Children and Young People's Mental Health

Essentials for Nurses and Other Professionals

Tim McDougall

• Publisher: Taylor & Francis
• Year: 2016
• Print ISBN: 9781138915459
• eBook ISBN: 9781317426462
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Children and Young People's Mental Health equips nurses and healthcare professionals with the essential skills and competencies needed to deliver effective assessment, treatment and support to children and young people with mental health problems and disorders, and their families. Drawing on McDougall's Child and Adolescent Mental Health Nursing and taking the Cavendish Report and Willis Commission into account, this new textbook has been designed to ensure those working in CAMHS can continue to provide a high quality, evidence-based service.

The book explores best practice in a variety of settings and addresses issues such as eating disorders, self–harm, ADHD, forensic mental health issues and misuse of drugs and alcohol in children and young people, as well as child protection, clinical governance, safeguarding and legal requirements. Furthermore, with young people contributing directly to several chapters, the book reflects the importance of involving them in planning, delivering and evaluating CAMHS services.

It is essential reading for all health and social care professionals and students working with children and young people, particularly those working in specialist child and adolescent mental health settings.

Part 1
Policy and strategy

Chapter 1
Changing roles in changing times

Laurence Baldwin

Key points:

• Although children (and young people up to the age of 18) make up a quarter of the UK population, services to meet their mental health needs have historically been neglected, poorly coordinated and underfunded. Currently, child and adolescent mental health services receive 6–8 per cent of the mental health spend in the NHS budget despite increased awareness of need. Across the UK, this increased awareness of mental health issues has not been matched with greatly increased resources or the parity of esteem that policy suggests is needed.
• The increased awareness and understanding is crystallised in the Future in Mind report (Department of Health 2015). While this is a good resource, the change in government has reduced its potential impact. Nonetheless, some increased funding has been made available in England although much of it will be spent on preventative measures rather than directly on healthcare provision. The emphasis on resilience and prevention is also evident elsewhere in the world; for example, in the Australian Headspace projects.
• The growth in the evidence base for child mental health, the greater access to guidance from the National Institute for Health and Care Excellence relating to child and adolescent mental health, and the introduction of a children and young people’s version of Improving Access to Psychological Therapies (via CYP IAPT) has brought an increased use of particular forms of therapies. It also brings a new emphasis on the use of routine outcome monitoring and other metrics that fit better with the way in which the NHS is commissioned and funded, but has some issues for professional practice and workforce planning.

Introduction

It is in the nature of publications like this that any attempt to look at policy necessarily becomes dated very quickly. Thus, this chapter looks at developments leading up to the current situation and draws some conclusions from the themes that have developed across the English-speaking world. Within the UK, the devolution of healthcare to the different administrations in England, Scotland, Wales and Northern Ireland has led, for example, to broadly similar services but with some differences in speed of implementation and emphasis. Across England, the commissioning arrangements through local clinical commissioning groups (CCGs) mean that there are variations in local provision whereas inpatient services are separately commissioned by NHS England and have been subject to a separate review.

This chapter also fails to do justice to the history and heritage of child and adolescent mental health services (CAMHS). The roots in the (social work-led) child guidance movement across the world and the rise of child psychological services and child psychiatry as a speciality in medicine and other professions has been covered elsewhere (see Black 1993; Cottrell and Kraam 2005; Williams and Kerfoot 2005). We do, however, try to draw out some of the implications of current changes for professional practice in nursing, social work, psychotherapies and the allied health professions in particular.

Background

In the past, very little policy attention was paid to the provision of services for child and adolescent mental health. An early UK report, Bridges Over Troubled Waters (Horrocks 1986), addressing deficits in provision of inpatient wards for young people was an exception to this, but it was not until a research report by Kurtz et al. (1994) led to the report by the NHS Health Advisory Service (1995), Together We Stand, that a four-tier model for CAMHS provision was proposed. The Health Advisory Service model was heavily based on Kurtz’s research-based description of existing CAMHS delivery, although it codified that provision and made the important suggestion of a link worker role between health-provided CAMHS and primary care, or universal services. This link worker role was called a primary mental health worker (PMHW) with no explicit reference to the CAMHS element, so it has been easily confused with other primary care staff and other health roles. Together We Stand, whilst being seen as very influential now, actually took a while to have any widespread traction on policy or service development.

It was not until the National Service Framework for Children, Young People and Maternity Services (Department of Health 2004) was published that the four-tiered model was recognised nationally and used by commissioners to describe the provision of community services and to recognise the need for PMHWs as part of the service. More influential at the time was the Mental Health Foundation (1999) publication Bright Futures, which introduced the idea that rather than coming under neither mental health nor paediatric services, children and young people’s mental health was ‘everybody’s business’. This concept helped change the prevailing culture so that more services started to consider emotional wellbeing as an important aspect of wider health and social care, and it was adopted as the title of a Welsh Assembly strategy for CAMHS (National Assembly for Wales 2001). Indeed, the title and the concept were taken up in other service areas, such as older adults (Department of Health 2005), but this led to loss of its distinctiveness and dilution of the idea’s effect.

Another thread in the development of CAMHS policy in the UK and elsewhere involves debate as to the degree to which CAMHS is part of a wider mental health policy or part of policy for children’s services. This can lead to confusion over which elements of policy (as with law) take priority. For example, when the National Service Framework for Mental Health was published (Department of Health 1999), it covered services for ‘working age adults’ – so this included young people aged 16 and 17 if they were working but not if they were in school or some other form of further education. The National Service Framework (NSF) for children (Department of Health 2004) specifically put CAMHS as the lead agency for young people’s mental health up to their eighteenth birthday (Standard 9), thus setting up conflicting policies for some young people, at least for a while. Likewise, workforce policy has not always coincided with or has set out different aspirations for the children’s workforce (Department for Children, Schools and Families 2008) whilst mental health workforce policy has followed a different pathway.

Current themes in policy and workforce

Rather than detailing exact policy moves across England, we look at different themes present in current policy and how they have influenced service delivery, or at least the policy that guides policy delivery, which may well be devolved across countries and regions, leading to different interpretations and implementations of policy locally.

Recognition of the existence of child mental health need and the importance of making provision

Within the competing world of healthcare funding, it has often been difficult for children and young people’s mental health to make its voice heard and to stake a claim on the limited resources that are available under any system for provision of care. Falling between mental health and paediatric services has led to CAMHS being seen as a ‘Cinderella service’ (YoungMinds 2014), and there remains a struggle for recognition that is only now being addressed. The YoungMinds submission to the House of Commons Health Select Committee noted that whilst one in ten young people have some form of mental health issue, only a quarter of those young people access services; it also drew attention to the fact that the CAMHS budget is around 7 per cent of mental health funding, which itself does not have parity of esteem with physical healthcare provision.

As with the Mental Health Foundation’s Bright Futures report (Mental Health Foundation 1999), it has often been for the third sector (voluntary and charity providers) to make the argument for increased provision and recognition of mental health and emotional wellbeing needs. Pressure from YoungMinds and others led to a review of inpatient CAMHS provision in 2014 (CAMHS Tier 4 Steering Group 2014) from which followed the Health Select Committee review of all CAMHS services in England (House of Commons Select Committee 2014). From this was developed the Children and Young People’s Mental Health and Wellbeing Taskforce, set up by the then Care Minister Norman Lamb, to make recommendations for future services. This expert reference group brought together a wide range of professional and service user representatives who reported in early 2015 with the Future in Mind document and accompanying resources (Department of Health 2015).

The Future in Mind report was clear in pointing out an economic argument for investment in CAMHS. In addition, because of an awareness that in the past, good words and high intentions have not always been followed by action, the report looked at how implementation might take place. It also highlighted that access to information which might drive change has been difficult within CAMHS. Part of this problem is to do with reliable prevalence data. The last general survey of mental health across the country was conducted by the Office for National Statistics (ONS) more than a decade ago (Green et al. 2005), and whilst there have been partial attempts at large-scale census since then, these have not been comprehensive. The Durham CAMHS mapping exercise (see National Child and Maternal Health Intelligence Network 2015), for example, was based on clinician-reported samples, whilst the Centre for Mental Health cohort study has only been able to focus on a younger age group (a millennial cohort who are still growing up) (Gutman et al. 2015). Recommendations for better data collection may be irksome for those who have to collect and input the data (usually the clinicians), but it strengthens the case for increased provision of resources. Similarly, increased collection of data on outcomes gives quantitative evidence for efficacy of services as well as demonstrating the level of need.

The importance of early intervention and the role of resilience

Whilst the importance of early intervention has been known about and advocated by various schools of thought for a long time, it has rarely been included in health policy, which has concentrated largely on secondary care. Community psychology, for example, has long stressed the need for dealing in a more systemic way with the conditions that lead to poor mental health (Casale et al. 2015). Bowlby’s theories of attachment (1988) – although criticised for putting excessive blame on the role of the mother (and not including fathers) – have been influential in helping understand infant mental health development, as have the psychodynamic models of Anna Freud and Melanie Klein. Developmental theories have always informed our understanding of young people’s psychological functioning but, again, have not strongly influenced how much importance we give to enabling children to develop healthy minds. The recent focus, however, on the function of resilience has helped to make people think more carefully about why some children and young people seem to survive and flourish when others in similar circumstances develop serious mental health conditions (e.g. Gilligan 2004).

In particular, this renewed interest has led to a greater focus on the role of schools in promoting and sustaining mental health from a public health and primary prevention viewpoint. There is not complete agreement on how best this should be done, however, and there are different solutions proposed for different settings. In Australia, a major study of school-based interventions (URBIS 2011) concluded that there was no ‘one size fits all’ solution, and schools should be careful in selecting the right approach for their setting based on their own demographics and needs. In the UK, the skills deficit (or often the lack of confidence to deal with mental health issues) has been addressed in part with the establishment of an online resource called MindEd, which is an electronic learning resource that is free to access and provides a range of teaching for professionals (see www.minded.org.uk).

The development of increased evidence-based practice within child mental health

As CAMHS have developed over the last few years, the practice has been increasingly informed by the rise of evidence-based practice. Mostly, this change is because the evidence base was previously very poor and finding research funding to deve...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Contributing authors
• Foreword
• Acknowledgements
• Abbreviations
• List of figures, tables and boxes
• Note
• Introduction
• PART 1 Policy and strategy
• PART 2 Common mental health and psychosocial disorders
• PART 3 Service provision
• Index