Summary ·         Evidence indicates rising demand for children’s and young people’s mental health services. Children and young people therefore need to be able to access mental health support including counselling, but access to counselling in schools varies locally. We urge the Committee to call on Welsh government to make access to counselling and support more consistent and more available through online channels in Wales. ·         Evidence also indicates that Adverse Childhood Experiences such as family relationship problems and parental conflict are root causes behind much of children’s and young people’s mental health problems. ·         We would therefore encourage the Committee to call for a more relational approach to responding to children and young people’s mental health problems, including: o   Equipping CAMHS workforce to better recognise and respond to family relationship problems o   A review of services for children and teenagers identifying the provision of family therapies as well as the effectiveness of family-focused therapies compared to individual one-to-one counselling o   Ensuring that family-focused therapies such as family counselling and systemic family therapy are commissioned as early intervention and available to all children and young people whose mental health is affected by family relationship problems. ·         We would also urge Welsh government to prioritise support for parental couple relationships as crucial pillars of children’s mental health in wider government policy (we are delighted that this is now included in Families First guidance), to reduce root causes of children’s and young people’s mental ill health, by (for example) developing a strategic vision for joining-up local children’s and young people’s mental health support and family relationship support services.

1.   Relate is the UK’s leading relationship support charity, serving more than one million people through information, support and counselling every year. Our vision is a future in which healthy relationships are actively promoted as the basis of a thriving society. We aim to develop and support healthy relationships by:

·         Delivering inclusive, high-quality services that are relevant at every stage of life

·         Helping couples, families and individuals to make relationships work better

·         Helping both the public and policy makers improve their understanding of relationships and what makes them flourish.

In Wales, we supported over 4,000 families last year.  In the UK, through our children’s and young people’s counselling service, we supported 7,582 children and young people in schools and dedicated young people’s mental health services in 2015/16, and we also supported a further 4,650 people through family counselling. Based on this experience of delivering counselling to families and children and young people, as well as our research and nearly 80 years’ expertise as the UK’s leading relationships charity, we are submitting evidence to this inquiry on the importance of family and couple parental relationships to children’s and young people’s mental health and wellbeing.

2.   There is increasing awareness of the prevalence of mental health problems and pressures on young people today, which we know have such potential to shape young people’s futures. Evidence indicates rising demand for children’s and young people’s mental health services but early interventions remain inconsistently available:

·         One in ten children and young people live with a diagnosable mental health condition– around three in every school classroom;[1]

·         30% of young people are reported to ‘always’ or ‘often’ feel ‘down’ or ‘depressed’, and 21% feel they do not receive the support they need from school;[2]

·         Two-thirds of young people attending school-based counselling are experiencing difficulties at ‘abnormal’ or ‘borderline’ levels, and have problems which have been present for a year or longer;[3]

·         The lifetime cost of a single case of untreated childhood conduct disorder is estimated to be approximately £150,000.[4]

3.   There is a strong evidence base which shows that counselling for children and young people is effective at improving mental health and wellbeing. A substantial body of research shows counselling in schools reduces depression, anxiety, and a range of other mental health problems:

·         International research shows that school-based counselling and psychotherapy interventions significantly reduce distress.[5]

·         Recent small-scale randomised controlled trials of school-based counselling have found that at 6 and 12 weeks young people showed significantly lower levels of distress than those in a waiting list control group, and data from ‘real-world’ settings similarly indicate that counselling is associated with a significant reduction in psychological distress.[6]

·         A meta-analysis of 30 UK studies found counselling in secondary schools was associated with large improvements in mental health (mean weighted effect size = 0.81) and counselling may indirectly benefit students’ capacities to learn.[7]

·         A controlled trial of 73 young people undergoing school-based counselling found it was effective at reducing severity of depression, suicidal risk, and anxiety.[8]

4.   However, despite counselling needing to be available in all secondary schools in Wales, many children and young people are waiting for long periods for help, and although school-based counselling is one of the most accessible counselling services for children and young people, provision can be patchy. Families contact Relate because waiting times for school-based services or Specialist CAMHS are too long.  In order to ensure availability of support for all who may need it, we urge the Committee to consider calling upon the government to make wider access to online counselling and support available to more children and young people in Wales.

5.   But access alone is only part of the picture. We also need to maximise the opportunities for counselling to support good quality family relationships. In order to be most effective, interventions need to be relational, seeing young people’s mental health in the context of their relational and familial environments. But the familial and relational sources of many young people’s mental health problems have often been under-recognised. We know that many of the problems children present with in counselling are symptoms of problems at home in the family environment and relationships: a survey of over 4,500 children seen by CAMHS services in 2015 found ‘Family Relationships Problems’ to be the biggest presenting problem – ‘severe’ or ‘moderate’ for over 25% of children, and ‘severe’, ‘moderate’ or ‘mild’ for over 50%.[9] Similarly, a meta-analysis of evaluations of counselling in UK secondary schools found family issues were the largest presenting issue (by a factor of almost two).[10] What is required is therefore a relational approach, which recognises the roots of many mental health problems in the family dynamics and in relationships – and which therefore does not restrict itself to symptom management, but addresses these root causes.

6.   We need a relational approach to mental health provision for children and young people – i.e. offering family counselling as well as one-to-one counselling for children and young people. Relational working in children and young people’s mental health services has the potential to reduce psychological distress and improve wellbeing. Greater emphasis within CAMHS on workforce development such that practitioners feel better equipped to recognise and address family relationship issues which lie at the heart of much child mental ill health would bear considerable fruit.

7.   Similarly, in order to address dysfunctional family relationships which often lie behind children’s and young people’s presenting issues such as depression or anxiety, Welsh government should ensure that early and late intervention children’s and young people’s mental health services include family-focused therapies such as systemic family counselling. Where mental health disorders are rooted in family relationships, children and young people should have access to family-focused therapies to address this root cause, which requires commissioners to ensure these therapies are commissioned locally. We would encourage the Committee to call upon the government to examine the best ways to ensure that family counselling is available in every area (for example, through guidance to commissioners).

8.   We would also urge the Welsh government to review services for children and teenagers across the country to examine the provision of family therapies as well as the effectiveness, where family relationships are an issue for children/young people, of family-focused therapies compared to individual one-to-one counselling.

9.   We would also urge Welsh government to prioritise support for parental couple relationships in wider government policy, to reduce Adverse Childhood Experiences (ACEs), the root causes of children’s and young people’s mental ill health. Recognising the relational roots of much of children’s and young people’s mental health problems should lead government to increase its focus on supporting parental couple relationships as the crucial pillars of children’s mental health. There is a wealth of evidence that family instability and poor-quality parental couple relationships have a significant negative impact on children’s wellbeing and mental health:

·         The recent evidence review for the DWP by the University of Sussex and the Early Intervention Foundation found that the quality of parental relationships and family functioning have a significant impact on children’s mental health and wellbeing – both in intact and separated families – and concluded that the quality of the inter-parental relationship is a ‘primary influence’ on children’s outcomes.[11] It showed that parents/couples who engage in frequent, intense, and poorly resolved inter-parental conflicts put children’s mental health and long-term life chances at risk, and children of all ages can be affected by destructive inter-parental conflict, with effects evidenced across infancy, childhood, adolescence, and adulthood.

·         High levels of couple conflict have been shown to be associated with less emotional availability[12] and less warmth[13] in parents towards children, as well as resulting in parents being perceived as more hostile and rejecting by children.[14]

·         Children growing up with parents who have low parental conflict – whether together or separated[15] – enjoy better physical and mental health,[16] better emotional wellbeing,[17] higher academic attainment,[18] and a lower likelihood of engaging in risky behaviours.[19]

·         Children whose parents have poorer relationship quality have more externalising behaviour problems (e.g. hyperactivity, aggression).[20]

·         Evidence demonstrates that persistent and unresolved parental conflict is likely to have a negative impact on maternal mental health, often leading to depression;[21] and that children who have a parent with mental health problems are at an increased risk of emotional and social problems.[22]

·         Inter-parental conflict can result in impaired parent-child relationships and can affect children’s and adolescents’ wellbeing and development,[23] leading to increased anxiety, withdrawal and depression, and behavioural problems including aggression, hostility and antisocial behaviour and criminality.[24]

·         Parental relationship breakdown, an ‘Adverse Childhood Experience’, doubles the likelihood of children experiencing poor outcomes such as behavioural difficulties compared to children whose parents remain together,[25] with evidence showing associations between parental relationship breakdown and child poverty, behavioural problems, distress and unhappiness, poorer educational achievement, substance misuse, physical and emotional health problems, as well as teenage pregnancy, and increased risk of children’s own relationships breaking down.[26]

10.        We would therefore urge the Committee to call on government to ensure that support for parental couple relationships and a whole-family approach is central to future plans. Given the strong evidence on the enormous impact family relationships have on children’s and young people’s mental health and following the acknowledgement of the importance of parental relationship quality in the new Families First guidance, we would encourage the Committee to call on Welsh government to develop a strategic vision for joined-up support services for families, including looking at how relationship support, mental health services and wider family support services could be brought together, with more holistic assessments of need, and smoother referral pathways. The strong evidence on the links between couple relationship quality, parenting and child wellbeing[27] presents a compelling case for joining-up children’s and young people’s mental health services with wider family and relationship support services in ‘family relationship hubs’, for example.

11.        We welcome the new pilot programmes to help identify and tackle mental health problems early in some local authorities.  In our experience, including a strong element of online support is crucial when attracting young people.  http://www.bbc.co.uk/news/uk-wales-41361491