Focus
Young minds 13 April 2009 Despite policy action, issues around adolescent mental health remain, writes Katie Mackintosh The recently launched Health and Sport Committee inquiry into child and adolescent mental health services (CAMHS) will address important questions, such as how to identify earlier young people at risk of developing mental health problems and what action is being taken to facilitate early intervention; how access to services and support could be improved; and how could the transition from CAMHS to adult mental health services be improved - all incredibly worthwhile issues for discussion. However, while Gregor Henderson, chair, Young Scotland in Mind, welcomes the inquiry, he says these questions are “relatively straightforward” and “almost answer themselves.” “Could problems be being identi- fied earlier? Yes. Are services accessible? Not as much as they need to be. Could the transition from CAMHS services to adult services be smoother? Yes. So they almost answer themselves.” Also, there is a sense of déjà vu about the inquiry, despite it being, as committee convener Christine Grahame pointed out to Alex Salmond, during a recent First Minister’s Questions, “the first such inquiry on the subject by any committee during the lifetime of the Scottish Parliament.” For the Scottish Needs Assessment Programme (SNAP) report on child and adolescent mental health, which was published in 2003, and the subsequent Scottish Executive Framework, published in 2005, have already looked closely at many of these issues. According to SNAP, about a quarter of Scotland’s population is under the age of 19. “At any one time,” it says, “about 10 per cent of them, 125,000 young people, have mental health problems that are so substantial that they have difficulties with their thoughts, their feelings, their behaviour, their learning, their relationships, on a day-to-day basis.” The report highlighted the need to address the whole continuum of mental health – from promotion to prevention to care - and went on to make ten key recommendations for making this happen.  Similarly, the ‘Children and Young People’s Mental Health: A Framework for Promotion, Prevention and Care,’ is a multi-agency document developed for “everyone who has a responsibility for children and young people.” In his foreward to the document, then Deputy Minister for Health and Community Care Lewis Macdonald said, “For the first time, we have a clear and comprehensive direction for children’s and young people’s mental health in Scotland. We now look to our partners in the NHS and local government to ensure that it is delivered.” However, in his recent appearance before the committee, Dr Graham Bryce, a consultant child and adolescent psychiatrist at NHS Greater Glasgow and Clyde who chaired the SNAP report, said that while we have seen some shifts, along the lines that SNAP suggested in areas such as education and culture, he said it has been a “disappointment” that what we have “not seen is a step-up in the capacity to embark on mental health improvement work with children and young people throughout Scotland in a way that is proportionate to the level of need that SNAP identified.” He said that what is most needed now is a mechanism to drive forward the implementation of the framework. He continued, “After examining the issue closely, we came up with a framework that encompasses promotion, prevention and care. We need all those elements. To emphasise one to the detriment of the others will not do. People might say that that will take a lot of time and resources, but so be it—this is about the mental health of our children. “I think that the framework is good enough, as is the evidence base— although it is still growing. The problem is that we have not found a mechanism to drive the implementation of the policy reliably. That is what is most needed.” However, despite this past body of work, it doesn’t mean that the topic, especially one as important as young people’s mental health, is not worthwhile revisiting, particularly as many of the early responses to the committee’s inquiry indicate some of the old issues still remain. In response to the committee’s question about what obstacles there are in identifying children and adolescents with mental health problems, Dr Michael van Beinum, Chair, Section of Child and Adolescent Psychiatry, the Scottish Division of the Royal College of Psychiatrists, wrote about the need to challenge stigma associated with mental health. “It needs to be recognised by all those working with children that impairing and disabling mental health problems in children and young people are common – around 1 in 10 of 5 to15 year olds at any one time will suffer from a mental health disorder. “Despite this, many such children do not have their mental health problems recognised. In part, this is to do with stigma, with children and young people reluctant to seek help for fear of being stigmatised, but is also a matter of a lack of recognition of mental health problems in children by adults working with them, including parents, a lack of training of staff working with children and a lack of specialist resources for children who may have mental health disorders. One way that stigma operates is by a lack of a shared understanding among professionals about the nature of mental disorder among those working with children, and that ultimately serves to deny these children a service.” Similarly, Young Scotland in Mind writes that within children’s mental health policy there is still an imbalance between work on illness and treatment and work on prevention and promotion. “Whilst it is obviously important to address both, too much attention is currently given to dealing with children and young people once a problem or illness has arisen than preventing it happening in the first place… “Put crudely, there is too much emphasis on addressing the ‘stock’ of problems and illness and not enough effort and attention given to addressing the ‘flow’ into and out of illness and problems. This imbalance leads also to poor investment and resource-allocation decisions where there is not enough of a balanced spread of investment in national and local promotion and prevention activities alongside care and treatment costs. In our view, this inquiry needs to address the shortfalls in policy and the lack of balance across promotion, prevention, care, treatment and support.” While in response to questions about the accessibility of CAMHS, Dr R M Wrate contrasted Scotland’s workforce provision with Norway’s. “For most of Argyll and its islands, less than three specialist CAMHS staff are available. For Moray, with twice the population, around nine specialist- CAMHS staff are present. “By comparison, the Lillehammer region, quite similar to Moray in both population and physical geography, is served by a staff group more than three times that number (32). They also have ready access to specialist beds not far to the south. Six of the 32 are based in Otta, a small town of 7,000, two hours up the valley north of Lillehammer (size c 22,000), which also acts as a hub for six more distant smaller populations (amounting, for that team of six, to a total population of c.23,000). Staff for each of these six more distant areas includes a local experienced co-ordinator for CAMHS (appointed from the well developed and quite high prestige public health system), who liaise with one another at the Otta base, ensure timely outpatient care, and organise visiting day-clinics, plus arranging caseconsultation sessions that are also open to other agencies in the community. “To the best of my knowledge, except for Fife, no other rural area of Scotland could conceivably offer vulnerable young people & their families anything like this level of support.” Similarly, the committee’s first oral evidence session – a roundtable discussion with a dozen professionals and then a presentation from former members of the SNAP report group – heard worrying evidence about the scale of the problem. Benjamin Napier, service manager, ChildLine, said that about one and a half million young people in the UK called ChildLine last year. In Scotland, he said 33,500 children received the counselling service, but added that about 30 per cent of calls couldn’t be processed through a counsellor, although they may have needed to be, because of the high demand for the service. However, he said because the service is confidential, free to use and available 24 hours a day, it provides an opportunity for young people with mental health problems to be identified early. “They can phone up and talk to one of our volunteer counsellors about anything that might trouble them. From that, we might be able to identify whether there is the potential for any further problems to develop,” he said. Identifying young people who are potentially at risk of developing mental health problems at an early stage is of key interest to the committee. And yet Dr Phil Wilson, GP and former member of the SNAP report group said that despite several known early indicators of mental health problems, there has been no data collection on early childhood mental health in the community as a whole, adding that the only piece of information relevant to mental health for all children under five that is being collected nationally is whether they can smile at the age of six weeks. However, he pointed to moves in Glasgow that he has been involved in to develop an evidence-based parenting support framework for the city, which will involve the systematic collection of information about children’s emotional wellbeing. “We have proposed that a structured parenting questionnaire be offered to all parents to assess their difficulties in parenting and that a structured tool for assessing parental mental wellbeing be administered when a child is 13 months old. “…At a slightly later age, information will be collected from two other strong indicators. One is a measure of child behaviour at two and a half years. There is strong evidence that children who have problematic behaviour at that age are highly likely to end up with major problems later in life—in fact, some work in the United States suggests that it is possible to predict at the age of three as many as 70 per cent of the children who will end up as in-patients in mental hospital or in prison… The final indicator, he said, is information about language, which, he said, is also a strong indicator of later mental health problems.  “We know that 70 per cent of children who do not have the capacity to put two words together meaningfully or do not have 50 words at the age of two and a half will go on to have a mental health diagnosis by age seven. Almost all of those children will require major input from health, education, social work and criminal justice services.” He said that despite these “robust” early indicators of mental health, an opportunity to identify children at risk is being lost by failure to collect this data. He added that he is hopeful that the pilot, which is due to start in Glasgow within the next couple of months, will reintroduce this. However, despite all of these informative and valuable contributions, it can’t be missed that they all come from adults speaking about children and young people, rather than from the young people themselves. Admittedly, in preparation for the inquiry, the committee undertook a number of informal visits to child and adolescent mental health projects around Scotland where they met and spoke to service users, and given the vulnerability of some of these young people, a return visit to the committee would be wholly inappropriate. And yet the SNAP report did stress the core importance of “recognising the right of children and young people to be heard, and their capacity to play a full part in thinking about mental health and in influencing the arrangements that we make to improve mental health.” A recent study undertaken by Barnardo’s Scotland’s young people’s rights and advocacy service, Hear 4 U, involved 450 young people in Ayrshire and Arran detailing their experiences of mental health services. And their straightforward responses give a real insight into their perceptions of mental health and the services there to support them. Asked how they think children and young people who are emotionally unhealthy would behave, one girl replied: “Probably irrationally, em, I don’t know, like they are maybe, I am trying to think what I would be like, you know. It is easier to think about myself. Maybe, em, shy themselves away a wee bit as well, like, not want to be around people then at the same time, they will, maybe. I don’t know, sometimes it is maybe that you are alone but that you want company of other people but you don’t want to make them, the effort to go and have to, you want people to come to you. You don’t want to go to them and you would just behave like you just wouldn’t be yourself.” Another describes her experience of being referred to mental health services. “The first thing that freaked me out was the voicemail saying that this is such and such from the community mental health team and I was like, oh, mental health, what is wrong with me and I am thinking, mental health, mental health, what is that? What you just think of is the bad things when you think of that.” While another boy describes his impression of the facilities. “I think the sign outside, I have to admit, is kind of in your face. The sign itself and the way it is positioned is very institutional, if you know what I mean. It looks very much like, you know, it is like, you know, Ailsa hospital, it looks very much like that from the outside, which can be quite uncomfortable for some young people. It can be scary for young people,” said one male, aged 15. The report concludes the importance of acknowledging the future involvement of children and young people in CAMHS and ensuring their voices are heard. And yet Frances Emmerson, service manager, Hear 4 U, admits that getting feedback from young people who are accessing mental health services can be extremely challenging. Similarly, she says: “Some of them who have been through services don’t want to come back to speak with us as it can feel like they are being brought back into something they had drawn a line under and moved on from.” But nevertheless, she said, given that many of young people’s mental health problems can develop from them keeping things bottled up inside, it is important to get the message across to young people that their opinions count. “If an adult has something fazing them they could go to find a lawyer or doctor, someone else to help. But children and young people don’t naturally feel they should have their say. “Often they think they have to carry their problems, that there is no one to listen to them. That is a huge worry to them. So I think there is a universal message that we need to try and get to young people, that it is ok for them to have an opinion.” And so in considering the wealth of evidence before them, the committee should make sure they remember it is not just what you ask, but who. Related articles: Being green for a living 3 September 2010 Road to reform 25 June 2010 Bricks and mortar 11 June 2010 Winning hearts and minds 28 May 2010 Bringing it home 26 April 2010 See all articles in this category Submit a comment |
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