1. About the RCPCH
The RCPCH works to transform child health through knowledge, innovation and expertise. We have over 500 members in Wales and over 17,500 worldwide. The RCPCH is responsible for training and examining paediatricians. We also advocate on behalf of members, represent their views and draw upon their expertise to inform policy development and the maintenance of professional standards.
For further information please contact Gethin Jones, External Affairs Manager for Wales: gethin.jones@rcpch.ac.uk or 029 2050 4211.
2. The emotional and mental health of children and young people in Wales
RCPCH welcomes the renewed focus on the emotional and mental health of children and young people (CYP) in Wales.
In January of this year, we published the State of Child Health 2017 (SOCH)report, which pulled together data from across the UK on 25 indicators to provide a snapshot of child health and wellbeing. Welsh teenagers were found to have amongst the poorest life satisfaction rates across the UK.
Between January and October 2016, we consulted 326 children and young people across the UK to obtain their experiences, explore their views on the indicators and to inform the recommendations. Feedback was sought through online and ballot paper surveys, semi-structured interviews, discussion activities and activity-based workshops.
Mental health was highlighted as a major area of concern for children and young people, particularly issues around self-esteem and self-confidence (on a personal level and within relationships), lack of support in both primary and secondary schools and the need to reduce waiting times for mental health services.
Children and young people felt they had a lack of knowledge around mental health, with specific anxieties around how to deal with mental health concerns in themselves and others, as well as questions about who they should turn to for guidance. Many children and young people thought that mental health education should be specifically taught from primary school onwards so that they could be more confident and better prepared to cope with the challenges of mental health in adolescence and adulthood.
3. RCPCH policy recommendations
The data highlighted in the SOCH report, along with this feedback from children and young people and input from RCPCH members informed a series of Recommendations for Wales that we published alongside SOCH.
The following recommendations are designed to maximise mental and emotional health for children and young people in Wales.
· The Welsh Government should take immediate steps to embed statutory and comprehensive personal, social and health education programmes (including sex and relationships education) across all primary and secondary schools. The new curriculum for Wales should use the Health and Wellbeing Area of Learning Experience to continue that approach.
· Estyn should inspect the provisionof personal, social and health education programme within a robust framework.
· The Welsh Government should ensure that compulsory evidence based health and wellbeing programmes are embedded in all primary and secondary schools which foster social and emotional health and wellbeing, through building resilience, and specifically tackling issues around social inclusion, bullying, drug and alcohol use and mental health.
· Professional bodiesrepresenting all those working with infants, children and young people in health, social care, education, criminal justice, and community settings should equip their members with the necessary tools to identify mental health issues through the promotion of resources such as the MindEd portal.
· The Department for Education and Skills should ensure that all schools make mental health support available to their pupils.
We note the recent announcement by the Health Secretary and Education Secretary that CAMHS practitioners will be recruited to work with schools in three areas across Wales in a pilot scheme designed to upskill teachers to recognise and deal with low level mental health problems; and to ensure that when further intervention is required, further support is available for teachers and children, along with pathways to specialist services. We greatly welcome this announcement of an innovative model being trialled. We welcome also the commitment to properly evaluate the pilot scheme with a view to rolling it out with an evidence base. However, work still needs to be done to support children in schools outside of these pilot schemes and in the interim period. Also, professionals who work with children outside of education still need to be upskilled to identify mental health issues and respond appropriately.
4. The views of children and young people
There recommendations are backed up by evidence from children and young people in Wales. We have conducted two roadshows in Wales over the past year to hear from CYP about their experiences with health services and thoughts on their own and their peers’ health. Mental health was identified as a priority at both, and is repeatedly cited as a major concern amongst CYP in all our engagement work.
Other common themes that came up in these sessions and which we regularly hear from CYP included:
· Waiting lists and insufficient provision of services: “We need better mental health services. ..better alcohol & drugs services & awareness”; “Feel that services don’t have time for you and are too busy… services are meant to see you regularly but they forget and don’t come”
· The need for teachers and other adults who work with CYP to have basic understanding of mental health and be able to signpost to services where appropriate: “Teachers need courses on mental health, more advice to parents & families on health issues”.
· The need for CYP to be meaningfully involved in the design of services they use: “Why give us surveys when 90% of the time you’ve made your decision. How can it change? How can it be different?”; “We know first-hand how to change the systems to help”
· The need for effective communication between agencies “Communicate between organisations to know what effect health issues have on young people”
5. Views from the frontline
Paediatricians, both in hospitals and in community settings, have substantial contact with children and young people experiencing mental health problems and neurodevelopmental disorders. To provide a case study and a view directly from a clinician, we asked a Community Paediatric Senior Registrar with experience in CAMHS to comment on some of the specific issues identified by the Committee.
Early intervention and prevention programmes teaching resilience; the role of education in preventing mental health issues.
“I have not seen any direct or clear effect on resilience from early intervention and prevention programmes as I have not heard it mentioned by children, families or professionals I work with. Early intervention is certainly required but this needs doing far more.
“I believe Education are in the best position to look out for mental health issues developing. There is no service able to monitor children and their families like schools. I believe investing in teaching resilience and mindfulness much earlier, in primary school, will equip all children with some coping mechanisms and help stop the stigma of mental health issues.”
The extent to which new (and/or reconfigured) services are helping to reduce waiting times in specialist CAMHS; whether the improvements in waiting times Welsh Government expected from CAMHS have been met.
“I am unsure of the effect seen on generic CAMHS waiting lists but, in some areas, other services have taken over a great section of the workload (ASD & ADHD) so any decrease in CAMHS waiting times has to be considered with the increase in waiting times for community paediatrics and neurodevelopmental assessments. I have also seen that, within six months in CAMHS, there have already been two waiting list initiatives, one in generic CAMHS and one in neurodevelopmental CAMHS and further ones are planned for the end of the summer. This suggests, with the current workforce/system, services are unable to stay on top of the number of referrals. It is clear that CAMHS are up against a near impossible task as the patients they have are extremely difficult to discharge so the numbers on their books are ever increasing.
“Within the CAMHS I have worked in there have been a number of agency staff employed for clinical duties and secretarial duties. There is stress felt in both the clinical and administration areas and, with limited admin support, the clinical staff have to carry out more admin tasks which limits their clinical time.”
The extent to which changes have addressed the over-referral of children and young people to CAMHS; Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS
“I have seen children who really needed a CAMHS review but which I struggled to get for them or for which they had to wait so long I was concerned about problems escalating further. It is understandable that thresholds for accepting referrals has had to change but this means other services, like community child health, need to be better equipped to deal with the mental health issues which remain unaddressed.
“A more effective way of working would be for closer CAMHS and community paediatric working. A CAMHS nurse therapist told me that she used to run a joint CAMHS/Paeds initial assessment clinic years ago in England so that tricky behavioural and emotional issues could be seen together and teased out and a management plan be developed together. She also used to run training in mental health which was funded jointly by health, education and social services so all three services attended the training and worked together more effectively. This is what we should be aiming to do more of as this would be efficient working at the same time as addressing everyone's need to be trained in mental health.”
The extent to which the funding has been used to meet the needs of vulnerable children and young people, for example, children who are in care, children and young people with ADHD and autistic spectrum disorders, and those who are already in or at risk of entering the youth justice system, including those who are detained under section 136 of the Mental Health Act 1983.
“School aged children who are referred for ASD (Autism Spectrum Disorder) are, in Swansea, referred by their school to ND (neurodevelopmental) team. This is now a separate service to CAMHS. It cannot however take on ADHD as these patients, once diagnosed and likely to require medication, need regular review which the ND team does not have capacity for. This, at the present time, remains unaddressed and does reflect the capacity issues of CAMHS services.
“There needs to be more support for families of children with ASD and ADHD such as a neurodevelopmental nurse who is able to see the families a few weeks after they have the diagnosis to go through any questions they have. There should also be more parent workshops & groups. ADHD often feels that it gets forgotten. There is less research into ADHD and less educational material is available for families. Children and their families have to rely on medication for control of symptoms as there is nothing else to offer. However, the NICE guidelines state that medication should be offered alongside parent support / education workshops. This means that for the ADHD population there is certainly no decrease in medication use.”
The work being done to ensure children and young people are more resilient and better able to tackle poor mental well-being when it occurs
“We are constantly seeing children and young people who have no coping mechanisms, no buffers or protective factors to help them through either mental health issues or difficult times in their lives. Resources are limited so the additional efforts could focus on those children identified by the ACE (Adverse Childhood Experiences) study, for example those who have been abused or experience domestic violence.”
Children’s access to school nurses and the role schools nurses can play in building resilience and supporting emotional wellbeing.
“The contact I have had from school nurses is that they don't have time to do their own job as they would like to, let alone now teach resilience.”
The take up and current provision of lower level support and early intervention services, for example, school counselling services.
“I have met children within CAMHS who have used their school counsellor but some don't like to go due to the stigma.”