Child and adolescent mental health – a guide for healthcare professionals
June 2006
Health inequalities
As discussed in the previous chapter, certain groups of children and young people are at greater risk of suffering from a mental health problem. In 2003, the Department of Health (DH) published 'Tackling health inequalities. A programme for action', which outlined strategies for dealing with health inequalities. [Go to note 44]. It includes strategies for children and young people, as well as at-risk groups, such as looked after children, BME groups, asylum seekers and homeless people. Standard 1 of the National service framework for children, young people and maternity services (children’s NSF) addresses the need to reduce health inequalities and increase access to services among those where take-up tends to be lower, such as looked after children. [Go to note 45]. For further information on the national service frameworks - read more here. There should be systematic assessment by primary care trusts (PCTs) to identify risk factors, such as deprivation. Multi-component programmes using a range of strategies are most likely to be effective. [Go to note 46]. 'Choosing health' and 'Every child matters' (read more here) also highlight the importance of focusing on improving service availability and take-up for children and adolescents who are at a greater risk.
Deprivation
Deprivation is a major risk factor and is highlighted by the ONS 2004 survey, as discussed in this section here. Evidence shows that there is a high prevalence of mental health problems among the homeless, including homeless children, and that homelessness is a risk factor. [Go to notes 47 and 8]. The BMA report, 'Housing and health: building the future' (2003) provides more information about the effects of accommodation on health, including mental health. [Go to note 39]. The government has set a target of halving child poverty by 2010, and eradicating it by 2020. The Child Poverty Review examined the reforms necessary to achieve this, and includes initiatives to increase investment in early years services for disadvantaged children, delivering more decent homes and supporting parents.[Go to note 48]. Given the impact of deprivation on child and adolescent mental health, achieving these goals could play a significant role in improving the mental health of vulnerable children.
The Sure Start programme is a key component in the government’s aims to tackle inequalities among children. It was launched in 1999 and aims to improve outcomes for children, parents and communities by supporting parents, increasing childcare and improving health and emotional development of young children. It generally focuses on children from birth to 14, and up to 16 for children with special educational needs and disabilities. It works to combat childhood deprivation and support the emotional development of children, especially those from disadvantaged backgrounds. Further information can be found at www.surestart.gov.uk - go to the website here.
Black and minority ethnic groups
Evidence reveals that the rates of mental health problems tend to be higher among people from BME groups, as they are more likely to experience risk factors associated with poor mental health, such as deprivation, discrimination and poor educational and employment opportunities. [Go to notes 49, 17 and 50]. However, people from black and ethnic minorities, including children, are not receiving appropriate treatment. The charity YoungMinds published a survey, 'Minority voices', in 2005 on the availability of mental health services to young people from BME backgrounds. These young people face a variety of specific barriers to accessing services, including: [Go to note 51
- cultural barriers. There is often a lack of understanding of different cultural and religious needs among health professionals, and there is a shortage of mental health professionals from BME backgrounds. Staff need to be trained in race equality and cultural competences; such training must be standard, and across the board
- people from different cultures may have different understandings of what mental health is. For example, the survey found that the stigma of mental health problems is particularly strong among people from certain backgrounds. Such attitudes can impact on how children seek and access treatment
- language barriers. English may not be the first language for these children, especially asylum seeking and refugee children, and translation services are not always available
- there is evidence of racism within mental health services. This presents as racist attitudes, practices and procedures that are discriminatory in outcome, if not in intent [Go to note 49]
- the YoungMinds survey found that a number of services, and particularly those targeted at young people from BME backgrounds, had either recently closed or were under threat of doing so. There is a lack of funding for such specialised services, which must be addressed
Refugees and asylum seekers
Refugee and asylum seeker children are at high risk of mental health problems. They have often suffered traumatic experiences prior to reaching the UK, and can face discrimination once here. They are likely to have come from countries with poor human rights records, may have witnessed acts of violence, and will need to cope with new social and cultural experiences in the UK. [Go to note 54]. Practical problems of living in the UK are particularly difficult for refugee and asylum seeking families, and they are more likely to be living in deprivation and poor conditions. [Go to note 55]. Their lack of understanding of the UK health and welfare services may hamper access to treatment, as can poor knowledge of other British systems. The legal status of asylum seekers can be uncertain, and this in itself can present an obstacle to receiving help. There are language and cultural barriers, and such children may be reticent about discussing their situation following previous experiences where either they or their parents may have been persecuted for their views. CAMHS staff may also find the experiences these children have been through difficult to cope with, and may need support and training in working with them. [Go to notes 51 and 17]. The BMA report, 'Asylum seekers: meeting their healthcare needs' (2002), discusses the specific healthcare needs of asylum seekers, including psychological wellbeing and the needs of children. [Go to note 56]. The DH is funding research into the emotional wellbeing and social functioning of unaccompanied asylum seeker children and young people. The intention is to increase understanding of the health and social care interventions that would meet the needs of this group. [Go to note 57].
Looked after children
As highlighted in the previous chapter here, looked after children (children in the care of local authorities) are at particular risk of mental health problems, with around 45 per cent of looked after children in the UK suffering from some form of mental health problem. [Go to note 40]. These children are likely to have been through a traumatic experience, may have come from socially and economically deprived backgrounds, or have parents with marital problems, and the majority are in care as a result of abuse or neglect. [Go to notes 58 and 59]. There were 60,900 children in care in England on 31 March 2005 [Go to note 61]; in 2004, there were 45,000 children continually looked after for over one year. [Go to note 60]. Sixty-eight per cent of looked after children are placed in foster care. [Go to note 61]. The experience of care may further exacerbate mental health problems that developed prior to entering care, and in some cases create new difficulties. The ONS study of the mental health of looked after children in England in 2002 found that 37 per cent of five to 17 year olds had conduct disorders, 12 per cent had emotional disorders and 7 per cent were diagnosed with hyperkinetic disorders. This was significantly higher than children from private households. [Go to note 40]. A mapping exercise of CAMHS found that 8 per cent of the total CAMHS caseload in 2004 was looked after children. [Go to note 62]. See the section here for further information on CAMHS mapping.
Table 2: Mental health disorders among children looked after by the local authority compared to children living in a private household (England, 2002)
Disorder |
5-10 year olds (%) |
11-15 year olds (%) |
||
Looked after children |
Private household |
Looked after children |
Private household |
|
Emotional disorders |
11 |
3 |
12 |
6 |
|
|
|
|
|
Conduct disorders |
36 |
5 |
40 |
6 |
|
|
|
|
|
Hyperkinetic disorder |
11 |
2 |
7 |
1 |
|
|
|
|
|
Any disorder |
42 |
8 |
49 |
11 |
Source: Office for National Statistics (2003) The mental health of young people looked after by local authorities in England. London: HMSO.
The ONS report placed children into four categories: residential care, foster care, living with their natural parents (subject to care orders), and living independently. It found that two thirds of children and young people living in residential care, two fifths of those in foster care or living with their natural parents, and one half of those living independently suffered some form of mental health disorder. [Go to note 40].
Table 3: Prevalence of mental health disorder among looked after children by type of placement (England, 2002)
Type of disorder |
Residential care |
Foster care |
Living with natural parents |
Living independently |
All placements |
Emotional disorders |
17.7 |
8.6 |
20.3 |
15.4 |
11.7 |
|
|
|
|
|
|
Conduct disorders |
56.2 |
32.9 |
28.1 |
46.2 |
37.0 |
|
|
|
|
|
|
Hyperkinetic disorder |
7.9 |
7.4 |
7.1 |
2.3 |
7.3 |
|
|
|
|
|
|
Less common disorders |
11.1 |
2.2 |
1.8 |
2.6 |
3.7 |
|
|
|
|
|
|
Any disorder |
68.0 |
38.8 |
41.9 |
51.3 |
44.8 |
Source: Office for National Statistics (2003) The mental health of young people looked after by local authorities in England. London: HMSO.
Looked after children and young people are more likely to experience poor life outcomes than those living in private households. This is often linked to mental health problems, and can be both a cause and a result of problems. For example, children in care are more likely to under-perform at school. The ONS survey found that about 60 per cent of all looked after children had some difficulty with reading, mathematics or spelling. Those with mental health problems were twice as likely to experience problems: in reading, 37 per cent of children with mental health problems experienced difficulties, compared to 19 per cent of children with no mental health problem. In mathematics, the figures were 35 per cent compared to 20 per cent, and for spelling, 41 per cent compared to 24 per cent. Similarly, there was a high level of young people in care who had been in trouble with the police in the previous year (14 %). There appears to be a link between mental health problems and offending: 26 per cent of young people with mental health problems had been in trouble with the police, compared to 5 per cent with no such problem. [Go to note 40].
It is vital that looked after children and young people have access to high quality care and support, and that this is targeted appropriately, both generally and in terms of mental health services. While CAMHS for looked after children have improved in recent years, more needs to be done to ensure that all children and young people with a mental health problem are able to access treatment effectively and quickly. [Go to notes 63 and 59]. In developing practices and policies, it is important that there is an understanding of the effects of state care on children, and the specific needs that these children may have. [Go to note 63] CAMHS professionals working with this group need relevant training and information to allow them to tackle the particular problems that they may face. Similarly, carers should be aware of the particular needs of these children, and their vulnerability to mental health problems and should receive appropriate support. [Go to note 64]. Children and young people should also be consulted about their wishes. It is important that looked after children have access to high-quality education, leisure and social care, as these can impact on a child’s emotional wellbeing and their resilience in a positive way. This is especially pertinent, given that looked after children are more likely to experience poor life outcomes. Secure placements are also an important factor in children’s mental health; children need stability and the opportunity to develop attachments to primary carers. [Go to note 63]. Being constantly moved around placements will disrupt not only their home-life and education, but also the continuity of any healthcare, including mental healthcare, that they may be receiving.
The DH has produced guidelines, 'Promoting the health of looked after children' (2002), which provides a framework for the delivery of services to looked after children by health and social services. It provides guidance on assessing the health of every child on entering care, and creating and implementing individual health plans. This includes mental as well as physical health, and health promotion. It states that all LAs should have CAMHS strategies in place, which should make specific reference to looked after children. It also emphasises the necessity of strong links between looked after children’s services and mainstream CAMHS. [Go to note 65]. The National Children’s Bureau and DfES have together developed Healthy Care, which aims to promote the health and wellbeing of children in care, and take forward 'Promoting the health of looked after children'. [Go to note 66]. 'Every child matters', 'Choosing health' and the children’s NSF all address the general needs of looked after children, though in very broad terms. The charity YoungMinds, in collaboration with the DH, has set up a Looked After Children Learning Network to support professionals working with these children and young people. More information is available at www.youngminds.org.uk/lac/ - go to the website here. [Go to note 67]. YoungMinds is also working with HeadsUpScotland (a project to improve the mental health of children and young people in Scotland) to develop training courses to enable those working with looked after children to provide appropriate mental health support. [Go to note 68].
Young offenders
Young offenders are at high risk of suffering mental health problems; 40 per cent have a diagnosable disorder.[Go to note 7]. Of the total caseload of CAMHS, 5 per cent were young offenders. (This figure does not include those in secure provision in the independent sector.) [Go to note 62]. There is also a high rate of suicide among those in young offenders’ institutions: 13 young people killed themselves while in prison in 2003, 16 in 2002 and 15 in 2001. [Go to note 17]. Youth offending teams have been set up to prevent offending by children and young people. They are comprised of a range of professionals, including health practitioners, and one of their functions is to try to prevent crime by addressing the causes of it. They also work with young people once they are in the justice system. [Go to note 69]. The Youth Justice Board has released guidance on working with young offenders with mental health needs, [Go to note 70] and YoungMinds runs a Young Offenders Mental Health Network to support practitioners. [Go to note 71]. The NSF states that PCTs should work with LAs and the Prison Service to ensure that young offenders have access to improved healthcare. [Go to note 46].
Although not a precursor to criminal behaviour in later years, there is a positive correlation between time lost from education and crime, with half of all male prisoners having been excluded from school. [Go to note 72]. Many of these children suffer from conduct disorders and there is evidence that they may also exhibit problems with social understanding, and disorders on the autistic spectrum. However, these disorders often remain undetected: one research programme found that a significant minority of children with disruptive behaviour have significant, previously unidentified, social communication difficulties. Gilmour J, Hill B, Place M et al (2004) Social communication deficits in conduct disorder: a clinical and community survey. Journal of Child Psychology and Psychiatry 45: 967-78. These children are therefore not receiving the necessary treatment, which could perhaps in turn help to prevent behaviour that would lead to exclusion. There needs to be better provision of integrated services to support such children, including mental health assessments and care.
16 and 17 year olds
Young people aged 16 and 17 often fall into a gap between child and adult services, and therefore do not receive adequate help and support. Many CAMHS do not currently provide services for those aged over 16, although the children’s NSF sets out a requirement for CAMHS provision to the age of 18. [Go to note 74]. There needs to be recognition that young people of this age may be at different levels of maturity: while some 16 and 17 year olds may be mature enough to receive treatment from adult services, this would be inappropriate for many. [Go to note 7]. A 2005 study of young people found that for this age group, the provision of appropriate care was a major concern. [Go to note 51]. Those who had experienced treatment through adult services had often found it daunting. Some young people in the survey had received inpatient care on adult wards and found themselves on mixed-sex wards; they highlighted how uncomfortable this made them feel. Young people should be allowed some choice about the services that feel most appropriate to them. There is clearly a need to extend the age range of CAMHS at a local level to ensure that the needs of 16 and 17 year olds are met. [Go to note 7].
The transition from child to adult mental health services (AMHS) can be difficult, and these problems can further compound a young person’s mental health problems. [Go to note 16] Services are not always effective at meeting the needs of young adults. While CAMHS tend to have a fairly broad remit, AMHS are more focused on severe and enduring disorders; thus many young people may be ineligible for treatment through AMHS. CAMHS also routinely work with the young person’s family, which is not necessarily the case with AMHS. A YoungMinds mapping exercise of services for 16-25 year olds found that while there are examples of effective services in England and Scotland, a comparatively low level of services are commissioned by PCTs, and the needs of this age group are not being met effectively. Only 16 per cent of CAMHS commissioners had initiatives in place to provide age-specific services to 16-25 year olds, and only 9 per cent had policies to improve access and services for this age group. [Go to note 16]. A need for more formal transition protocols was also highlighted in the survey. [Go to note 16]. It is important that there is a smooth transition from CAMHS to AMHS, and that child and adult services work together to guarantee adequate support for all. The children’s and mental health national service frameworks require LAs and health services to ensure there is no gap in provision, something that is stressed in the 2005 consultation, 'Youth matters'. [Go to note 74]. See the section here for more information on 'Youth matters' and the national service frameworks. The DH is currently funding a two-year project which aims to improve access to age appropriate services and transition to AMHS, as well as reducing age-related inequalities. [Go to note 75].
Children with learning disabilities
Please see the section here for a definition of learning disabilities. Children with learning disabilities are more likely to suffer from mental health problems: 40 per cent suffer from some form of mental disorder, and the incidence is even higher among those suffering from severe learning disabilities. The existing services are insufficient to provide adequate support for this group. Only one third of specialist CAMHS provide specific services for those with learning disabilities. [Go to note 7]. A service mapping exercise carried out by the charity YoungMinds also found gaps in services aimed at this group of children and young people.16 The children’s NSF outlines means of rectifying this shortfall.
Recommendations
- The provision of appropriate mental health services to 16 and 17 year olds must be improved. Young people should not be receiving adult care when they are not mature enough to do so. CAMHS should be extended to encompass this age group in all areas.
- Collaboration between CAMHS and AMHS must continue and improve to ensure a smooth transition to adult services.
- The provision of mental health services to looked after children and young people must be improved. CAMHS professionals and registered carers need training in order to support these groups in their particular needs.
- The current inadequacy of services for children and young people with learning disabilities must be addressed.
- The reforms outlined in the Child Poverty Review must be implemented to end child deprivation and therefore reduce risk factors for mental health problems.
- Current inequalities experienced by BME groups must be tackled:
- initiatives set out by NIMHE and DH must be properly implemented
- healthcare professionals and providers of CAMHS should receive training in cultural values and beliefs, to enable them to care for children and young people from BME backgrounds more effectively. Language translation services must be available
- racism within mental health services must be tackled and eliminated.
- Barriers to receiving care faced by asylum seeker and refugee children must be addressed.
- Actions must be taken to improve access to mental health services in young offender institutions, and to tackle the high rate of suicide among young offenders.