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||Emotional and mental health needs of children and young people aged 0 – 18 years
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Good mental and emotional health is essential to enable children and young people to fulfil their potential. Mental and emotional health problems are an important and common group of disorders affecting about 1 in 10 children and young people living in the UK (1). Mental health is best seen as a continuum, ranging from mental wellbeing, to severe and enduring mental disorders that cause considerable distress and interfere with relationships and daily functioning. Mental health problems vary in their nature and severity, and affect individuals differently over time. The factors that affect mental and emotional health are complex, ranging from individual biological factors to complex societal issues. Mental health conditions in childhood and adolescence are particularly important due to the far reaching consequences on health, social and educational outcomes. Mental health problems unlike other health problems tend to start early and persist into and throughout adulthood. It is recognised that by the age of 14 about half of all lifetime mental health problems start (2). This highlights the long term nature of mental illness and the importance of intervening early to prevent mental illness alongside early recognition and treatment.
In terms of children and young people’s emotional mental health and well-being, according to the National CAMHS review (2008), children and young people state that it’s not just about children being ‘happy’ but feeling ‘in control’ or ‘feeling balanced,’ It’s about children and young people “having the resilience, self-awareness, social skills and empathy required to form relationships, enjoys one’s own company and deal constructively with the setbacks that everyone faces from time to time,” (1) . The term ‘wellbeing’ is a broad concept encompassing emotional, psychological and social wellbeing.
Unmet needs and service gaps
Needs of children and young people
- Increasing referrals to tier 2 and tier 3 CAMHS for children and young people who are self-harming
- An increasing number of presentations to the Emergency Department (ED) at Queens Medical Centre by children and young people who are self-harming.
- An overall increase in the complexity of cases presenting both to ED and CAMHS.
- A significant number of children in Nottingham City are exposed to domestic violence either as part of their family life or within their own relationships.
- School nurses are seeing an increasing number of children and young people who are experiencing emotional and mental health problems.
- School nurses are seeing an increasing number of children who are self-harming. Due to waiting time into be seen within tier 2, school nurses are holding and ‘counselling’ children who may be at significant risk to themselves.
- Some stakeholders stated that Schools needs to take greater responsibility for raising awareness of self-harm. This will hopefully be ameliorated by the development of the Kooth counselling services being placed within the City schools and the SHARP team self-harm specialist team within tier 2.
- The age of children and young people presenting to services with regards to self-harm is lowering to age 7.
- There are a significant number of children in Nottingham who are witnessing/experiencing domestic violence with an estimated 3 children in every classroom. Research states that children who experience DV have a 4 fold increased risk of experiencing mental and emotional health issues. Therefore there are a substantial number of children in Nottingham who may be experiencing/witnessing DV however their emotional and mental health needs are not being catered for.
- A number of high profile suicides of young people in the city where previous self-harm was a prominent feature.Behavioural Issues/ ASD/ADHD
- A significant number of referrals to CAMHS are related to behaviour which is taking up significant time and resources. It is anticipated that the new emotional health and wellbeing pathway commissioned by the NHS Nottingham CCG will help to divert these referrals away from CAMHS, if appropriate.
- A significant number of referrals from GPs to community paediatricians for behaviour and suspected ASD/ADSD. However there is a view that there is limited resources within community paediatricians to cope with the sheer number of referrals being made on a weekly basis (again this should be alleviated with the development of the Emotional Wellbeing Pathway) and that community paediatricians do not have a wide source of opportunities to refer onto to support parents, therefore pharmacological treatment is used as a first line of treatment rather than parenting and psychological support.
- Stakeholders expressed care of children with behavioural issues should be multidisciplinary and focused on the child’s needs rather than medical diagnosis
- A recognition that many of the referrals coming through to both community paediatricians and CAMHS tier2 are caused by attachment issues. Therefore work should be focused on parenting programmes.
- Stakeholders felt that there needs to be a greater emphasis on early intervention, identifying emotional and mental health problems early in order to ‘break the cycle’.
- It is also recognised that resilience needs to be systematically promoted within the school setting starting within primary schools.
- Some stakeholders felt there is a perceived gap around teaching young people to work through and manage issues themselves.
- There needs to be more emotional and mental health training and support provided to universal services due to sheer numbers of children and young people accessing these services.
- Schools needs to take on a greater role in promoting emotional health and wellbeing as well identifying children who are at risk of emotional and mental health problems.
Issues related to the provision of CAMHS Services
Overall stakeholders recognised there are blockages at every tier of CAMHS and there is no step up step down approach within Nottingham City which allows children to move up and down the tiers of CAMHS depending on their level of need. It is also recognised by stakeholders the children and young people are not at the heart of the service in terms of the development and care and this needs to be developed further.
Universal Services (tier 1)
- The numbers of pupils seen by school nurses for emotional and mental health problems are increasing (557 from April until October 2013).
- There is still a need for tier 1 services to be trained in dealing with young people self-harming (despite the new services coming on line). In particular there needs to be recognition by schools and school governors that self-harm is a public health challenge.
- GPs are referring to community paediatricians rather than into CAMHS services due to being ‘bounced’ around the existing CAMHS provision.
Tier 2 Services
- Neither universal services nor community paediatricians currently receive any feedback from the CAMHS services with regards to the children and young people they refer into the SPA.
- There is a lack of knowledge within clinical children’s services of the skills and competences of the tier 2 work force.
- The community paediatricians currently do not receive feedback from the SPA on the care plan and outcomes of the children/ young people they have referred.
- There is a lack of knowledge from referrers into the CAMHS service on the outcome of referral through the SPA process.
- A number of referrals made into the SPA (tier 2) by the community paediatrician have been ‘bounced back’ to them instead of being placed within tier 2.
- It was reported that there are increasing waiting times for children to be seen in tier 2 after a referral has been made into the SPA due to the numbers of referrals being made into CAMHS. In some cases children and Young people are waiting up to 8 weeks to be seen initially within CAMHs after a referral has been made. However this issue is now being dealt with, with the introduction of the CAPA model within tier 2.
- There appears to be reduced capacity within tier 2 due to an increase in the number of referrals.
Tier 3 Services
- The Head to Head service are not filling all their numbers of planned sessions for Nottingham City. However the cases that they are working with are extremely complex and taking up significant time.
- There is a significant waiting time for tier 3 services.
- Tier 3 services including the special self-harm team work office hours Monday to Friday, which does not cater to the demand for the service as the majority of ED presentations which would warrant a special tier 3 intervention are at an evening or weekend.
- The self-harm team are only able to see a small proportion (2 assessments per professional per day) of those young people who are admitted to a paediatric bed in QMC for self-harm due to the sheer number of admissions. This is causing an increase in bed stays within the paediatric wards for the young people until the young people can be assessed and having a knock on effect and increasing pressure in paediatric care.
Looked After Children
- The CAMHS Looked after Children team has seen an increase in the number of referrals which is a reflection of the increasing number of children and young people entering into care.
- There is currently no monitoring system to assess the emotional and mental health of all children who are in care. The SDQ questionnaire is only used for children who have been referred into the team to assess their emotional and mental health.
Tier 4 Services
- There is recognition locally and nationally that there are a limited number of inpatient beds within tier 4 (12 beds locally for all children and young people who live in Nottinghamshire and Derbyshire).
- There are issues that local children and young people have been placed out of area due to impatient capacity.
- In patient unit at Thorneywood is mainly occupied by long term stay patients. There is currently no step up step down pathway for children and young people who no longer require inpatient care but require intensive support.
Secondary Care- Queens Medical Centre
- There are an increasing number of children who are presenting and admitted to ED at QMC with emotional and mental health issues.
- Children and Young People who present to ED with self-harm on a Friday afternoon or over the weekend are not assessed by the CAMHS self-harm service until a Monday morning. The consequence of this is that children and young people have to stay over the weekend in a paediatric bed which again causes pressures on paediatric care.
- If a young person is admitted to QMC over the weekend, it will not be the specialist self-harm team that undertakes the assessment, a Registrar Psychiatrist or a Consultant Psychiatrist will undertake the assessment using a different risk assessment tool from the self-harm team and will only assess and not refer onto appropriate CAMHS services.
Transition to Adult Services
- Stakeholders expressed mixed views about transitioning from child to adult mental health services. Many reported that in general, transitioning appeared to work ok. Where it did not work well, cases were complex or had been out of area. It was felt in these cases; transitions weren’t always planned far enough in advance, particularly where there were complex needs.
- Transitions were reported to work well when young people have significant mental health disorders that clearly map onto adult services. For example, it was felt there was a good match between child and adult psychosis services.
- Several stakeholders however reported that adult and child services are configured differently with some young people not necessarily meeting criteria to be seen in adult services, particularly for emotional or behavioural conditions.
- Linked to the above, it was felt that transition was a vulnerable time for the young person, potentially having left school, losing other support networks and potentially losing support from CAMHS.
- Young people who present with emotional and mental health issues on the cusp of transition into adult services may not necessarily be placed with the most appropriate level of care.
Recommendations for consideration by commissioners
- Antenatal and perinatal health needs to focus more on emotional and mental health of mothers with the development of specialist mental health midwives to support mothers with post natal depression. This is due to the link between antenatal anxiety at 32 weeks and the link to behavioural and emotional problems in children. This recommendation will be fed into NHS Nottingham City CCG midwifery review.
- Develop universal programmes which address how to parent effectively as part of antenatal care for example based on the Family Partnership programme in the USA. This recommendation will be fed into the Nottingham City Emotional, Mental Health and Wellbeing pathway which is in development.
- Utilise the school readiness check at age 4 to undertake an emotional and mental wellbeing check of the child and pass on any information to the school and school health.
- Systematic support should be provided to families with children and young people who are experiencing domestic violence at all risk levels as assessed by DART. There needs to be recognition the impact of DV on children’s emotional and mental health.
- Ensure all services are linked into Nottingham City Council’s Family Support Strategy.
- All adult mental health services should have a Key Performance Indicator to support the emotional and mental health needs of children particularly when parents are diagnosed with a mental health condition.
- All children’s services to consider parental mental health, substance misuse and domestic violence as a factor affecting child emotional and mental health and to signpost/refer to appropriate services.
- All primary care (GPs, school nurses and health visitors) and schools (all teachers) should have comprehensive training in the skills and knowledge required to recognise children and families who may be experiencing emotional and mental health issues.
- A comprehensive self-harm training programme should be developed and delivered to all GPs, schools (both primary and secondary including teachers) and school nurses.
- Roll out the Public Health England Tool Kit for emotional health in schools.
Children and adolescent mental health services and proposed pathways
- Identify resources to develop a new CAMHS pathway in light of the increased number of referrals and improve partnership working with adult mental health services
- Utilise tier 2/3 service usage data to deliver a multi-disciplinary and skilled community CAMHS pathway provision where the child and young person is at the centre of delivery. This includes appropriate venues for meeting families and children and young people, suitable waiting times to the point of invention and length of intervention time.
- Ensure that the CAMHS pathway systematically supports universal services after the point of referral.
- Undertake a whole CAMHS workforce review to ensure there are the right skills and competences in relation to working with children and young people who are experiencing emotional and mental health problems. Develop a skills and competences quality standard for all CAMHS workforce.
- Develop a multi-agency assessment process with a single point of access which is inclusive of all appropriate referrers into the CAMHS service.
- Support the workforce and service users to smooth transition of patients between tiers and transition to adult services to minimise duplication of assessments.
- Develop an appropriate pathway for children and young people who attend emergency department (ED) for self-harm
- .All young people who are admitted to QMC over the weekend with self-harm should have the standardised self-harm risk assessment tool undertaken as done by the specialist tier 3 self-harm team.
- Provide a responsive CAMHS service which works into the evenings and weekends to minimise the number of admissions to QMC by young people and the need for inpatient beds.
- All referrals should work towards a standardised waiting times and all interventions should be standardised to ensure children and young people are at the heart of the service.
CAMHS specific services
- All looked after children (LAC) undertake a strengths and difficulties questionnaire SDQ) every 6 months as part of their LAC review. This will ensure that all LAC will be monitored for changes in their emotional and mental health state and subsequently be referred into the CAMHS looked after children team to appropriate interventions.
Improving local data on children and young people’s mental health
- Develop a core dataset to be reviewed at the CAMHS Executive, taking account of the development of a national CAMHS minimum dataset and the use of outcome measures such as The health of the nation outcomes scale for children and adolescents (HoNOSCA), for more information please go to http://www.liv.ac.uk/honosca/faq.htm.
- A systematic change needs to be implemented across the CAMHS which focuses on the outcome of the child/young person rather than the process. Investigate the possibility of a newly commissioned data system or that existing data systems talk to each other to ensure a smooth referral or transition between tiers of CAMHS children and young people.
Sarah Quilty- Public Health Manager
Lynne McNiven- Consultant in Public Health
Deb Hooton- Head of Commissioning Children and Families
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