The challenges facing Children’s mental health provision in the UK.

The case for a schools based model of integrated mental health support

for children, their families and educational providers.

• The workshop will explore the national and local challenges to accessing mental health provision for Children and Young people.

• A presentation of an alternative provision model for mental health support in Schools for Children, Families and Staff.

• Mental Health in Children and Young People

• 1 in 10 children and young people aged 5 - 16 suffer from a diagnosable mental health disorder - that is around three children in every class (1).

• Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm (2).

• There has been a big increase in the number of young people being admitted to hospital because of self harm. Over the last ten years this figure has increased by 68% (3).

• More than half of all adults with mental health problems were diagnosed in childhood. Less than half were treated appropriately at the time (4).

National Context

• Nearly 80,000 children and young people suffer from severe depression (5).

• Over 8,000 children aged under 10 years old suffer from severe depression (6).

• 72% of children in care have behavioural or emotional problems - these are some of the most vulnerable people in our society (7).

• 95% of imprisoned young offenders have a mental health disorder. Many of them are struggling with more than one disorder (8).

• The number of young people aged 15-16 with depression nearly doubled between the 1980s and the 2000s (9).

• SOURCES• 1 Green, H., McGinnity, A., Meltzer, H., et al. (2005).

Mental health of children and young people in Great Britain 2004. London: Palgrave. • 2 Mental Health Foundation (2006). Truth hurts: report of the National Inquiry into self-harm

among young people. London: Mental Health Foundation• 3 YoungMinds (2011)

100,000 children and young people could be hospitalised due to self-harm by 2020 warns YoungMinds. London: YoungMinds.

• 4 Kim-Cohen, J., Caspi, A., Moffitt, TE., et al (2003): Prior juvenile diagnoses in adults with mental disorder. Archives of general psychiatry, Vol 60, pp.709-717.

• 5 Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young people in Great Britain 2004. London: Palgrave.

• 6 Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young people in Great Britain 2004. London: Palgrave.

• 7 Sempik, J. et al. (2008) Emotional and behavioural difficulties of children and young people at entry into care. Clinical Child Psychology and Psychiatry, 13 (2), pp. 221-233.

• 8 Office for National Statistics (1997): Psychiatric morbidity among young offenders in England and Wales. London: Office for National Statistics.

• 9 Nuffield Foundation (2013) Social trends and mental health: introducing the main findings. London: Nuffield Foundation.

• 10 Collishaw, S. et al. (2004) Time trends in adolescent mental health. Journal of Child Psychology and Psychiatry, 45:8, pp 1350–1362.

Local Context

Challenges to CAMHS• Funding / Resources• User Engagement - Voluntary• Referral Process – criteria• Diagnostic Lead – elimination model• Current Acute Presentations - Inpatient• Tier 1 and 2 services reduced –

preventative/supportive resilience development reduced

• The Public Health England report submitted to a health select committee inquiry cites research indicating a sharp worsening of the trends. In the last three to four years, there has been a steep rise in self-harm.

• Childline reports that in 2013 it experienced a 41% increase in reports of self-harm and a 33% increase of children reporting suicidal thoughts over the previous year.

• Public Health England concludes that 30% of English adolescents have sub-clinical mental health problems

In the select committee hearing, Peter Fonagy, made the point: "We make children very responsible for their lives but we give them very little control over them." later he added “The combination of responsibility and lack of control always creates stress in anyone at any age.”

Health CommitteeOral evidence:

Children’s and Adolescent Mental Health and CAMHS

, HC 1129Tuesday 1 April 2014

• http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-committee/childrens-and-adolescent-mental-health-and-camhs/oral/8443.html

NHS England report on mental health services

• The presentation says that 35% of adults with anxiety or diagnosable depression are not in contact with mental health services, but this rises to 76% of those aged five to 15.

• It notes that only 6% of spending on mental health goes on services aimed at children and young people, even though 50% of lifetime mental illness starts by the age of 14.

England's child mental health services 'failing three-quarters of kids'

'Cinderella service' hit by budget cuts and increasing demand Jamie Doward The Observer, Sunday 18 May

2014

• Only a quarter of all mental health conditions are receiving the treatment they need, according to a study produced by the body charged with improving the health service in England.

NHS report

• The report also provides evidence that, as a result of a rise in young people needing treatment for complex mental health conditions, assessments for conditions such as attention deficit hyperactivity disorder (ADHD) and autism are being delayed, while others are not being identified or treated

Jamie Doward The Observer, Sunday 18 May 2014

Sarah Brennan, Chief Executive of YoungMinds says,“The last national study was done 10 years ago and so we have no up-to-date national information on the numbers of children and young people with mental health problems," Brennan said. "Planning service provision without current data is extremely difficult, fraught with risks and not cost-effective."

Jamie Doward The Observer, Sunday 18 May 2014

CAMHS Data Mapping Review Discontinued post April 2010

Schools are containing increasingly more complex mental health

presentations

Health and Education• Different Languages / Different Agendas?• Diagnosis, Symptoms, Treatment, Symptom

management, Aetiology, Recovery.• Can Education support Mental Health?• Can Mental Health be supported in schools

through the use of a psycho-educational model (emotional mindfulness)?

• Do children need more than a cognitive educational model to understand their own emotional experience?

A new model

• Non Diagnostic led• Emotional and Psychological Development

and wellbeing• An integrated service Education and Health• Developmental and Integrated services

replacing external referral lead model• A new Parental engagement model.• Evidencing progress in wellbeing

Internal Referral System

• Training – What is mental health• Treatment for Mental Health• Consent for Treatment• Engagement • Levels of participation• Confidentiality

Concerns raised

• Key worker• Health• Education• TAC / AR

Referral Form Completed *

Multi-disciplinary Meeting Health / Therapy to discuss referral

Individual Consultation with staff

Team Intervention :Meeting / Milieu Therapy

Individual work• Observation• Assessments• Joint work with staff• Individual psychotherapy

Report toKey workerTAC / ARHealthTherapy

InterventionGathering a picture Report / Review

Parent meeting / External network meeting / Health agency – GP

Staff development  Training

Review

*Consent from Parent / Social worker

Process diagram to access emotional and psychological support 

TMMay 2014 ©

Concerns raised

• Key worker• Health• Education• TAC / AR

Referral Form Completed *

Multi-disciplinary Meeting Health / Therapy to discuss referral

*Consent from Parent / Social worker

Gathering a picture

View:Referral FormConsent - Parental engagementMulti-Disciplinary MeetingsNon-Stigmatising

Process diagram to access emotional and psychological support 

Multi-disciplinary Meeting Health / Therapy to discuss referral

Individual Consultation with staff

Team Intervention :Meeting / Milieu Therapy

Individual work• Observation• Assessments• Joint work with staff• Individual psychotherapy

Intervention

Parent meeting / External network meeting / Health agency – GP

Staff development  Training

Integrated therapeutic support programmeThis is both an assessment system which identifies areas of difficulties and a programme to monitor outcomes through the identification and monitoring of a range of therapeutic interventions. The support programme is intended to support the development of a young person’s capacity to grow and recover in areas of educational, emotional, social and psychological development.

Report toKey workerTAC / ARHealthTherapyParentsGP

Report / Review

Review

Process diagram to access emotional and psychological support 

Concerns raised

• Key worker• Health• Education• TAC / AR

Referral Form Completed *

Multi-disciplinary Meeting Health / Therapy to discuss referral

Individual Consultation with staff

Team Intervention :Meeting / Milieu Therapy

Individual work• Observation• Assessments• Joint work with staff• Individual psychotherapy

Report toKey workerTAC / ARHealthTherapy

InterventionGathering a picture Report / Review

Parent meeting / External network meeting / Health agency – GP

Staff development  Training

Review

*Consent from Parent / Social worker

Process diagram to access emotional and psychological support 

TMMay 2014 ©

www.psfs.org.ukFilm: Dawn House School

What is Mental Health

• Task: Discuss in pairs “What is Mental Health, and what causes mental illness?”

• Similarly discuss “What is Emotional Wellbeing?”

How might these be different and similar? How might we support them within Schools?

Environmental / Social

Psychological

Biological / Diagnostic Developmental/ Life Experiences/ Life events (past and present)

Factors Contributing to Mental Health and Emotional Wellbeing

• Mental health and wellbeing is an important part of overall health and wellbeing and can be affected by different factors, including life events such as relationship breakdowns, bereavement and work stress as well as mental health conditions such as depression or anxiety. Health Scotland has two definitions which are helpful in understanding what we mean by mental wellbeing and mental illness:

• Mental wellbeing: There are many different definitions of mental wellbeing but they generally include areas such as: life satisfaction, optimism, self esteem, mastery and feeling in control, having a purpose in life, and a sense of belonging and support.

• Mental illness: Mental illness refers to a diagnosable condition that significantly interferes with an individual's cognitive, emotional or social abilities e.g. depression, anxiety, schizophrenia.

It is also important to remember that it is natural to feel happy when something positive happens to you, to feel sad or angry when a bad event

occurs, or scared and anxious if you are dealing with something worrying. Part of ensuring good mental health and wellbeing is recognising that it is natural

to feel different emotions, but also knowing when you perhaps need some help in dealing with life events and mental health conditions.

http://www.nhsinform.co.uk/mentalhealth

Mental Health

Emotional Wellbeing

Factors Influencing both• Internal Psychological model• Environmental• Developmental• Systemic• Biological• Trauma / PTSD / Developmental Trauma

Barriers to communication / understanding

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and Emotional Wellbeing

Environmental Psychological

Biological / Diagnostic Developmental/ Life Experiences/ Life events (past and present)

Factors Contributing to Mental Health and Emotional Wellbeing

House moveAnxiety in the home – anxious parentSchool Leaver – loss of stability last year9 years at school – long period of relative stability

Self Harm , Suicide Social AnxietyAgoraphobiaOCD type behaviourConcrete sense of emotional experienceOver Identification with others – early phase

ASC

Fearful of change, fear of being alone. Concern about future living arrangements – possible residential college explored

• Mental health and wellbeing is an important part of overall health and wellbeing and can be affected by different factors, including life events such as relationship breakdowns, bereavement and work stress as well as mental health conditions such as depression or anxiety. Health Scotland has two definitions which are helpful in understanding what we mean by mental wellbeing and mental illness:

• Mental wellbeing: There are many different definitions of mental wellbeing but they generally include areas such as: life satisfaction, optimism, self esteem, mastery and feeling in control, having a purpose in life, and a sense of belonging and support.

• Mental illness: Mental illness refers to a diagnosable condition that significantly interferes with an individual's cognitive, emotional or social abilities e.g. depression, anxiety, schizophrenia.

It is also important to remember that it is natural to feel happy when something positive happens to you, to feel sad or angry when a bad event

occurs, or scared and anxious if you are dealing with something worrying. Part of ensuring good mental health and wellbeing is recognising that it is natural

to feel different emotions, but also knowing when you perhaps need some help in dealing with life events and mental health conditions.

http://www.nhsinform.co.uk/mentalhealth

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and

Emotional Wellbeing

Mental Health and Emotional Wellbeing are interlinked, but not necessarily causal. In children with ASD or Asperger Syndrome much of their behaviour could be understood as symptoms similar to mental health conditions such as OCD, Anxiety, Mood swings. This type of behaviour is sometimes dismissively referred to as ‘part of being on the spectrum’. Whilst there may be some truth to this, these symptoms could also be an indication of an emotional disturbance indicative of a mental health condition.

Early detection and intervention is key to maintaining good emotional wellbeing and could be seen as a preventative factor in the development of Mental Health.

Displaying concerning behaviour may be indicative of a mental health condition but it could also be a response to abnormal life events or a response to normal developmental

experiences in childhood.Children’s presentation must always be understood within the context of development, maturation, family context, early developmental history, comorbid presentations such as neurodevelopmental conditions and wider systemic understanding.

Definitions• Mental Health • Emotional Wellbeing

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and

Emotional Wellbeing

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and Emotional Wellbeing

Mental Health

Emotional Wellbeing

Factors Influencing both• Internal Psychological model• Environmental• Developmental• Systemic• Biological• Trauma / PTSD / Developmental Trauma

Barriers to communication / understanding

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and

Emotional Wellbeing

Presenting behaviour / Observable behaviourAnxiety, Low Mood, Self Harm

Symptom ManagementPsychological, Pharmacological, EnvironmentalLevels of engagement in psychological work (CBT, Group, Systemic, Psychodynamic, EMDR)

DiagnosisBased upon current symptoms and causal groupings

Aetiology -  origins/causation• Genetic• Biochemical• Developmental history• Life events – trauma / PTSD• Current Environment – family

Levels of presentation

• Attachment Trauma• Developmental Trauma

• The presentation reveals that cuts are increasingly being reported in places such as south-west London. It says the Maudsley Child and Adolescent Mental Health Services reports cuts across its London boroughs ranging from 17% to 38%, and quotes the concerns of mental health teams across the country.

• One team said that its £1m budget was to be slashed by £300,000 from next year. As a result, it was having to draw up plans to become an urgent assessment and urgent treatment service only.

• Specialists would be unable to deliver the therapy for which they had been trained. Another acknowledged that its specialist and early intervention services were being dismantled.

• A third said that an increase in both routine and emergency presentations had left it with no choice but to give priority to clinical risk cases over routine follow-up activity, such as assessments for ADHD and autism.

• The document quotes statistics, which reveal that in England there is only one mental health specialist per 30,000 young people under 20, compared with one per 5,300 in Switzerland, 6,000 in Finland and 7,500 in France.

Jamie Doward The Observer, Sunday 18 May 2014

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and Emotional Wellbeing

Consent for Treatment

• What is consent• Different levels for consent• Who is consenting• Statutory provision – Mental Health Act• Voluntary engagement

Psychological Services for Schools copyright 2013 Module KN1 Introduction to Mental Health and Emotional Wellbeing

Treatment

• Pharmacological – biochemical imbalances Depression - Antidepressants, Anxiety – mood stabilisers, Psychotic Illnesses – Antipsychotics

• Psychological Therapies – individual, group, systemic models

• Applied environmental management. (Risk, Anxiety management, emotional processing)

• Body focussed treatments – exercise, diet, lifestyle, sensory focus, relaxation, mindfullness.

• Psycho-educational understanding of ‘flight-fright’ mechanism in PTSD. Hyper/Hypo arousal systems.