Mental Health: a case for placing it centre-stage

18 Apr

I           The Health and Education Select Committee

In the last week of March 2017, MPs on the Health and Education Select Committee received oral evidence from experts in the final session of their joint inquiry into the role of education in preventing mental health problems in children and young people.

Baroness Tyler of Enfield, the chair of the values-based child and adolescent mental-health system commission, Lord Layard, director of the Well-Being Programme at the London School of Economics, and Natasha Devon, a former government mental health champion, among others, presented evidence.

The main points raised during the session included the following.

  1. Embedding well-being and mental health awareness across the whole school was very important. Baroness Tyler explained that well-being in the school context includes parents and teachers. She welcomed the move to place Sex and Relationships education (SRE) on a statutory footing and called for compulsory personal, social, economic and health education (PSHE) in all schools.
  2. Senior leaders should be encouraged to measure how schools were influencing the well-being of children through surveys, and their integration into school improvement plans. Lord Layard asked the committee to run a pilot with volunteer schools to re-balance the present focus on measuring academic performance only.
  3. The impact of school funding pressures on mental health should be measured. Natasha Devon highlighted the effect of cuts on access to school support services including counsellors, to the enrichment curriculum and to subjects like sports, drama and music which support positive mental health.

The cross-party group of MPs on the Committee questioned ministers on their record on education and children’s mental health. Edward Timpson MP, Minister of State for Vulnerable Children and Families, said: “There was still much to be done” to address patchy and variable access to mental health services for young people across the country.

The MPs involved recognised that governing boards are responsible for promoting the well-being of children and young people and required to ensure that they set a supportive ethos and culture.

II          Future in Mind:      Study by the Department of Health

Meanwhile, Future in Mind, a Department of Health Study carried out in 2014/15, has estimated that:

  • 6% or nearly 850,000 children and young people aged between 5-16 years have mental disorders;
  • 7% or nearly 340,000 children aged 5-10 years have mental disorders; and
  • 5% or about 510,000 young people aged between 11-16 years have mental disorders.

This means in an average class of 30 school-children, three will suffer from a diagnosable mental health disorder. The most common diagnostic categories are conduct disorders, anxiety, depression and hyperkinetic disorders, i.e. Attention Deficit Hyperactivity Disorder (ADHD).

Altogether, 5.8% or just over 510,000 children and young people have conduct disorders; 3.3% or about 290,000 children and young people have anxiety disorders; 0.9% or nearly 80,000 children and young people are seriously depressed; and 1.5% or just over 132,000 children and young people have severe hyperkinetic disorders (severe ADHD):

While the Government’s ambition has been that all young people achieve as well as they can academically and leave school prepared for life in modern Britain, little till now has been done to help them manage their mental health and well-being – a vital underpinning to achieving this (academic) objective.

Around one in ten children and young people aged between 5-16 years have a diagnosable mental health disorder, (an average of three in every classroom) and a further four or five children per class potentially have problems or conditions, albeit less severe. The Government has decided to invest £1.4 billion in children and young people’s mental health services before 2020. However, the Future in Mind report stated that providing more specialist services was not enough on its own to meet the challenges we face in improving mental health outcomes. There needs to be a greater focus on prevention and early intervention.

Schools and colleges have an important role to play in developing young people’s resilience and promoting their mental well-being. The report states that to make a real difference we need to listen to young people and capture the enthusiasm they have for driving better mental health and well-being themselves. Young people consider that they need information or help for mental ill-health.  Apps or websites and their friends are the two sources they most frequently turn to first. They have also signalled that they would like to see more peer support available as a way of promoting their mental well-being and that they would like more settings to benefit from safe, effective programmes.

The upshot of the Future in Minds report was that the government established The Children and Young People’s Mental Health and Wellbeing Taskforce in September 2014 to consider ways to make it easier for children, young people, parents and carers to access help and support when needed and to improve how children and young people’s mental health services are organised, commissioned and provided.

There is now an urgency in taking steps to address young people’s mental ill-health, especially as the internet is being increasingly misused in myriads of ways by them. Social media, paradoxically, is isolating them giving rise to anxiety and depression.

Jo Cox, the MP murdered in June 2016 by a maniac, established the “Loneliness Commission”.  In March 2017, Relate, the counselling service, published information indicating that people are very lonely.  In particular, young people tend to suffer more than most, a finding supported by London’s Kings College.   Relate’s survey covered the 16-to-24 age group and Kings College focused exclusively on 1,000 teenagers, 62% of whom said that they felt lonely – albeit not always.  In 2015/16, Childline revealed that 19,481 contacts were made by young people struggling with thoughts of ending their own lives, more than double the number in the previous five years.

According to Stephanie Marsh (writing in The Guardian on 8 April 2017), between 2009 and 2016, the number of children and young people coming to A & E with psychiatric conditions more than doubled.  In the past four years, hospital admissions of teenagers with eating disorders nearly doubled too.

Marsh informs her readers about 17-year-old Maelo Manning, who began a politics blog, Libdemchild, aged 10.  Maelo Manning (who is now 17 years old) considers that there is a mismatch between adult perception and teenage reality resulting in adults hating teenagers and regarding them as layabouts who don’t work hard.  Manning laughs at the notion that social media causes loneliness.

She said: “Lots of teenage girls now are very involved in feminism and teenagers in general are really politicised – especially when Isis was formed, then with Brexit and with Trump.  The Scottish referendum got a lot of interest because of the discussion of lowering the voting age to 16.

“I’d say that loneliness is caused by parents who don’t take an interest in their kids. It has to go beyond ‘How was your day?’  And when their teenager gives a monosyllabic reply, the parents consider that all is fine and their job’s been done.”

Manning said that a lonely teenager isn’t moping in her/his bedroom, but rather is restless and unrooted.  “I think parents are so worried about seeming intrusive that it becomes difficult for their kids to get close.  We want to be able to talk to our parents.  We really rely on their guidance.”

III        National Task Force on Mental Health

The Children and Young People’s Mental Health and Wellbeing Taskforce set out the core principles and requirements for creating a system that properly supports the emotional well-being and mental health of children and young people.

The themes are the

  • promoting resilience, prevention and early intervention;
  • improving access to effective support – a system without tiers;
  • caring for the most vulnerable;
  • accountability and transparency; and
  • developing the workforce.

Mental health victims’ suffering range from short spells of depression or anxiety to severe and persistent conditions that isolate, disrupt and frighten them. Their ill-health can result in lower educational attainment. Children with conduct disorder are twice as likely as other children to leave school with no qualifications. Also, victims are strongly associated with behaviours that pose a risk to their health, such as smoking, drugs and alcohol abuse and risky sexual behaviour.

The government, till now, has been reluctant to invest in mental health because human nature is fashioned to act after tragic events rather than take measures to prevent such events occurring in the first place. The Task Force acknowledged that 75% of mental health problems in adult life (excluding dementia) start by the age of 18. “Failure to support children and young people with mental health needs costs lives and money. Early intervention avoids young people falling into crisis and saves on expensive and longer term interventions in adulthood. There is a compelling moral, social and economic case for change.”

The complexity and severity of the current set of challenges facing child and adolescent mental health services (CAMHS) are manifold and include the following.

  1. There are significant gaps in data and information and delays in the development of payment and other incentive systems. These are all critical to driving change in a co-ordinated way.
  2. There are gaps in organising treatment.  The last UK epidemiological study suggested that, at that time, fewer than 25% – 35% of those with diagnosable mental health conditions accessed support. There is emerging evidence of a rising need in key groups such as the increasing rates of young women with emotional problems and young people presenting with self-harm.
  3. Mental health sufferers have considerable difficulties in accessing help. Data from the NHS benchmarking network and recent audits reveal increases in referrals and waiting times, with providers reporting increased complexity and severity of presenting problems.
  4. Commissioning arrangements are complex. There is a lack of clear leadership and accountability arrangements for children’s mental health across agencies including Clinical Commissioning Groups (CCGs) and local authorities, with the potential for children and young people to fall though the net.
  5. Access to crisis, out of hours and liaison psychiatry services are variable and in some parts of the country, there is no designated place of safety recorded by the Care Quality Commission (CQC) for under-18s.
  6. Specific issues face highly vulnerable groups of children and young people and their families who find it particularly difficult to access appropriate services.

IV        Recommendations

(a)        Recommendations of the Taskforce

(i)            The Taskforce is of the view that the best mental health care and support must involve children, young people and those who care for them in making choices about what they regard as key priorities.  Evidence-based treatments, which meet these young people’s goals and address their priorities, should be provided. These treatments need to be offered in ways they find acceptable, accessible and useful.

(ii)           Providers must monitor and commissioners must consider the extent to which the interventions available fit with the stated preferences of young people and parents/carers so that provision can be shaped increasingly around what matters to them. Services need to be outcomes focused, simple and easy to access, based on best evidence, and built around the needs of children, young people and their families rather than defined in terms of organisational boundaries.

(iii)          Delivering this means making some real changes across the whole system. It means the NHS, public health, local authorities, social care, schools and youth justice sectors working together to

  • place the emphasis on building resilience, promoting good mental health, prevention and early intervention;
  • simplify structures and improve access by dismantling artificial barriers between services making sure that those bodies that plan and pay for services work together and ensuring that children and young people have easy access to the right support from the right service;
  • deliver a clear joined up approach linking services so care pathways are easier to navigate for all children and young people, including those who are most vulnerable and people do not fall between gaps;
  • harness the power of information to drive improvements in the delivery of care and standards of performance ensuring we have a much better understanding of how to get the best outcomes for children, young people and families/carers and value from our investment;
  • sustain a culture of continuous evidence-based service improvement delivered by a workforce with the right mix of skills, competencies and experience; and
  • make the right investments – being clear about how resources are being used in each area including what is being spent – and equip all those who plan and pay for services for their local population with the evidence they need to make good investment decisions in partnerships with children and young people, their families and professionals. Such an approach will also enable better judgements to be made about the overall adequacy of investment.

(b)          What schools could do?

At a time when resources are scarce, it is not unusual to stop investing in young people’s mental health.  However, if such a measure is taken, it will be perilous because everything else about vulnerable children will suffer – including their academic progress and achievement.

It is crucial now more so than ever before to invest in promoting children’s well-being.   A modicum of investment in a counselling service such as A Place2Be will not go awry.  If that is too expensive, then continuing professional development (CPD) of staff becomes a must.  Theresa May, the Prime Minister, has promised to fund the training of staff in two-thirds of secondary schools – one member of staff per school – with a view to cascading the knowledge down to the rest of the staff members.  This will not be enough.   Apart from the process being corrupted (remember the game of Chinese whispers?) it will take far too long to train all other staff members.

In the 66th of Governors’ Agenda, (see page 27), we wrote about Pooky Knightsmith’s proposals for every school’s governing body to address a number of questions.   These still apply.

In addition, parents need at least as much training as school staff.   Parenting is the only profession that I know of which does not require someone to be trained before take on the role.     Accordingly, in several families, children succumb to mental ill-health.

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