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Topic on a Page - Mental Health & Emotional Wellbeing (Children & Young People)

Data
Sources:

Public Health England: Public Health Profiles

Data Profiles: Children's and Young People's Mental Health

Measuring mental wellbeing in children and young people 2015

Association for Young People's Health:

Key data on Young People 2017

NHS Digital:

Mental health of children and young people in England 2017

Supporting Information:

Kings Fund:

Mental Health

Mental Health Foundation:

Children and Young People

National Institute for Care and Health Excellence (NICE):

Pathway: Social and emotional wellbeing for children and young people overview

Depression in children and young people: identification and management [CG28] September 2017

Conduct disorders in children and young people

Depression in children and young people: identification and management [NG134] published June 2019

NHS England:

Mental Health: Children and Young People

NHS Evidence:

Mental Health Children and Young People

Post Traumatic Stress Disorders (PTSD)

Conduct Disorder

Emotional Disorders

Attention Deficit Hyperactivity Disorder (ADHD)

Hyperkinetic Disorder

Autism in Children

Eating Disorders

Anxiety Children

Depression in Children

Department of Health:

Government Response to the Health Select Committee's Inquiry into Suicide Prevention

Joseph Rowntree Foundation (JRF):

Children's Mental Health

Young People and Mental Health

Social Care Institute for Excellence (SCIE):

Children and Mental Health

Young People and Mental Health

Care Quality Commission (CQC):

Review of children and young people's mental health: Phase 1 report

House of Commons Library Briefing Papers:

Children and Young People's mental health – policy, CAHMS services, funding and education

Troubled Families Programme (England)

Local Government Association (LGA):

Ordinary residence guide: Determining local authority responsibilities under the Care Act and the Mental Health Act

Lincolnshire Partnership Foundation Trust (LPFT):

Healthy Minds Toolkit for Education Staff

Linked Topics:

Topic last reviewed: Apr-18

JSNA Topic: Mental Health & Emotional Wellbeing (Children & Young People)

Background

"Half of all mental health problems have been established by the age of 14, rising to 75% by age 24. One in ten children aged 5-16 has a diagnosable problem such as conduct disorder (6%), anxiety disorder (3%), attention deficit hyperactivity disorder (ADHD) (2%) or depression (2%). Children from low income families are at highest risk, three times that of those from the highest. Those with conduct disorder - persistent, disruptive and aggressive behaviour - are twice as likely to leave school without any qualifications, three times more likely to become a teenage parent, four times more likely to become dependent on drugs and twenty times more likely to end up in prison." Source: Five Year Forward View for Mental Health (2016)

National Mental Health charity Young Minds explains that mental health affects all aspects of a child's development including their cognitive abilities, their social skills as well their emotional wellbeing. With good mental health, children and young people do better in every way. They enjoy their childhoods, are able to deal with stress and difficult times, are able to learn better, do better at school, navigate the online world they grew up in so they benefit from it and enjoy friendships and new experiences. Childhood and teenage years are when mental health is developed and patterns are set for the future. A child with good mental health is much more likely to have good mental health as an adult, and to be able to take on adult responsibilities and fulfil their potential.

One in ten young people have a mental health problem. That’s the equivalent of three in every classroom. NHS Mental Health Services Data shows that nationally; of the 1,168, 409 people in contact with mental health services at the end of January 2018, 269,425 (23.1%) were aged under-19.

Mental health problems in children and young people cause distress and can have wide-ranging effects; there are also known associations between mental health problems in childhood and adolescence and poorer physical health, as well as the possibility of developing at-risk health behaviours. Young people with an emotional disorder are more likely to smoke, drink and use drugs than other children; more likely to have time off school and fall behind in their education; and are more likely to earn less money as adults or to experience unemployment. As well as the personal cost, the estimated long term cost to the economy of mental health problems is £105bn a year.

Despite this significant impact, children and young people face substantial difficulties in getting help. In response to these issues, the government set out clear direction on how to make it easier for children and young people to access high quality mental health care when they need it in its strategy document Future in Mind (April 2015). In Lincolnshire, there is a focus on addressing children and young people’s emotional and mental health concerns at an early stage so they do not escalate into more serious mental health conditions.

Context

National Strategies, Policies & Guidance

Future in Mind (2015)
In March 2015, the Government published Future in Mind, a national taskforce report into children and young people's mental health. The taskforce considered ways to make it easier for children, young people, parents and carers to access help and support when needed and how to improve the way children and young people's mental health services are organised, commissioned and provided. The taskforce made a series of recommendations for transformation clustered around five key themes:

  • Promoting resilience, prevention and early intervention: acting early to prevent harm, investing in early years and building resilience through to childhood
  • Improving access to effective support – a system without tiers: changing the way services are delivered to be built around the needs of children, young people and families
  • Care for the most vulnerable: developing a flexible, integrated system without barriers
  • Accountability and transparency: developing clear commissioning arrangements across partners with identified leads
  • Developing the workforce: ensuring everyone who works with children, young people and their families is excellent in their practice and is delivering evidence based care

Five Year Forward View for Mental Health (2016)
Published by the NHS this report sets out that children and young people are a priority group for mental health promotion and prevention, and called for the Future in Mind recommendations to be implemented in full. The report stated that early intervention and quick access to good quality care is vital – especially for children and young people. Waiting times should be substantially reduced, significant inequalities in access should be addressed and support should be offered while people are waiting for care.

The aims of Five Year Forward are that by 2020/21, at least 70,000 more children and young people should have access to high-quality mental health care when they need it. Placing greater emphasis on prevention, early identification and evidence-based care; NHS England declared that they will continue to work with partners to fund and implement the whole system approach described in Future in Mind, building capacity and capability across the system so that by 2020/21 we will secure measurable improvements in children and young people’s mental health outcomes.

Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT):
CYP IAPT is a service transformation programme delivered by NHS England that aims to improve existing Child and Adolescent Mental Health Services (CAMHS) working in the community.

The programme works to transform existing services provided by the NHS and partners from local authority and third sector organisations that together form local area CAMHS Partnerships. The programme aims to create, across staff and services, a culture of full collaboration between child, young person and/or their parent or carer.

Local Strategies & Plans

Key agencies in Lincolnshire have come together to plan, develop and design a single approach to transform mental health and wellbeing services for Lincolnshire Children and Young People. This Transformation Plan is consistent with the strategic outlook described in the multi-agency led Lincolnshire Crisis Care Concordat.

A Mental Illness Health Needs Assessment for Lincolnshire was produced in August 2016 with the aim of identifying the mental ill health needs of children, adolescents, and adults living in the County.

The mental illness health needs assessment has been developed to inform the development of a Suicide Prevention Lincolnshire Local Action Plan 2016.

The Lincolnshire All-Age Autism Strategy is aligned with the National Autism Strategy Fulfilling and Rewarding Lives (2010).

The Lincolnshire Transforming Care Plan "Building the Right Support" 2016

What is the picture in Lincolnshire

What the data is telling us

Public Health England (PHE) publishes the Children and Young People's Mental Health and Wellbeing profiles (YPMHW) with a range of indicators around needs, protective factors, prevention and finance. The full profiles can be accessed on the website and the key findings from the Lincolnshire profiles are summarised below.

The estimated prevalence rates are provided in the absence of an alternative. To calculate those, the prevalence given in the ONS survey Mental Health of Children and Young People in Great Britain (2014) were applied to the number of children aged 5-16 resident in the area stratified by age, sex and socio-economic classification.

Based on the estimates the following number of children aged 5-16 in Lincolnshire would be expected to experience mental health issues in 2015 (numbers are rounded to the nearest 100):

  • Mental health disorders – around 8,800 (9.4%),
  • Emotional disorders – around 3,400 (3.6%),
  • Conduct disorders – around 5,300 (5.7%),
  • Hyperkinetic disorders – around 1,400 (1.5%).

The results should be interpreted with caution and consideration of local data and intelligence.

In the school year 2016/17 there were over two thousand pupils in Lincolnshire schools with a statement of special educational needs (SEN) where primary need is social, emotional and mental health. The rates of social, emotional and mental health needs in Lincolnshire school are below the national levels (2.13% of school age children compared to 2.33% in England).

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) is used to measure wellbeing in 15 year olds. The survey consists of 14 positively worded items, which measure aspects of feeling well and functioning well such as feeling relaxed and optimistic as well as ability to handle problems and autonomy. Participants were asked to rate how often they felt like each of the 14 statements (on a scale from 1 to 5). Overall score for an individual is a sum of the points from all the statements and average (mean) WEMWBS scores are reported to local authorities. The mean score for Lincolnshire (47.6 in 2014/15) was slightly lower than the England results. (Source: PHE CYPMHW)

The What About YOUth? (WAY) survey was established to collect robust local authority (LA) level data on a range of health behaviours amongst 15 year olds. During the school year 2014/15 the responses from Lincolnshire young people were in line with the national level for many aspects affecting health and wellbeing (like bullying or involvement in risky behaviours like alcohol or drug taking). In Lincolnshire, the proportion of 15 year olds who reported having been bullied in the past couple of months was slightly greater than nationally (56.2% compared to 55% in England). Whilst the proportion that reported 3 or more risky behaviours was 16.9% compared to 15.9% in England. At the same time, the greater proportion of pupils reported positive satisfaction with life in Lincolnshire than nationally: 66.7% compared to 63.8% in England. Source: PHE, Health behaviours in young people

In the financial year 2016/17 there were 99 hospital admissions of Lincolnshire residents aged under 18 due to mental health conditions; these include acute Paediatric and CAMHS in-patient beds. The measure includes all first finished episodes for all persons aged 0 to 17 years with primary diagnosis of mental and behavioural disorders (ICD10 codes F00 to F99). The number of admissions recorded in 2016/17 equates to the rate of 68.9 per 100,000 population; lower than the national rate of 81.5. For 2016-17, there were 14 admissions for 0-17 year olds across Lincolnshire for eating disorders, this equates to a rate of 9.7 per 100,000 (Source: PHE, Overview of child health)

In the financial year 2016/17 there were 237 hospital admissions due to self-harm in people aged 10 to 19 in Lincolnshire. Analysis of the admission rates show that the self-harm admissions in children aged 10-14 have decreased in Lincolnshire from 296 per 100,000 population in 2015/16 to 172.4 in 2016/17. Whereas the national rates have not lowered and compared to Lincolnshire are significantly higher: 230 per 100,000 population. In Lincolnshire the self-harm admission rate in people aged 15-19 was 578.2 per 100,000 population in 2015/16 and has reduced to 410.7 for 2016/17. The national picture remains relatively the same for 2016/17 at 658; Lincolnshire being lower again. (Source: PHE CYPMHW)

There is local intelligence providing more insight into the issues of self-harm in Lincolnshire. The report Suicide Topic and Self Harm in Lincolnshire, 2017 Annual Review highlights that self-harm affects mainly younger people. It shows that the hospital admissions due to self-harm are highest in people aged 15-19 out of all the age groups. In the financial year 2015/16, 39% of all the admissions due to self-harm affected people aged under 20, and rates for 15 year olds were especially high. In the youngest age groups (10-19) four out of five admissions were for females.

According to the 2014 Adult Psychiatric Morbidity Survey, the profile of people who self-harm is very different in terms of age and sex from that of people who take their own life, and the great majority of people who engage in these behaviours do not go on to die by suicide. In Lincolnshire, there were 6 suicide deaths of a person aged between 15 and 19 registered during the calendar years 2014 to 2016. Majority of those were male deaths. (Suicide Topic and Self Harm in Lincolnshire, 2017 Annual Review)

Transforming Care in Lincolnshire
In October 2015, NHS England published 'Building the right support', a national programme to develop community services for people with a learning disability and/or autism. This programme known as ‘Transforming Care’ is a national programme to change how we deliver and commission services to children, young people and adults with learning disabilities and/or autism, including those with mental health condition or challenging behaviours. ‘Transforming Care’ aims to transform the way services are commissioned and delivered to stop people being referred to hospital inappropriately, provide the right model of care, and drive up the quality of care and support for people with learning disabilities and/or autism.

In response to the national programme, the Lincolnshire Transforming Care Partnership (TCP) was established to drive local transformation. The Partnership was formed in January 2016 bringing together Lincolnshire County Council and the four local CCGs – South West Lincolnshire CCG, South Lincolnshire CCG, Lincolnshire West CCG and Lincolnshire East CCG. Each local TCP were required to develop a Transformation Plan which describes the local vision for improving outcomes with a focus on more joined-up community based support and a reduced reliance on in-patient beds (non-secure, low and medium secure) which may include the closure of some in-patient facilities.

The Transforming Care plan will continue to be developed in partnership with people with a learning disability and / or autism, their families and carers to make sure the plans meet their needs and continue to drive up quality of care.

The most recent school census data available shows there are 10,137 children and young people that have special educational needs relating to either a learning difficulty, learning disability or emotional and/or behavioural problem in Lincolnshire schools; there are 438 children and young people whose learning difficulty or disability is either severe or profound and 1,332 with autistic spectrum disorder.

There are 138 Lincolnshire children and young people with either; learning disabilities, autistic spectrum disorder or emotional and/or behavioural problem in either independent or non-maintained schools, of which 41 are in the county and 28 are in counties bordering Lincolnshire.

Children’s and Adult Services are currently working together to redesign the support provided to young people in transition. The intention is to identify dedicated resources that will be responsible for:

  • Identifying young people from age 14 that are likely to require additional support, particularly where their current placements are for 52 weeks;
  • Supporting service users, families and carers to ensure that the most appropriate services are accessible in order to meet their needs;
  • Working with Children’s Services and adult mental health to ensure a smooth transition for young people that are accessing CAMHS;
  • Working with Adult Social Care, where young people are in out of county placements, to identify suitable, community supported living for those that are not able to live in the family home.

Trends

The PHE Overview of Child Health shows the level of hospital admissions for mental health conditions since 2010/11. Nationally, the rate has been decreasing gradually from 109.4 per 100,000 population in 2010/11 to 81.5 in 2016/17. Whereas in Lincolnshire the rate for 2010/11 being significantly lower than the national figure at 68.2 per 100,000 population, rose steadily to a peak of 94.8 for 2015/16, but has decreased to 68.9 for 2016/17. The decrease in hospital admissions is a positive trend, but it does not provide full picture of mental health prevalence or it impact on other services like A&E, primary care or specialist mental health provision. (Source: PHE CYPMHW)

The admissions for self-harm in children and young people increased between 2011/12 and 2015/16 in Lincolnshire and nationally, with both local and national rates having similar values. However, whereas nationally the rate continued to rise from 87.3 per 100,000 in 2015/16 to 888 per 100,000 in 2016/17. The rates decreased in Lincolnshire over the same period from 874.2 per 100,000 in 2015/16 to 583.1 per 100,000 in 2016/17. Further analysis shows that Lincolnshire rates for 10 to 14 year olds and 15 to 19 year olds are significantly lower than national average. (Source: PHE CYPMHW)

Key Inequalities

Social disadvantage and adversity increase the risk of developing mental health problems. According to the Annual Report of the Chief Medical Officer 2013, children and young people from the poorest households are three times more likely to have a mental health problem than those growing up in better-off homes.

The percentage of children in low income families (children living in families in receipt of out of work benefits or tax credits where their reported income is less than 60% median income) were lower in Lincolnshire than nationally: 15.2% in Lincolnshire compared to 16.6% in England in 2015. There are however pockets within Lincolnshire where percentage of children in low income families exceeds 40%. Those areas are concentrated along the east coast and around Gainsborough. For more details please see HMRC Personal tax credits: children in low-income families local measure: 2015 snapshot at 31 August 2015.

Research by the Mental Health Foundation has identified certain risk factors that make some children and young people more likely to experience problems than other children. These include:

  • having a long-term physical illness
  • having a parent who has had mental health problems, problems with alcohol or has been in trouble with the law
  • experiencing the death of someone close to them
  • having parents who separate or divorce
  • having been severely bullied
  • having been physically or sexually abused
  • living in poverty or being homeless
  • experiencing discrimination, perhaps because of their race, sexuality or religion
  • acting as a carer for a relative, taking on adult responsibilities
  • having long-standing educational difficulties.

Local evidence exists to estimate the level of some of those risk factors. For example, 16.9% of 15 year olds in Lincolnshire are reported as having a long-term illness, disability or medical condition diagnosed by a doctor, compared to 14.1% in England. The What About YOUth (WAY) survey, 2014/15 showed that 56.2% of young people in Lincolnshire reported that they had experienced bullying, similar to the level for England, whilst this figure is high at first glance, further analysis is needed to offset this data against the relevant "Protective Factors" such as resilience, support network, education and existing mental health, to ascertain if mental health conditions can be attributed.

In Lincolnshire in 2016, there were 2720 children and young people identifies as 'in need' due to abuse or neglect. This equates to the rate of 191.3 per 10,000 people aged <18, that is higher than England's rate of 171 per 10,000.

Housing, educational attainment, alcohol, drugs and adult mental health issues have JNSA topics dedicated to the specific subjects.

The NSPCC paper Achieving Emotional Wellbeing for Looked After Children reports that almost three quarters (72%) of children in residential care experience some form of emotional and mental health problem.

In Lincolnshire, 625 were recorded as looked after in March 2016. This equates to the rate of 43.9 per 10,000 people aged under 18. That is lower than England's rate of 60.31 per 10,000. Emotional wellbeing of looked after children is measured through a strengths and difficulties questionnaire (SDQ). A higher score indicates greater difficulties (a score of under 14 is considered normal, 14-16 is borderline cause for concern and 17 or over is a cause for concern). An average difficulties score of looked after children aged 5-16 in Lincolnshire was 15.1 in 2015/16 which was slightly higher than England score of 14. (Source: PHE CYPMHW)

Inequalities in accessing services for those children and young people who are Looked After and those receiving support from Youth Offending Services have been considered as a priority in the transformation of the CAMHS service and these children and young people are able to access services in an equitable and non-stigmatising way; they have also been provided with a number of additional supportive measures such as specific reduced waiting times.

The total number of referrals to Lincolnshire CAMHS between April 2016 and March 2017 was 4,808. This number does not represent single individual cases but includes some individuals with more than one condition requiring CAMHS intervention, or repeat referrals during the year.

Current Activity & Services

In September 2015 following a review of the CAMHS service, involving over 55 stakeholder groups, and in accordance with Future in Mind recommendations, Lincolnshire collaboratively developed with the CCGs the Lincolnshire Local Transformation Plan which set out a single approach to transform mental health and wellbeing services for Lincolnshire Children and Young People, consistent with the strategic outlook described in the multi-agency led Lincolnshire Crisis Care Concordat. This plan set out multiple priorities for service provision and ambitious aspirations for future provision that required radical service transformation and ongoing joint working across agencies including Schools and Health and also Service Users. A new service delivery model was developed and Commissioners were successful in securing an additional £1.4 million through transformation funds to deliver the new model from April 4th 2016.
Lincolnshire Child and Adolescent Mental Health Service

Transformed mental health services for children and young people in Lincolnshire are no longer delivered according to tiers and are delivered through:

  • A Single Point of Access
  • Core CAMHS; an integrated CAMHS provision delivering evidenced based pathways and focused on outcomes
  • Crisis Intervention and Home Treatment service available 24 hours a day, 7 days a week
  • A community based Eating Disorder Service known as CAMHS EDS
  • Support to vulnerable groups including Young People with a Learning Disability
  • Care and support through transition to adult services if appropriate
  • Support to Universal Services such as education and early help practitioners including:
    • A Professional Advice Line
    • Consultation Clinics
    • A full programme of training for staff working in Universal Services
    • The development of self-help psychosocial education materials
    • The development of a directory of the local CAMH Services and other potential services that may be beneficial to the Young Person

Core CAMHS
Core CAMHS deliver care through a number of evidenced based pathways such as depression, anxiety, PTSD and trauma, self-harm etc.

There are a wide range of interventions offered, including access to self-help and groups interventions.

CAMHS Crisis & Home Treatment Services (C&HTS)
The C&HTS provides crisis response and crisis support via intensive home treatment and aims to avoid admission of children and young people to inpatient services. Where inpatient services have been appropriate, the service facilitates early discharge.

Young People’s Eating Disorder Service
The Young Person’s Eating Disorder Service (EDS), implements a NICE Guidance eating disorder pathway including Anorexia Nervosa, Bulimia, Binge Eating and Atypical Eating Disorders. Working in partnership with the C&HTS, 24 hour delivery of care is provided.

Experts by Experience
Peer Support Workers have been employed by the CAMH service; they are young people who have lived experience of poor mental health and emotional wellbeing challenges and are using their own experience to help others. “Through peer support services we can offer each other relationships that are respectful of our experiences, our ways of communicating, and how we have learned to tell our story. We can challenge each other to both face and to move beyond these stories and patterns. We can build new community norms that replace the illness environments that have kept us trapped,” (Source: Mead S. 2003)

Additional support for specific groups of Children and Young People who have additional needs such as children who are: looked after, adopted, have a learning disability and a mental health problem and those within youth offending services.

CAMHS User Feedback
Children and Young People who access CAMHS services and their parents/carers provide user feedback through service questionnaires. Overall satisfaction rates are good; 93% over 2016-17. Issues arising from negative returns are fed back into the continuous improvement plan for the service.

Lincolnshire Educational Psychology Service
The Educational Psychology Team employs a small number of educational psychologists and is part of the Special Educational Needs and Disability Service of Children's Services. Educational psychologists work with others to achieve positive outcomes for children and young people.

An educational psychologist usually becomes involved with a child or young person when those working with the child in the pre-school setting or school feel puzzled about how to:

  • continue to enhance the child’s learning
  • manage the child’s behaviour more effectively

Educational psychologists will work in partnership with other key adults in order to plan appropriate interventions to support the child.

Drop in sessions and bookable consultations
In some districts the educational psychologists may organise ‘drop in sessions’ or ‘bookable consultations’ at a local school or Children’s Centre. These usually occur on a monthly basis and give parents and carers an opportunity to book an appointment to discuss their concerns with an educational psychologist.

Telephone helpline
For those parents who are not able to access an educational psychologist, or who wish to talk through a particular issue around their child’s development or educational progress, a telephone helpline is available.

Emotional Wellbeing Support

Emotional Wellbeing and Mental Health Online Portal
Following engagement with relevant stakeholder groups in 2016/17, Lincolnshire County Council identified the need for an online portal where young people would have access to information and advice in one place, which can help support them when experiencing emotional wellbeing, mental health or behavioural concerns.

The Emotional Wellbeing and Mental Health website was set up and went live in October 2017. The information provided within this pathway is designed to help families of children and young people experiencing emotional wellbeing, mental health or behaviour concerns and the professionals working with them.

Young people in Lincolnshire now have a single point of access to information and advice about local and national services that can offer support for common emotional wellbeing, behaviour and mental health concerns. This will also help families of children and young people experiencing these concerns and the professionals working with them to access the right services at the right time.

Information is available about a wide range of common emotional wellbeing, behaviour and mental health concerns, including:

  • anxiety and stress
  • body image
  • bullying
  • depression
  • eating concerns
  • exam stress
  • gender identity
  • phobias
  • self-harm

Healthy Minds Lincolnshire
From October 2017, to further support early intervention and prevent escalation when children and young people in Lincolnshire are experiencing emotional wellbeing concerns, that do not require a clinical intervention, such as CAMHS, the Healthy Minds Lincolnshire is being delivered by Lincolnshire Partnership NHS Foundation Trust through a partnership agreement on behalf of Lincolnshire County Council, supported by the Lincolnshire Learning Partnership.

Healthy Minds Lincolnshire provides emotional wellbeing support to children and young people up to 19 years old (25 if special educational needs/disability or leaving care). Supporting with a range of emotional wellbeing concerns e.g. exam stress, worries, low mood, low body image, self-harm, relationship difficulties, low self-confidence.

The service offers:

  • Cognitive behavioural therapy (CBT) techniques, which are designed to help young people think about things differently and learn to cope in a more positive way.
  • Support and advice to parents and carers.
  • Bespoke training to education and children’s services professionals designed to build confidence in dealing with emotional wellbeing issues and providing a toolkit to support children and young people’s needs.

Children and young people are supported by the service at school and where this is not possible they can be seen at home or in a suitable local venue such as GP surgery or children’s centre.

Primarily referrals are made by a trusted professional known to the child and family, however, if a young person does not feel that they can talk to a professional, they can self-refer by contacting the advice line.

Working with partners to promote resilience

The 'Inclusive Lincolnshire' Strategy
"All pupils and schools in Lincolnshire are our collective responsibility where every pupil and school is known, valued and supported to achieve in all areas."

The 'Inclusive Lincolnshire' Strategy recognises that there is no single solution to reduce the number of pupil exclusions and outlines synergistic change across schools, the Local Authority and providers, in order to achieve better outcomes for Lincolnshire pupils and schools. The strategy describes the call for change in the way in which pupils with challenging behaviour are supported and the need to shift away from specialist and statutory intervention to earlier help and support. Ensuring that capacity and skills are aligned at all levels, and the thresholds between each level are clearly understood and implemented.

To support the Strategy the Lincolnshire County Council Inclusion Toolkit has been developed for use in schools, to share effective practice in relation to meeting social and emotional wellbeing; enhancing social interactions and creating inclusive cultures. The aim is to inform the teaching of children and young people about how to interact with each other effectively; increasing inclusion and learning, and links to the SEND Code of Practice: 0 to 25 years (2015) which makes it clear that underlying needs giving rise to behaviour must be assessed and addressed.

The intention is that the sharing of good practice will ensure that all schools have access to evidence-based examples of how to meet the needs of young people and are clear about reasonable expectations of schools.

The Toolkit is a resource that can be used in schools to support reflective practice and support strategic development. The toolkit can be used to aid colleagues in schools in the production of SEN Offers and Provision Maps for student need. When individual (or group) intervention takes place the toolkit may be used to inform the writing of Pastoral Support Plans (PSPs) for young people.

Behaviour Outreach Support Services (BOSS)
In order to support those children and young people who are displaying social and emotional difficulties and challenging behaviour, but where a CAMHS intervention is not appropriate, from September 2016, Lincolnshire County Council commissioned Family Action to deliver a county wide Behaviour Outreach Support Services (BOSS) that is available for all Maintained Mainstream Schools and Academies in Lincolnshire. The aim is to support the ability of school staff to positively manage pupils displaying behaviour that challenges. The primary focus of the BOSS is on "early intervention" and "prevention of escalation" of pupils' behaviour difficulties and support aiming at "positive outcomes for pupils"; allowing pupils to stay in mainstream.

The Service key principles are:

  • To identify the needs of the individual pupils and not just respond to the diagnosis label
  • Pupils to attend educational maintained provision within their own communities, wherever appropriate
  • To invest in approaches and policies which are successful in identifying and meeting the needs of pupils with behaviour that challenges them
  • Retain skills, knowledge and expertise within the School setting to aid resilience and sustainability
  • Identify where lessons have been learnt and implement these across the service where appropriate

The core offer of the BOSS service consists of:

Targeted Outreach Support: Provision of locality based direct intervention and support for pupils, individually or in small groups, focussed on pupils at risk of exclusion, upon referrals from Schools. This support will develop the skills of the school staff to better meet the need.

Intensive Intervention: Referral to flexible bespoke pre-exclusion placements in specialist provision or alternative pathways. These are time-limited interventions with pupils at the point of permanent exclusion. Schools will need to have accessed the targeted outreach support.

The Service also:

  • Forms part of the Universal support for Children and Young People across Lincolnshire
  • Contributes to the All Age Autism Strategy
  • Supports at identified key transition stages including progression from Primary to Secondary School and from Children's Services to Adult Services and
  • Supports pupils through early help arrangements.

Children and Young People living with domestic abuse
Research has shown that children and teenagers living with domestic abuse and violence can have very different reactions to the situation. They create their own views and coping strategies to manage the situation – sometimes resorting to drugs and alcohol and self-harm.

By providing counselling and therapy for a child who is living with domestic violence and abuse the child feels safer, learns that violence is not their fault, learns that violence is not the best way to resolve problems, helps them to feel cared for and understood, helps them feel that someone listens to them and that it is ok to talk about feelings. By denying the situation it makes children believe that violence is normal, blame themselves for the situation, and feel lonely, confused and isolated.

In Lincolnshire, Lincolnshire County Council commissions Lincolnshire Partnership Foundation Trust to deliver Child and Adolescent Mental Health Services. Within the detailed service specification there is provision for those children and young people who are suffering from the impact of Post-Traumatic Stress Disorder (PTSD) and Trauma, which may include domestic abuse.

Child or Young Person's Presentation:

  • As a result of a single trauma or familial or extra familial abuse, the child may display repetitive, intrusive memories, thoughts, images and emotions during wakefulness and trauma-related nightmares during sleep
  • Where symptoms have been present for more than 3 months after a trauma and could include hyper-vigilance, avoidance, flashbacks, or a marked increase in unexplained temper tantrums or episodes of other distress
  • Complex presentations as a result of multiple or historical abuse may involve early life disruption and an unstable environment, the young person may exhibit re-experiencing, avoidance /numbing

Support from CAMHS:

  • Psychological therapies in line with NICE guidance that address PTSD and Trauma
  • Therapeutic interventions to address other conditions that may emerge when children and young people are experiencing the impact of domestic violence, such as anxiety disorder, depression, self-harm etc.
  • Working in partnership with other agencies, such as Social Care, Health, Education and Early Help to deliver services in line with Working Together to Safeguard Children, CAMHS staff attend child in need and child protection meetings regularly, including those where domestic abuse is a factor
  • Working with children and young people being supported with domestic abuse, CAMHS staff complete Early Help Assessments, initiate Team Around the Child and hold Lead Professional role, where appropriate. See guidance for Early Help in the LSCB – Multi-agency Domestic Abuse Protocol.

Unmet Needs & Gaps

Upskilling the workforce including Universal services
The children and young people's mental health 'system' is much broader than the specialist CAMHS services, encompassing support offered by GPs, schools, community health centres and local hospitals. Thus any consideration of the CAMHS workforce needs to include an understanding of the appropriate role of universal staff such as teachers. All professionals who are in trusted roles of responsibility with young people require basic understanding of mental health needs and the local offer of support. This is currently not in place and many teachers, youth workers, GPs, social workers and NHS staff struggle to know how to identify and help young people in their care with mental health needs. This leads to the high numbers of referrals to specialist services, many of which are considered by these services as 'inappropriate" and sent back to the referrer. There is often a disconnect between the attitudes of staff within universal services and those within specialist CAMHS as to what constitutes an appropriate referral. This is due to the different languages, organisational cultures, training and perspectives of staff in these different parts of the system. Such barriers can get in the way of a smooth pathway for young people in need of support. Future in Mind called for joint training to be provided for teachers and CAMHS staff and further, training of universal staff such as teachers in techniques such as mental health first aid. In partnership with LSCB, LPFT is delivering multi-agency mental health training, specifically in regards to children and young people to universal services, including education.

Transition to Adult Mental Health
Given that mental health problems often emerge in late adolescence, for those young people who are accessing mental health support it is imperative that they receive continuity of care; if young people lose touch with services or have their care disrupted at a crucial point, there is a risk that this could have a significant impact on their future health and wellbeing.

Acknowledging this crucial point in mental health care, Lincolnshire services are working together to:

  • Develop and support effective transition protocols (signed off by the Lincolnshire Transitions Service Governance Board) to facilitate a child or young person’s move to Adult Mental Health Services or to a different service, to ensure they do not experience a break in care or get lost in the system
  • Ensure that transition takes place at a time that is right for the child and young person and they are fully informed through-out the process.
  • Ensure that Home Treatment/ Crisis Resolution services have established relationships and protocols to ensure effective bed management with inpatient arrangements and suppliers.

Transition protocols are being co-designed with other appropriate services (in line with the NHSE National Specification for Transitions from CAMHS Guidance 2015). The protocols should include processes for advanced planning in order to identify early, those young people who may require transition to other services. Transition is a process undertaken over time. It may include, but is more than, a planned transfer to an adult service. Primary care services must be included to achieve streamlined, efficient and effective transition for all patients. This is, particularly true for those patients needing a range of health and social care services during their transition and beyond.

A plan of flexible support for the young person will determine what is required for effective transition out of the service – this will include securing relevant networks and on-going universal provision as required. Those young people who do not meet the threshold for adult services may be best supported in primary care, or in other agencies, or they may be discharged with a clear plan, which tells them and their family what to do if they become unwell.

Reducing Stigma
The stigma associated with mental health problems can prevent young people accessing services quickly. There is an average delay of ten years between the time that young people first experience the symptoms of a mental health problem and when they receive help. Only a small proportion of this time is after referral to services. Therefore, in order to reduce this delay, there must be a focus on tackling stigma and raising awareness of mental health problems, not just improving waiting times within.

The Time to Change initiative has made strides to tackle stigma. Since the start of the campaign in 2007 there has been an 8.3% improvement in public attitudes towards mental health. An institute of Psychiatry evaluation of the campaign found a clear and consistent link between awareness of the campaign and changes in attitude.

Nevertheless, stigma associated with mental health, and accessing mental health services remains a significant barrier to the identification and early treatment of young people with mental health problems.

Social Media and Young People's Mental Health
Over the past two decades, there has been a sharp increase in children’s use of digital media. The wide availability of mobile phones, tablets and gaming has fundamentally reshaped young people’s relationships with the online world. We know that children are now spending more time in front of screens; messaging on Apps, creating their own blogs, consuming the content of their peers who are broadcasting their own YouTube channels. The evidence outlined in the Resilience for the Digital World review by Ecorys demonstrates the very real impact that the digital world can have on young people’s mental health and wellbeing.

The heightened anxiety that social media use can bring is affecting the mood and sleep of many children. The widened and more immediate access to age-inappropriate and/or distressing content is also having a knock-on impact on young people’s self-esteem and perceptions about their bodies. Similarly, bullying has followed many young people from the playground and classroom to their online profiles. This means that not only can the perpetrators continue their harassment online, but also this behaviour can attract additional bullying from strangers.

That said; the review also highlights the important role that the web plays in supporting young people to share their concerns about the stresses they face in the everyday life, as a distraction from traumatic events, and a space to explore their identity and network with others managing a mental health condition. Young people tell us that digital media can result in positive benefits, such as building a sense of belonging, keeping in touch with a group of friends that share similar values and providing comfort and support to their peers.

Social Media and how it is impacting on children and young people's mental health is increasingly on the agenda and strategies to manage this effectively are being developed:

  • Schools are developing E-safety as part of the curriculum
  • Engaging, accessible and age-appropriate information about mental health on the CAMHS website and apps are being developed, so they can help themselves and each other if they are struggling.
  • Teachers, social workers and professionals working in Child and Adolescent Mental Health Services need to be upskilled up to understand young people’s experience of the online world and how to help them to build their digital resilience

Local Views & Insights

The Lincolnshire Participation Strategy and Charter has been developed in partnership through Lincolnshire Participation Action Group (LPAG), a cross-sector group of practitioners working with children. The Strategy provides a framework for the participation (in decision-making) of children in Lincolnshire. Listening to and acting on the views of children is essential for the development of effective services. LPAG and Children’s Services ask that all organisations (and teams within larger organisations) sign up and make this commitment.

The Charter has four key principles of Participation:

  • Children have equal opportunity to be involved
  • Children have equal opportunity to be involved
  • The involvement of Children is a visible commitment which is properly resourced
  • The involvement of children is monitored, evaluated, reported and improved.

Risks of not doing something

  • As well as the impact on the individual child and family, mental health problems in children and young people result in an increased cost to the public purse and to wider society. Those with acute conduct disorder incur substantial costs above those with some conduct problems, but not conduct disorder. A study, What works for whom (2nd ed.) by Friedli and Parsonage estimated additional lifetime costs of around £150,000 per case – or around £5.3bn for a single cohort of children in the UK. Costs relating to crime are the largest component, accounting for 71% of the total, followed by costs resulting from mental illness in adulthood (13%) and differences in lifetime earnings (7%).
  • In straitened financial times, ensuring best value for the taxpayer investment is vital. The Centre for Mental Health in its report 'Investing in children's mental health' has analysed the return on investment from addressing the four common disorders in childhood. For instance, it has been estimated that children with early conduct disorder are ten times more costly to the public sector by the age of 28 than other children.
  • We need to value the importance of recognising and promoting good mental health and wellbeing in all people, not just focusing on mental illness and diagnosis. There is evidence that supporting families and carers, building resilience through childhood to adulthood and supporting self-care reduces the burden of mental and physical ill health over the whole life course, reducing the cost of future interventions, improving economic growth and reducing health inequalities.

What is coming on the horizon?

Development of accessible information for service users and professionals to understand the specific needs of children and young people in regards to mental health and emotional wellbeing, including development of a dedicated CAMHS website, App and leaflets, driven by consultation with children, young people, parents and carers.

What should we be doing next?

  • A review of all services that promote mental health and emotional wellbeing including a full CAMHS service review to be carried out in 2018
  • Working with Schools to raise awareness of mental health issues, train teaching staff on early signs of MH and reducing stigma amongst the CYP themselves
  • Delivering a multi-agency workforce training plan so that all staff feel confident in working with children and young people's emotional wellbeing and mental health. Children often disclose their worries to a non-specialist member of staff and it's important that staff and parents feel confident working with children and young people's emotional wellbeing and mental health.
  • Delivering a multi-agency workforce training plan so that all staff feel confident in working with children and young people's emotional wellbeing and mental health. Children often disclose their worries to a non-specialist member of staff and it's important that staff and parents feel confident working with children and young people's emotional wellbeing and mental health.
  • Utilise a wider breadth of service user groups that involve engagement with children and young people. Young Inspectors and further service user groups identified through consultation
  • Gap needs analysis

Regional and national engagement
Increasing involvement with regional and national groups to learn and share best practice and link in to joint working opportunities or reciprocal arrangements, LPFT and LCC are contributors to the following working and steering groups:

  • Lincolnshire Future in Mind Steering Group
  • Lincolnshire Suicide Prevention Steering Group
  • East Midlands CYP Mental Health Future in Mind Steering Group
  • East Midlands Children's Clinical Steering Group
  • East Midlands Crisis Learning Network
  • East Midlands Eating Disorder Network
  • East Midlands Regional CYP IAPT Collaborative

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk