children and young people aged 8 years and over, and adults aged 18 years and over who self-harm.
NICE: Self-harm in over 8s: short-term management and prevention of recurrence (guidance): short-term management and prevention of self-harm in children and young people aged 8 years and over. It covers the first 48 hours following an act of self-harm.
NICE: Social anxiety disorder (guidance): recognising, assessing and treating social anxiety disorder in children and young people, from school age to 17 years, and adults (aged 18 years and older).
PHE: The Mental Health of Children and Young People in England: describes the importance of mental health and wellbeing among children and young people and the case for investment in mental health.
6. Transition to adult services
The point of transition from CYPMHS is a time of potential upheaval for young people. They 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 offer of support can change dramatically19,20.
There are significant risks of young people disengaging or being lost in the transition process. This can result in young adults re-presenting 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 Mind13 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.
65% of CYP MH Local Transformation Plans published in 2016 highlighted transition as a key area for development21. NHS England has introduced a financial incentive to improve transition planning under the national mandatory Commissioning for Quality and Innovation (CQUIN) scheme 2017 to 2019.
The Transitions Out of CYPMH CQUIN sets out requirements for joint agency transition planning. It includes a survey to ask young people transitioning out of CYPMHS whether they feel ready for discharge, and whether they are meeting their personal transition goals following transition.
6.2 Evidence and further information
Joint Commissioning Panel for Mental Health: Guidance for commissioners of mental health services for young people making the transition from child and adolescent to adult services: 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. Evidence based guidance is given 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: Commissioning for Quality and Innovation National Scheme 2017-19: the Transitions out of CYPMHS CQUIN indicator specification sets out what is required of providers to improve the transition process across England, and how success is measured.
NHS England: Model service specification for transitions from child and adolescent mental health services: sample service specification based on a range of quality standards and best practice. An updated version will be published in 2017.
NICE: Transition from children’s to adults’ services for young people using health or social care services (guidance): guidance on the transition from children’s to adults’ services. Not specifically for mental health services, it 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.
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Felitti V, Anda, RF., Nordenberg, D., Williamson, DF., Spitz,A., Edwards, V., Koss, MP., Marks, JS. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American journal of Preventative Medicine (1998)14(4):245-58 ↩ ↩2
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;8:135 ↩
McLaren S, Belling R, Paul M, Ford T, Kramer T, Weaver T, et al. ‘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) 13(1):254 ↩