A fifth of children have mental health problems and one in 15 self-harms, but they are getting lost in a system with no idea what to do with them. It's time for a radical rethink of care pathways for young people, writes Andrew McCulloch
The 2004 national service framework for children and young people stated that within 10 years 'all children and young people who have mental health problems will have timely access to integrated, high-quality, multidisciplinary mental health services'.
On present performance this target is wholly unrealistic. And despite the vital importance of childhood mental health problems, we have to question whether it is even the correct target. After all, if a young person can successfully be treated by a non-specialist service such as a suitable counsellor, why would they need to be referred to a specialist service anyway?
All services for children need to take mental health on board, so that we can reserve specialist mental health services for those who need specialist care.
Each year around one in five children suffers from mental health problems. These require treatment in their own right - to relieve suffering and to support families and children's education - but treatment has a particularly vital role in trying to prevent problems in later life.
Research has suggested that over half of adults with a mental illness diagnosis in adulthood had mental health problems in childhood. This represents not only hundreds of thousands of suffering families, but also a burden on the wider economy, health service and sometimes the criminal justice system that could possibly have been avoided by earlier intervention.
It is estimated that a child with a conduct disorder, for example, will generate 10 times the costs to the public purse than a child with no significant problems by the time they are 28.
In addition, we have seen significant apparent increases in childhood mental health problems over the last 30 or 40 years, including a 70 per cent increase in depression and anxiety among teenagers. These increases now seem to have plateaued but at a high level - at least one in 15 young people currently self harms, for example.
A recent report from Unicef identified British children as the unhappiest in Europe while last month the Primary Review into education drew attention to the high levels of anxiety among primary schoolchildren as young as seven.
On this basis you could argue that the government's strategy of investing in and gearing up child and adolescent mental health services is sensible, especially as this has been coupled with a good framework for supporting families and early intervention in Every Child Matters.
More recent announcements from the Treasury and children, schools and families secretary Ed Balls about extra money for schools to work with mental health practitioners and the recognition of the need for more personalised services for struggling children are encouraging. Especially if they signal a recognition that mental health issues need to be considered by all services, not just those overseen by the Department of Health.
Nevertheless, much policy is fundamentally about making existing services work better and there has been little consideration of whether form has followed function, or of the views of parents and young people. We need to take stock of the direction we have been travelling in, and look to more effective ways of reaching young people and the problems they face.
At the Mental Health Foundation we have done a number of pieces of work over the last seven years to listen to the voices of young people and parents. Young people report either becoming lost in a system that seems unsure what to do with them, or being presented with services they find unsuitable or inaccessible. Similarly, parents report being offered services on a one-size-fits-all model, at the wrong time in the wrong place and sometimes using the wrong model.
The truth is that even with sustained investment, it would not be possible for specialist child and adolescent mental health services to provide for all young people's mental health needs. We know that some professionals' caseloads are already unsustainably high. Yet research shows that specialist services are only actually seeing 25 per cent of children with diagnosed mental health problems. It seems clear that they would never be able to tackle all diagnosed cases, let alone all other young people that need help but do not have a diagnosis, without unrealistically high levels of investment.
There has never been a comprehensive service model for children and young people's mental health. Historically, child and adolescent mental health services have been small scale, under-funded and under-resourced. They contain some fantastic staff and some pockets of excellent practice but they are rarely locked into the rest of the system in a comprehensive way. There are few other areas where we would expect all types and levels of morbidity to be dealt with by specialist services - such a model is likely to be inefficient and inaccessible.
Our research and service development work suggests that a more effective model would be one in which most troubled young people receive mental healthcare from universal services or primary care, in an environment in which they feel comfortable. This will mean training and investment in frontline services and professionals that care for children and young people, but are not themselves mental health specialists. In this way, universal services and primary care can fulfil their potential as primary mental health services, while specialist services can deal with the more complex cases and offer consultancy, training and support to others.
Whether we like it or not, children and young people will only engage with anything labelled 'mental health' with the greatest reluctance. Our Youth Crisis project that ran from 2002-07 looked in detail at the kind of services young people are looking for. Young people are quite clear they want accessible, generic drop-in centres, early intervention and mental health promotion. They prefer services delivered by the voluntary sector or that are separately designed for them.
Schools are ideally placed to carry out mental health promotion work themselves, rather than just relying on specialist services to come in and do the job for them. While some progress has been made in this area, more needs to be done to implement 'whole school', long-term programmes where the emphasis is on promoting good mental health. Anti-bullying strategies have also been shown to have a positive impact on young people's mental health, if applied correctly, but these have been rolled out patchily without always being informed by the best available evidence. In England we have been lagging behind best practice elsewhere in protecting children's mental health at school.
Primary care trusts need to give urgent priority to the development of generic 'one-stop shops' for young people, where they can gain easy access to mental health advice and support alongside help with other areas of their lives, from debt to sexual health or housing. The key advantage to this approach is that a young person can access help in an environment they find non-stigmatising, so that problems can be addressed early without the need for specialist services to get involved in many cases.
Such primary care centres would be especially helpful as sources of advice and places of referral for GPs, who are often the first point of contact between a young person and services. GPs do their best but are often singularly ill-equipped to deal with young people's mental health problems and many young people have reported dissatisfaction with GPs' skills and attitudes.
Voluntary sector organisations have proved to be particularly capable of providing this type of generic 'one-stop' service, as outlined in our recent report Listen Up! They are also in a position to guide young people through one of the most problematic 'gaps' in our healthcare system - the transition from child and adolescent to adult mental health services.
In some areas this gap is more than just a metaphor, with adult services only becoming available as many as three years after a young person loses access to child and adolescent mental health services. More attention needs to be given to the age group affected by this transition, 16 to 25-year-olds, as this is when young people begin to get lost to the system and mental health problems can become embedded.
We have a rich skill set to cope with young people's mental health problems and we are starting to have the money, too. But unless we use these assets more wisely, the challenges will often remain unmet, with profound consequences for our young people and the nation's future.
While the NHS is not solely responsible for meeting this challenge, its role needs urgent clarification. I am eagerly awaiting the release of the Children's Plan by the Department for Children, Schools and Families later in the year in the hope that it will bring a major policy shift, taking children and young people's mental health permanently into the mainstream.
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