1. Introduction
We welcome the opportunity to comment on the Children, Young People and Education Committee’s inquiry into the emotional and mental health of children and young people. Given the investment that has been made into Children and Adolescent Mental Health Services (CAMHS) in recent years, the focus that has been placed on these services and the previous reviews it is appropriate to take time to consider the issues covered by the inquiry and look at how we can all best meet the needs of children and young people.
We acknowledge and lend our support to the importance of and need to have arrangements in place for an early intervention and prevention approach to emotional and mental health services for children but we wanted to focus this submission on the children who are in need of care and support services from social care including those who are or have been care experienced.
The reality is that the investment made thus far to CAMHS services in Wales has had little impact on these children who are less likely due to structural / service issues or the complexity of their needs to have benefitted from the changes that have been made. We recognise the challenge of needing to address prevention and early intervention as well as fund intensive services but none the less believe that a specific shared and joint approach with a clear health role should be developed for these children and young people.
2. Issues / Challenges being faced
We know that most children will live fulfilling lives and enjoy their childhood. In recent years we have seen more and more young people becoming aware of issues and seeking help and advice from services which is to be welcomed. Males are now more willing to access these services than in the past. We are seeing anxiety and stress representing the most common reported problem, along with self-worth issues and relationship difficulties. Recent surveys suggest that young people continue to place a much higher priority on their mental health than their predecessors, and are more likely to seek help. Perhaps partly as a result of such heightened awareness, greater than ever demand is being placed on mental health services.
However, the challenges faced by some children and young people will have a profound effect on their emotional and mental wellbeing. As well as evidence of substantial numbers of children and young people in the general population who are increasingly struggling with problems such as anxiety, depression and self-harm, there are also smaller numbers who are struggling with potentially life-threatening conditions such as eating disorders and psychosis and those in need of extensive and ongoing care and support services most often due to abuse, neglect or disability. As well as the obvious effects on their health, this harms their life chances, with research showing those who develop problems in the early years fall behind socially and academically.
The Local Government Association’s (LGA) publication, ‘Best start in life: Promoting good emotional wellbeing and mental health for children and young people’, identifies a number of key messages setting out why mental health and wellbeing in childhood matters. These include:
· Pregnancy and early years are critical; early interactions directly affect the way the brain develops and so the relationship between baby and parents is vital
· One in four babies live in households affected by domestic violence, mental illness or drug and alcohol problems
· One in five mothers suffer from depression, anxiety or in some cases psychosis during pregnancy or the first year after birth. Teenage mothers are three times more likely to suffer from post-natal depression
· Once a child has fallen behind in the early years they are more likely to fall further behind than catch up
· Those with mental health and conduct disorders are twice as likely to leave school without qualifications
· The cost to the economy is estimated at £8.1 billion for each annual birth cohort – that’s almost £10,000 per baby. Nearly three quarters of that is linked to the impact on the child.
Figures from the Early Intervention Foundation show that in Wales, we spend £1.1bn per year on the range of damaging problems that affect children and young people. This includes mental health problems as well as issues such as domestic violence and abuse, child neglect and maltreatment, youth crime and exclusion from education and the labour market. While this figure is substantial, it is only the immediate fiscal cost so does not capture any lasting effects into adult life and sometimes into the next generation, nor the wider social and economic costs.
By the age of 18, three quarters of people who go on to develop mental health problems in adulthood will already have started to experience these symptoms. The cost to children’s life chances and their future wellbeing is profound, as is the cost to society in increased costs and lost opportunities.
There are specific additional issues and costs for care experienced children. Analysis by Loughborough University suggests that a lack of support for looked after children’s emotional wellbeing, and allowing placements to break down, could be more expensive than providing specialist support to prevent such placement breakdowns. The analysis shows for example that:
· One child’s unstable and unsupported experience of care cost £22,415 more per year (including health, social care and criminal justice costs) than another child’s stable and well supported care journey
· If a child who experienced nine placements had received a package of specialist support to keep his placement stable, this could have saved an estimated £67,851 over 11 years (approximately a 10 per cent reduction in costs)
NSPCC, 2015, Achieving emotional wellbeing for looked after children.
The pressure on all public services is exacerbated by the ongoing cuts, while the excoriating cuts in local authority budgets have diminished the prospects of developing early intervention and prevention services focussing on emotional well-being and mental health. Supporting children, young people, families and carers before a crisis and before the need for specialist interventions will always be preferable to more costly and interventionist options. However, assuming such services are available is, in much of Wales, a specious assumption with few options available other than the increasingly limited statutory provisions. “Signposting” at an early stage of need, while admirable, presumes the existence of early intervention and prevention services.
2.1 How are services currently experienced?
The identification of many of the issues comes from young people themselves, who report struggling to access support for emotional and mental health issues. Over the past twenty-five years through previous reviews and inquiries of CAMHS, as well as Together for Children and Young People (T4CYP), children and young people have repeatedly voiced their concerns about the paucity of access to services, the inconsistency of provision, the adult focus of the models of intervention and the absence of child friendly environments for those who do receive services. There is a need to continue to strengthen the focus on prevention across the range of services, to build resilience of children, young people and families, reduce reliance on statutory services and facilitate de-escalation from intensive support where appropriate. Importantly, this needs to include health services working with community-based organisations to support children and young people in the development of life skills and refocusing resources towards early, direct interventions that strengthen the resilience and functionality of families. Our recent experience underlines increasingly that young people often hold the key to unlocking solutions to what may appear to be “wicked” issues, and it is particularly the case that a co-production approach is suitable here. Young people are themselves very interested in changing the support that is available to them and know what ‘good’ would look like.
The recent Public Health Wales CAMHS Needs Assessment recognised that children who are looked after or in need are known to be at greater risk of mental health problems. It also identified a lack of connectivity between different policy and service areas working in children’s mental health. Whilst the Social Services and Well-being (Wales) Act 2014 offers one definition of well-being, in practice there are differences in social services, education and health policy and legislation. Some positive examples of integrated practice have been designed and are delivered independently within each of these areas but a more systematic and integrated approach at a national, strategic, regional and local level, would benefit children and young people. The differences in definitions and understanding together with the continued lack of connectivity lead to additional challenges and a lack of shared ownership in discharging the well-being duty. There is a compelling and pressing requirement to develop a common language, assessment tools and strategic planning framework. At present, different agencies have varying definitions of the words used in relation to emotional wellbeing / mental health/illness and also of terms such as ‘prevention’ and ‘early intervention’. In turn this can lead to inconsistency in those who meet thresholds for services, including CAMHS and specialist CAHMS, even though presenting needs can often be very similar.
There are a range of local authority services provided to children and young people to help support their emotional and mental health needs, needs which will often be complex. These include early help and preventative services delivered under a plethora of funding arrangements, including, Families First and Flying Start, interventions linked to the provision of care and support under part 4 of the Social Services and Well-being (Wales) Act 2014. Moreover, for those children and young people who are looked after, we provide or purchase a range of fostering, residential provision and specialist interventions aimed at improving their well-being and that of children and young people who leave the looked after system into varying arrangements at varying ages. These are in addition to the range of health and education services such as Speech and Language Therapy, Occupational Therapy, sensory, educational psychology (EP), physiotherapy, child psychology and CAMHS. However, our recent evidence to the Public Accounts Committee to their inquiry on care experienced children and young people, demonstrated the very real and significant pressures and challenges being experienced across local authority children’s services. This includes increasing demand and complexity of cases, which negatively impacts on both the availability and cost of appropriate placements, as well as leading to an increasing need for assured access to services to support these placements. The reality is that in the face of increasing demand and complexity, services for the care and protection of vulnerable children are now, in many areas, being pushed to breaking point; both financially and practically. The crisis experienced within the provisions for children who are looked after is exacerbated by the disconnect across service areas. The frustrations experienced by so many professionals at the inability to align services consistently for children regardless of their geographical placement and frequent mismatch between presenting behaviours and formal diagnosis / service offers is acute but pale into insignificance against the frustration and sadness of children, young people and families.
Our evidence to the Public Accounts Committee also recognised the fact that CAMHS in Wales are under more pressure than ever before and despite additional investment and staffing, still does not meet demand. Despite some very committed work by individuals within health, local authorities continue to face a challenge in sourcing health services to offer sufficient priority to the emotional and mental health needs of children in care and care leavers. This results in the burden of responsibility being placed on local authority children’s social services. There has been a long standing disconnect between the access threshold applied by CAMHS and the presenting emotional needs of looked after children and care leavers. The issue of looked after children and care leavers’ rights to an appropriate range of provision to meet their psychological and emotional health needs, when they need it and for as long as they require it, including the transition into adulthood, needs to be urgently addressed on an all-Wales basis. There are isolated examples of psychological therapies being deployed to good effect by health services to meet the needs of specific groups of looked after children which, if extended across Wales, could go some way to addressing this. In addition to the pockets of good practice found in health, the National review of care planning for children and young people subject to Public Law Outline pre proceedings, undertaken in 2016 by Care and Social Services Inspectorate Wales (CSSIW), found a number of local authorities had compensated for the deficit in provision by diverting social work resources into psychological provision.
The requirement for psychological and psychiatric assessment, intervention and support through the Family Courts and then into placements continues to be an area of unmet need. Local authorities are resorting to filling the gap with expensive and often unsustainable solutions to broker between the demands of the courts and the availability of the health services. The assessments are frequently then repeated when resource does become available in order to revisit recommendations and identify services available locally.
The National Adoption Service (NAS) have also submitted separate evidence to the inquiry and we would wish to endorse their comments. They point to some of the difficulties faced by adopters in accessing a service from CAMHS, linked to lack of therapeutic support as well as the lack of ‘adoption awareness’ within the service. They also point to the fact that the prevention / early intervention ethos of the mental health measure and the T4CYP programme, does not appear to have had an impact on demand for targeted and specialist support for children and young people. The NAS call for there to be:
· timely access to an adoption aware CAMHS service
· access to a range of psychological therapies that help adopted children recover from the result of early trauma or early attachment problems
· support in managing children and young people who display challenging behaviours, particularly aggression and violence to adults
· adopters having access to consultations with CAMHS; and
· improved links between CAMHS and regional adoption services.
3. Relevant developments
Population Needs Assessments under the Social Services and Well-being (Wales) Act
All regions have recently published their own population assessments. The issue of access to CAMHS is highlighted by a number of the assessments as an area which needs to be addressed.
It is recognised by some regions that more support is needed for those not reaching CAMHS thresholds and many regions report increased referrals in recent years. In response many regions are already reviewing and responding to pressures on CAMHS services in their area. The recently produced National Population Assessment Report identifies that current provision in response to the emotional and mental health needs of children and young people needs development and includes the following proposals:
· developing a single point of access for CAMHS
· developing a single point of access for primary mental health and family support services
· school counselling services
· raising awareness of mental health in schools and promoting youth mental health first aid
· self-harm pathway between health and education and PSE lessons addressing self-harm
· educating those working with young people on dealing with someone who self-harms or is experiencing anxiety and depression
· emotional well-being services being directly provided
· a CAMHS crisis response service.
The focus remains on increasing the availability of support to address the emotional needs of children and young people, to prevent escalating need or unnecessary referrals to CAMHS.
Together for Children and Young People Programme
Previous reviews of specialist CAMHS in Wales have identified that the service is under more pressure than ever before but does not have the capacity to meet demand. ‘Together for Children and Young People’ (T4CYP) was launched by the Minister for Health and Social Services in February 2015. Led by the NHS in Wales, this multi-agency service improvement programme is aimed at improving the emotional and mental health services provided for children and young people in Wales. We have welcomed the significant investment of over £7.6m into young people’s emotional and mental health in Wales which supports this programme of work. However, much of this work has been focussed on specialist CAMHS services and health provision. Whilst this is in part a reflection on the demands being placed on services we believe there are opportunities to have a greater focus on early intervention and preventative services, with Regional Partnership Boards providing an avenue to embed joint planning and joint decision making through local arrangements.
Adverse Childhood Experiences
Adverse childhood experiences (ACEs) are now well documented potentially traumatic events that can have negative, lasting effects on physical and mental health and well-being. These experiences range from physical, emotional, or sexual abuse of the child, to parental separation, parental substance misuse, domestic violence, parental mental illness, or the incarceration of a parent or guardian. There is an increasing focus on reducing ACEs such as alcohol and drug use, domestic violence, mental illness, as well as continuing to address child maltreatment, verbal, physical and sexual abuse. Although there are opportunities across childhood and adolescence to prevent or moderate the effect of ACEs, the evidence shows that we can have the greatest impact if we focus our efforts in preventing and/or protecting against the impact of ACEs for both parents and children during the first 1000 days of life from conception to age two.
Those families who may have more complex or entrenched difficulties require assessment and coordination by a specialist worker to develop and deliver plans which will incorporate a range of specialist responses from dedicated services such as Family Support Services and Looked After Children teams. Children and young people known to be at greater risk of mental health problems include those experiencing family breakdown; those in the Looked After System; those showing behavioural problems making them at risk of exclusion from school and children who have experience of trauma. It is important to identify those at risk of mental ill health as early as possible. ACEs have a major impact and multiple long-lasting effects into later adult life; the wide-ranging health and social consequences of ACEs emphasise the importance of preventing them before they happen.
We know that the impact of adverse experiences of children looked after have been shown to have a lifelong effect, making it all the more important to address the well-being of children whilst in care or in the arrangements that those who cease to be looked after move on to. A recent research paper from the Wales Adoption Cohort Study by Cardiff University, examined the presence of Adverse Childhood Experiences (ACES) in a cohort of 370 children placed for adoption in Wales in 2014/15. This showed that 47% of the cohort had experienced at least 4 Adverse Childhood Experiences (ACES) before they were placed for adoption, compared to 14% in the general population and placing this group of children in the highest risk group for later life difficulties. Although there is not a comparable study for children who remain looked after, their early and ongoing childhood experiences are likely to be similar and therefore be at a similar or even increased risk of later life difficulties. These experiences will often manifest themselves at critical transition points in a child’s/young person’s life (e.g. physiological changes, or changes in schooling). It is important the right services are in place at these times to build resilience both for the children/young people and their parents / carers and wider families. Good well-being underpins any chance of success in ensuring children in care flourish and move on from traumatic experiences. Levels of subjective well-being are found to predict future health, mortality, productivity and income.
All regions have discussed the significant impact of ACEs in their population assessments, for children experiencing them to the long-term impact on adults who have experienced them. Many regions are looking to address the impact of ACEs through action plans and preventing ACEs through tackling the causes. This is being done through a broad sweep of initiatives including parenting support and the development of programmes using other funding sources e.g. the Police Innovation Fund.
4. What needs to change
A continued emphasis on emotional, mental health and well-being is essential so that services can identify early where there may be additional need for support. This is vital to prevent young people requiring the services of specialist CAMHS and our only option for tackling the impact of ACES and reducing the likely recurrence of ACES in future generations. The focus on the work to minimise, reduce and repair the impact of ACEs carries an imperative but there needs to be an equal and significant emphasis on improving services for children, young people and their families who are experiencing and living with emotional distress and trauma.
Timely access to the right emotional and mental health care is crucial if we are to support better mental health among children and young people and reduce the long-term pressure on all high level need services such as CAMHS and children’s services.
The Public Health Wales CAMHS needs assessment identifies that the current model of CAMHS may not be appropriate for the current complex service environment, so we need to consider whether the current model is fit for the future. Current practice tends to transpose an Adult Mental Health model of service provision onto children’s services, so whilst a child’s difficulties may have arisen because of things happening in their environment the system makes it their responsibility to make changes in their lives. The expectation is that they are able to present themselves for therapy with the ability to take control of their lives, having an understanding and insight into how their difficulties arose and then being able to take action to make these changes. However, a child’s ability to be able to do this is much more limited than an adult[1]. Young people themselves also warn us that we must not medicalise growing up[2], they highlight the importance of getting appropriate help at the earliest possible opportunity, rather than allowing problems to escalate to crisis point.
The agreed view of AWHOCs is that changing to an integrated approach to assessment and provision of care that is less clinic based and more multi-agency in approach is an essential element to any successful future provision. The development of a national pathway and approaches would go some distance in addressing the differences we experience across Wales. This change would have impact upon the lives of looked after young people in all areas regardless of whether they continue to live in their home local authority and health board area or move elsewhere.
To date, the emphasis on the additional funding allocated to children’s mental health services has been towards improving specialist CAMHS within the existing model of provision. However, the greatest gains are more likely to be made by strengthening universal prevention and early intervention services, rethinking how we deliver services for those most in need with presenting behaviours of trauma regardless of diagnosis and improving the capacity of the whole system to respond to the needs and concerns identified by children, young people and their families.
Specialist CAMHS should be for the very few children who need a medical model and is an important and vital resource. However, there needs to be far greater collaboration and shared learning between specialist CAMHS and professionals working in earlier intervention and other areas of specialism. Our experience has demonstrated the need to improve access to emotional wellbeing / mental health services at an early stage, thus preventing the need for longer term interventions from CAMHS. There continue to be significant numbers of young people who require psychological support (intensive or remedial intervention) and examples of positive services although there remains very limited provision.
Sometimes the way that health, education and social care services are provided can make it particularly difficult for looked after children to get the help they require to address their health needs. They may have missed school-based interventions through unstable schooling, and increased absence. Those placed outside their local authority area can face problems accessing health services for a variety of reasons. The limited resources of emotional wellbeing / mental health services may mean it is difficult to respond to the unrecognised or undiagnosed mental health needs of looked after children – who may also suffer mental health stigma. Those children and young people in care, on the edge of care or who have been in care are doubly disadvantaged. Not only are they more likely to have health needs but the services they need to help and support them are often harder for them to access.
Looked after children and young people often have higher levels of health needs than their peers, and these are often met less successfully – leading to poorer outcomes. In particular, they have significantly more prevalent and more serious emotional and mental health needs (mainly because of the frequency with which these children enter care with problems arising from poverty, abuse, neglect, or trauma from other family circumstances). This does not mean that every child or young person who is looked after has greater needs. Yet, practitioners providing services to children and young people, and to families with children, need to be aware of the increased likelihood that this might be so. ‘The system’ must be able to identify those individuals whose needs are greater and to provide the support they need, both in a timely manner. It is also important that this access and support continues to be available for those children and young people who move on to alternative arrangements so that there is continuity but also support for latent vulnerability that re-emerges at a later stage.
The Making Sense report, written by young people, advocates support from people they trust - friends, educational counselling services and teachers - as a way to address the majority of children and young people’s emotional needs and overall development. This finding is very much in keeping with the spirit of early intervention as advocated by both the Social Services and Well-Being Act and Well-being of Future Generations Act.
Improving the mental health and wellbeing of young people is of course not just a job for CAMHS, it is a task in which all practitioners in contact with children and families have a role to play. However, all require the skills, resources and confidence to effectively support children and families. It is vital to raise awareness and knowledge of mental health issues in the community, including in schools, to improve outcomes and reduce stigma. Staff training and development is crucial, but so is development and support for foster carers and postadoption support where needed. There are a number of key elements to consider in our approaches, including:
· Children, young people and families benefit most from an integrated approach to support provision, which follows them through their ‘life journey’. Treating their physical and mental health needs holistically, through services which are properly ‘joined up’ and can continue regardless of geography, avoids the problems of negotiating a fragmented system.
· Early identification and support of health needs, particularly emotional and mental health needs, greatly reduces escalation of problems, the costs of which – both personal and economic – can have a major impact both on individuals and wider society.
· Children in care generally have fewer problems accessing services if they are placed in their ‘home’ authority, which also helps to maintain important social relationships. Support is especially important at times of transition.
· It is recognised that access to support for care leavers can be particularly challenging, as leaving care coincides with a transition from children’s health and wellbeing services such as CAMHS to adult’s services. We need to make sure there are clear pathways in place which identify what happens at key transition points, such as when a child leaves care. There is a need to carefully manage transition from CAMHS to adult mental health services to maintain continuity of relationships and manage different experiences of services. Services need to be joined up at an earlier stage for young people and their families to be informed and aware of adult services.
There also continues to be a role for information, advice and assistance services, including Family Information Services (FIS) to coordinate some of these services. Dewis Cymru is also available as an online directory of services. For example, Wrexham FIS have a partnership approach in supporting families awaiting treatment or diagnosis from CAHMS.
5. Conclusion
The current system is fragmented and stretched public services budgets are leaving many children and young people without opportunities to access early help services while at the same time children and their families who are experiencing significant trauma are floundering without the services to meet their needs. Community services need to be given greater support to help children and young people with mental health issues access services as early as possible in a bid to stop their condition from deteriorating. We would like to see the following changes developed and implemented
· A common language to inform one approach to understanding, assessing and responding to children and young people’s emotional well-being and mental health needs
· One national strategic framework and model for improving the emotional well-being and mental health of our children and young people that brings together leaders in health education, social services, police and third sector as equal partners
· One national integrated approach to assess and support looked after and formerly looked after children and young people
· One national integrated approach to assessment and support young people who require Secure Accommodation that focuses on responding to the crisis and safe and sustainable exit
We are all aware of the need to implement meaningful change with alacrity. For children and young people, a failure to arrest the current and long lasting crisis will have a profound impact on their future.