1.The Mental Health Foundation is pleased to have the opportunity to respond to this consultation on the first 1,000 days of a child’s life. As a public mental health organisation centred on preventing mental ill health, our response will take a life course approach and explore how best to protect and improve emotional and social capabilities and development for early years.
2.In working to reduce the prevalence and the distress caused by mental health problems, across the life course, but recognise that to make the biggest difference, we need to start at the earliest point, focusing a good deal on childhood development and early years. Recent statistics show the total number ofCAMHS referrals to treatment in Wales have doubled between April 2010 (1,204) and July 2014 (2,342), with young people awaiting outpatient’s treatment at the highest numbers (2,410) compared to adults (1,291) and those in later life (682)[1]. The delay in identifying children at risk and providing effective early intervention means that many young people enter adulthood with untreated conditions, and for others, symptoms only develop once they have reached adulthood. Prioritising children and their families is therefore a worthwhile priority investment.
3.We call for universal and targeted programmes to provide support for families and parents. Our response will draw on evidence and knowledge generated by the Mental Health Foundation and is in line with the recommendations outlined in ‘The Early Years: Foundations for Life, Health and Learning[2]’, and 'Early Intervention: The Next Steps'[3]. As a member of the Maternal Mental Health Alliance[4], we call for investment in evidence-based maternal mental health services. In addition to our calls for specialist clinical services, we strongly advocate for innovate peer support and self-management approaches for partners and families, like the evidence based Mums and Babies in Mind[5], Young Mums Together[6] and Creating Connections[7] programmes we’ve piloted successfully, to be made available across Wales.
Promote and protect the health and wellbeing of children from pregnancy
4.The security generated from a child’s attachment to parents or guardians is central to a child’s psychological and social development[8]. We are pleased to see that the significance of this relationship is reflected in the Welsh government’s Mental Health Delivery Plan 2016-2019[9], particularly the aims and actions outlined in section 5. To achieve the goals identified in the plan, we call for further investment in infant programmes aimed at helping parents identified as high risk develop sensitivity to their infants[10] as well as ensuring that in every local area perinatal commissioning and delivery complies with NICE guidance and that they follow recommendations on what needs to be in place to create effective perinatal care pathways[11].
5. We welcome the plans actions to support women with mental health problems, or those considered to be high risk. Having a parent with a mental health problem can affect the development of a child[12] if not managed correctly. It is estimated that between 10% and 20% of women develop a mental health problem during pregnancy or within the first year after having a baby[13], with around 50% of women with perinatal mental health problems not identified or treated[14]. Prevention has a central role to play within the infant and perinatal mental health pathways. While actions to provide support to this group are identified in the Welsh government’s delivery plan, we would like to see increased investment in specialist provision as well as public mental health interventions reduce the distress experienced by women and their wider family[15]. Further to this, we argue that in order to prevent mental ill health developing amongst this group, the goal should be increased from ensuring 10% of new mothers are in contact with community perinatal support to reflect the fact that up to 20% of women develop a problem during pregnancy or in the year after.
Tackle child health inequalities, with a specific focus on child poverty and disabled children.
6.The relationship between poverty and mental wellbeing is a complex one, however we know that socio-economic disadvantages place people at greater risk of developing mental health problems. Children and young people living in these circumstances are two to three times more likely to develop mental health problems, and evidence points to this increasing the likelihood of further disadvantage throughout the life course[16]. The UK Millennium Cohort Study (MCS) found that having severe mental health problems was strongly related to parental education, parental occupation and family income. 17% of 11 year olds in 2012 from families in the bottom fifth of income distribution were identified as having severe mental health problems compared to 4% in the top fifth[17] highlighting the urgent need for early intervention and support in the first 1,000 days. Our publication Poverty and mental health[18] explores the complexity of the relationship between mental health and poverty and informs the Joseph Rowntree Foundation's anti-poverty strategy.
7. The Welsh government’s ‘Tackling Poverty’ programmes such as ‘Flying Start’ and ‘Families First’ demonstrate a clear commitment to achieving the childhood equality objectives outlined by the administration which we warmly welcome. Importantly, the programmes demonstrate the relationship between poverty and mental health and identify parents and carers at high risk. It is paramount this relationship is understood by policy makers, particularly since the Institute for Fiscal Studies has suggested that child and working age poverty will increase across the UK over the next decade partly as a result of the recent recession[19].
8. While poverty and economic inequalities are recognised and addressed in the programmes noted above, we would like to see this relationship reflected across Welsh government policy more widely. We call for the Welsh government to identify poverty as a social determinant of mental health in the national mental health strategy, particularly highlighting its impact on children, and implement policies with clear goals and timelines to effectively address childhood inequalities.
Reduce child deaths and injury prevention, particularly in the most deprived parts of Wales where infant mortality is much higher than the least deprived.
9. Poor mental health and wellbeing can have direct negative influence on health outcomes and life expectancy. We call for the promotion and protection of mental wellbeing from birth to be at the centre of the Welsh government’s public health strategy. Neglecting it undermines public health interventions to reduce health inequalities and ultimately prevent premature death from preventable conditions[20].
10. In 2014, the infant mortality rate was 3.6 deaths per 1,000 live births, which is the lowest ever recorded in England and Wales[21]. While this downward trend is certainly going in the right direction, the Marmot review: ‘Fair Society, Healthy Lives’[22] recognises that deprivation continues to be independently associated with an increased risk of infant mortality. The report highlights a study reviewing all infant deaths in England and Wales (excluding multiple births), and identifies a link between low birth weight and higher levels of deprivation. Based on the analysis, the report concludes that a quarter of all deaths under the age of one could be avoided if all births had the same level of risk as those to women with the lowest level of deprivation[23].
11.Tailored interventions are urgently required to support this high risk group. We would like to see recognition of the link between deprivation and infant mortality reflected more widely across policy by the Welsh government as it is not identified as an issue in Together for Mental Health Delivery Plan 2016 – 2019, or in The Wellbeing of Future Generations (Wales) Act 2015. Despite reductions in child deaths, evidence from the Marmot Review demonstrates the impact deprivation can have on mortality and should therefore be integrated into cross departmental policies.
Support effective child development and emotional and social well-being - specifically interventions that are delivered outside the health service which can help to detect and address developmental delays.
12.Addressing health inequalities associated with mental health and poverty which ultimately impact developmental delays involves evolving and adapting our social arrangements and institutions. Outside of the health service, public sector responsibilities across housing, welfare, education and social security all play an integral role in advancing mental health equity and the measures to protect emotional and social wellbeing.
13.Taking housing as an example, we know that having somewhere safe, warm, secure and suitable to live is fundamental to mental wellbeing[24]. Quality of housing impacts on people’s wellbeing with poor standards adversely affecting both physical and mental health[25]. Having control over the internal environment is important for mental wellbeing and people living in cold, damp housing are more likely to experience poor mental health.
14.Poor housing not only affects adults, but children too. Those children who live in poor housing have increased chances of experiencing stress, anxiety and depression. It is also likely to have a negative impact on the child's physical health, educational attainment, and opportunities in adulthood[26]. We welcome section 9 of the Mental Health Delivery Plan identifying “fair access to housing and related support and promote access to mental health services amongst people who are homeless or vulnerably housed”[27] as a priority area, however we would like to see this section explicitly recognise the impact on the role of housing in relation to the wellbeing of children, parents, and families.
Reduce the adverse impact on the child of psychosocial issues such as poor parenting, disruptive family relationships, domestic violence, mental health issues and substance misuse through effective safeguarding.
15.The family relational environment is of fundamental importance during pregnancy, infancy and childhood to future mental health[28]. Secure attachment results in positive emotional and social development, with children being better able to cope with stress, having a higher perception of self-worth and being able to adjust better to adversity and change[29]. It is therefore predictive of mental wellbeing in adulthood.
16.Findings from the first Welsh Adverse Childhood Experience (ACE) study show that children who experience stressful and poor quality childhoods are more likely to adopt health-harming behaviours during adolescence and adulthood which can themselves lead to mental health problems and diseases in later life, as well as impacting educational attainment[30]. With this knowledge, we are deeply concerned that the rate of children subject to Child Protection Plans and on Child Protection Registers has increased in all four nations of the UK. Between 2002 and 2014, there was a 72% increase in Wales, which was the second highest across the UK[31] highlighting the need for tailored programmes and interventions for children experiencing adverse childhood experiences.
17. While we are pleased to see that the implementation of “appropriate” safeguarding policies and agreed standards for training on safeguarding and vulnerable adults included in the Mental Health Delivery Plan, the actions outlined are not tailored to the specific needs of children. Early identification of heightened risk or problems when they first arise can mean the most appropriate support is provided to either promote and support good mental health. To leave risk factors unaddressed can lead to a cycle of increased vulnerability and distress throughout the life course. It is therefore vital that tailored safeguarding measures are included in the policies of the Welsh government.
19.Parental mental health problems can also have a significant impact on children’s growth and development throughout childhood. UK research has identified parental mental health problems as a significant factor in around 25% of new referrals to social service departments[32]; more than one third of adults with mental health problems are parents and it is estimated that two million children live in households where at least one parent has a mental health problem[33]. As mental health problems can affect any one of us, services must be accessible in every local area to provide support parents, but in particular those who are at heightened risk of, or are managing, mental health problems. We are encouraged by the cross party political commitment to improving the experiences of infants in the 1001 Critical Days Manifesto[34] across the UK, particularly as a driver to increasing and transforming health visiting services. It is vital that focus continues to be on recruiting and training specialist parent and infant mental health midwives and health visitors who will enable early identification of those in need of additional support, for example the work of the Health Education England Specialist Health Visitors in parental and infant mental health[35].
[1] Mental Health Foundation. (2016). Fundamental Facts: Wales. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/FF16%20Wales.pdf
[2] Tickell, C. (2011). The Early Years: Foundations for life, health and learning An Independent Report on the Early Years Foundation Stage to Her Majesty’s Government. Retrieved from: http://www.educationengland.org.uk/documents/pdfs/2011-tickell-report-eyfs.pdf
[3] Allen, G. (2011). Early Intervention: The Next Steps: An Independent Report to Her Majesty’s Government Graham Allen MP. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/284086/early-intervention-next-steps2.pdf
[4] Maternal Mental Health Alliance. Retrieved from: http://maternalmentalhealthalliance.org/
[5] Mums and Babies in Mind. Retrieved from: https://www.mentalhealth.org.uk/projects/mums-and-babies-mind
[6] Young Mums Together. Retrieved from: https://www.mentalhealth.org.uk/news/big-lottery-funding-awarded-scale-young-mums-project-2015
[7] Creating Connections. Retrieved from: https://www.mentalhealth.org.uk/projects/creating-connections
[8] Bowlby, J. (1988). A Secure Base. Parent-Child Attachment and Healthy human Development. Routledge: London.
[9] Welsh Assembly. (2016). Mental Health Delivery Plan. Retrieved from: http://gov.wales/docs/dhss/publications/161010deliveryen.pdf
[10] Faculty of Public Health and Mental Health Foundation. (2016). Better Mental Health for All: A Public Health Approach to Mental Health Improvement. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/Better%20MH%20for%20all%20web.pdf
[11] Faculty of Public Health and Mental Health Foundation. (2016). Better Mental Health for All: A Public Health Approach to Mental Health Improvement. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/Better%20MH%20for%20all%20web.pdf
[12] Knapp, M., McDaid, D., & Parsonage, M. (2011). Mental Health promotion and Mental Illness Prevention: The Economic Case. Retrieved July, 2, 2016 from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf
[13] Bauer, A., Parsonage, M., Knapp, M., Iemmi, V. Adelaja, B. (2014). The costs of perinatal mental health problems. Centre for Mental Health and London School of Economics
[14] Bauer, A., Parsonage, M., Knapp, M., Iemmi, V., & Adelaja, B. (2014). The costs of perinatal mental health problems. [online] London: Centre for Mental Health. Available at: http://www.centreformentalhealth.org.uk/costs-of-perinatal-mh-problems
[15] Goldie, I., Elliott, I., Regan, M., Bernal, L., and Makurah, L. (2016) Mental health and prevention: Taking local action. London: Mental Health Foundation
[16] Goldie, I., Elliott, I., Regan, M., Bernal, L., and Makurah, L. (2016) Mental health and prevention: Taking local action. London: Mental Health Foundation
[17] Morrison Gutman, L. et al. (November 2015) Children of the New Century: Mental health findings from the Millennium Cohort Study. London: Institute of Education, UCL and Centre for Mental Health
[18] Elliott, I. (June 2016) Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy. London: Mental Health Foundation.
[19] Brewer, M, Browne, J. and Joyce, R. (2011). Child and Working-Age Poverty from 2010 to 2020. London: Institute for Fiscal Studies
[20] Department of Health. (2012). The Public Health Outcomes Framework for England, 2013-2016.
[21] Office of National Statistics. (2014). Childhood mortality in England and Wales. 2014. Retrieved from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2014
[22]http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review
[23] Marmot, M. (2010). Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post 2010. London: IHE.
[24] Mental Health Foundation. (2016). Mental Health and Housing. London: Mental Health Foundation.
[25] Harris, J. et al. (2010). Health, mental health and housing conditions in England. London: NatCen and Eaga Charitable Trust.
[26] Chance of a lifetime: The impact of bad housing on children’s lives. (2006). Retrieved from: https://england.shelter.org.uk/__data/assets/pdf_file/0007/66364/Lifechancereport.pdf
[27] Welsh Assembly. (2016). Mental Health Delivery Plan. Retrieved from: http://gov.wales/docs/dhss/publications/161010deliveryen.pdf
[28] Gerhardt, S. (2014). Why love matters: How affection shapes a baby’s brain (2nd Edition). Routledge
[29] Kenny, M.E. and Sirin, S. (2006). Parental Attachment, Self-Worth, and Depressive Symptoms Among Emerging Adults. Journal of Counselling & Development, 84, 61-71.
[30] Mental Health Foundation. (2016). Fundamental Facts: Wales. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/FF16%20Wales.pdf
[31] Mental Health Foundation. (2016). Fundamental Facts: Wales. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/FF16%20Wales.pdf
[32] Tunnard. (2004). in Hansson, U., O’Shaughnessy, R. and Monteith, M. (October 2013). Maternal Mental Health and Poverty: The Impact on Children’s Educational Outcomes. UNESCO Chairs: National University of Ireland Galway and University of Ulster,
[33] Hansson, U., O’Shaughnessy, R. and Monteith, M. (October 2013). Maternal Mental Health and Poverty: The Impact on Children’s Educational Outcomes. UNESCO Chairs: National University of Ireland Galway and University of Ulster.
[34]1001 Critical Days Manifesto. (2015). Retrieved from: http://www.1001criticaldays.co.uk/manifesto
[35] Specialist Health Visitors in Perinatal & Infant Mental Health What they do and why they matter. (2016). https://www.hee.nhs.uk/sites/default/files/documents/Specialist%20Health%20Visitors%20in%20Perinatal%20and%20Mental%20Health%20FINAL%20low%20res.pdf