Nottingham Insight

Good mental and emotional health is essential to enable children and young people to fulfil their potential and achieve positive health, social and educational outcomes. Mental wellbeing can be influenced by a range of individual, familial, social and environmental factors that can impact on children and young people throughout their development. Whilst good emotional and social wellbeing is associated with good physical health, academic engagement and economic independence, poor mental health can have significant long lasting and far reaching impacts on children and young people. The government’s Future in Mind strategy, published in 2015, states:

“Mental health problems cause distress to individuals and all those who care for them. These range from short spells of depression or anxiety through to severe and persistent conditions that can isolate, disrupt and frighten those who experience them. Mental health problems in young people can result in lower educational attainment… and are strongly associated with behaviours that pose a risk to their health” (DHSC 2015).

Half of all long-term adult mental health disorders are established by age 14 and three quarters by the age of 24 (Kessler, 2005). The impacts of poor mental health can be seen on social relationships, educational attainment, physical health, crime, homelessness and employment prospects (Department of Health, 2009).

Children are at a higher risk of developing mental illness if they experience adverse events in childhood, are looked after by their local authority, if they have a long-term illness or disability, if they are a young carer or if they have a parent with a substance misuse problem. On the other hand, children with stable home lives, who attend school regularly and who have positive relationships with their peers and adults have a reduced risk for mental illness

Nationally, there has been a gradual rise in the number of CYP with a mental health disorder over the last decade so that in 2017 one in eight 5 to 19-year-olds had at least one mental health disorder compared to one in ten in 2014.

Currently, it is estimated that 8718 children in Nottingham City have a diagnosable mental health disorder at any one time. In 2018/19 there were 1763 children and young people referred to CAMHS Single Point of Access (SPA), 1014 referrals to Specialist CAMHS, 308 referrals to CAMHS Crisis Resolution and Home Treatment service (CRHT) and 141 referrals to CAMHS for Children in Care. Many more children and young people will seek support through informal networks and charity/voluntary
services, and as is the case across the UK, it is likely that others will not seek help and will not be identified as needing help.

Nottingham has developed strong, evidence-based strategies to support children and young people, particularly through improving access to mental health services, including the recent introduction of a policy to allow self-referrals. Additionally, through supporting development of robust pathways in perinatal mental health and tailored Child and Adolescent Mental Health Services (CAMHS) for targeted groups such as the Mental Health Support Teams in Schools and Colleges.

There has also been significant investment in the workforce; not only in the NHS, but across a wide range of public sector roles, in addition to this, schools have made a concerted effort to build resilience. There is good evidence to show that school-based interventions can be a cost-effective investment.

However, despite good progress there are still significant unmet needs and gaps. National policy (Long Term Plan, 2019) recognises the need to improve the experience young people have with their mental health and that changes need to be made to improve transitions and support for young children and young adults. These ambitions are described in more detail in the targets and performance section.

Unmet needs and gaps

Many services in the public sector are still commissioned in isolation. With mental health in particular, this is untenable due to the complexity of interactions between different risk factors and behaviours. For example, parental substance misuse may cause poverty and familial stress, which may result in a mental disorder, which then becomes a risk factor for other behaviours such as crime or risk-taking. There needs to be a whole-systems approach to mental health commissioning.

Reductions in funding to early intervention services have resulted in a reduction of universal provision and of parenting support, particularly around the skills they need to help support the positive mental and emotional development of their children.

Transition to adult care is still cited by young people as needing improvement, and although work has been undertaken recently to improve the process, there could still be more done to improve the quality of the experience. Many patients do not urrently return their post-transition surveys, however, and alternative methods of assessing the quality of transition may need to be undertaken.

Social media is both a risk and an opportunity. There is much in the media about online bullying and negative consequences of interactions, such as the promotion of unrealistic expectations, cyber-bullying and developing a fear of missing out. However, apps and web support offer new ways for children and young people to access services and to connect with peer support networks in what is often their preferred medium. The landscape changes fast, and there is undue focus on misuse of particular platforms in media reports, rather than on promotion of positive safety messages.

Local CAMHS are only commissioned to work with children and young people with neurodevelopmental issues where mental health is the primary presenting issue. There is a significant need for children, young people, adults and families to be supported to understand the impact that neurodevelopmental needs have on their functioning and support with developing positive coping strategies. This is being addressed by the provision of Small Steps, however, demand for the service exceeds capacity.

There is a gap in formal psychology input where children have adverse childhood experiences, or are below CAMHS threshold for emotional health difficulties e.g. anxiety which can impact on a behavioural/developmental
presentation, and lack of formal cognitive assessments to determine whether behavioural/developmental needs are related to an underlying learning disability.

There is a gap in mental health support for Children in Care from other local authorities and for Nottingham children in care placed in other local authorities Other Local Authority Children in Care do not have access to the Children in Care CAMHS service in Nottingham. Young people who are the responsibility of Nottingham City but are placed elsewhere have variable levels of mental health support depending on the placement location. The choice of placement is often very limited, particularly for children with complex needs.

There is a lack of high intensity long-term mental health support for children and young people with the highest level of mental health need alongside unsafe or challenging home environments. This results in frequent acute hospital presentations, delayed discharges and repeat psychiatric inpatient admissions. The crisis team, social care and CAMHS are currently unable to provide the high intensity long-term mental health support required for this cohort.

Training for professionals to support for young people with Autism Spectrum Disorder (ASD) is not yet in place. There is growing evidence that young people with ASD are at increased risk of suicide and co-morbid mental health conditions. There is currently a lack of effective training for mental health professionals to understand how young people with ASD may present differently when experiencing a mental health crisis and how best to then support them.