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Adolescent Lifestyle Survey - Appendix

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					Agenda Item No:
Report to: Presented by: North East Lincolnshire PCT Board 9th June 05 Louise Garnett, Communities Count, Public Health Department Louise Garnett 31st May 2005 ADOLESCENT LIFESTYLE SURVEY
X OPEN X FOR ACTION CLOSED
FOR INFORMATION FOR COMMENTS

Report Author: Date: Subject: Status: Reason:

Executive Summary
Between November 2004 and January 2005 members of the Public Health Department undertook an Adolescent Lifestyle Survey across North East Lincolnshire secondary schools. The aim was to establish baseline information on the health-related behaviours of local 11-14 year olds, with a view to monitoring trends over time. All but one mainstream secondary school in North East Lincolnshire took part. The survey gathered responses from more than 3,300 pupils living in the area, representing more than 40% of all resident 11-14 year olds. The results of this survey will be used to inform the development of local health and well being strategies, including, the Community Strategy, the Children’s Services Plan, and the healthy schools programme. The survey was jointly commissioned by NEL PCT and the Local Strategic Partnership. Funding was also provided by North East Lincolnshire Teenage Pregnancy Partnership, Safer Communities (Drug and Crime) Partnership Board, and the Connexions service.

Summary of Key Implications
The full report is available at www.nelpct.nhs.uk. Key findings and recommendations are summarised in the appendix summary report.

Recommendations / Action for the Board
NEL PCT Board note the findings and endorse the recommendations.

1. Introduction The results are based on a self-report survey completed between November 2004 and January 2005 in all but one mainstream secondary school in North East Lincolnshire. It was not possible to conduct a complete census of all secondary school pupils because of the costs involved and the likely burden on each of the schools. We were also asked not to involve Year 11s in the survey because of the demands placed upon them and their teachers in this important examination year. However we wanted a sufficiently large sample across North East Lincolnshire to ensure adequate precision of prevalence estimates across the population as a whole, as well as within school year groups. Each school was asked to administer a confidential questionnaire to at least three mixed ability classes in each year group. We selected the tutor groups at random and an average of 12 classes per school were selected to participate. This was to ensure that the classes were as representative as possible, as well as being large enough to allow schools to generalise from their own results about their whole school population. Once the classes were selected, each school was given a letter to distribute to parents or guardians informing them about the survey. Parents were invited to reply only if they were not willing for their child to take part. The questionnaire was designed so that it could be completed anonymously during a single class period, preferably in exam type conditions. Guidance notes were prepared for the relevant teachers and schools were offered support in administering the questionnaire. At least 2 local schools took up this offer. More than 90% of those invited to take part completed a questionnaire; the main reason for non-response being authorised absence from school. Less than 1% refused to participate. Overall we had just over 3300 responses representing 40% of the total resident population of 11-14 year olds in North East Lincolnshire. The forms were processed during January and February 2005 and analysis began in mid March of this year. The following results represent a summary of the key findings and recommendations of the survey. A full technical report is also available. Key findings for North East Lincolnshire 2. SMOKING HEADLINES  Teen smoking is not illegal in this country and whilst it is the leading behaviour related cause of illness and premature death, adolescent smoking does not attract as much public anxiety as under age drinking or other substance misuse.  One of the reasons why the decline in adult smoking has halted in recent years is because older quitters are rapidly being replaced by young people

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taking up the habit for the first time. Reducing smoking initiation amongst the young is therefore essential if the downward trend in adult smoking is to be re-established.  Although the majority of children do not smoke, teen smoking rates are above the national average in North East Lincolnshire. Overall, 9% 11-14 years were regular smokers. This compares with 5% nationally. Teen smoking peaks at 12-13 years of age and is particularly high amongst girls. By the age of 14, almost a quarter of girls, (24%) and 14% boys are regular smokers, compared with 14% and 11% nationally. In spite of universal anti-smoking education, and targeted health promotion activities, we estimate there are at least 800 regular smokers in North East Lincolnshire secondary schools, most of whom have been smoking regularly for more than a year. Almost three-quarters of these young smokers live with other (adult) smokers, suggesting that familial influences on children’s smoking habits are very strong. More than half of teen smokers buy cigarettes from shops and most say they find it easy to purchase tobacco. The rest either ask others to buy cigarettes for them or get them in some other way. It is not known what role ‘smuggled’ cigarettes play in this alternative teen market. There are clear social class differences in smoking rates. In schools with high rates of Free School Meal eligibility, pupil smoking rates were three times the local average and almost four times the national average. Unless the uptake of teen smoking is tackled, inequalities in smoking related health outcomes are likely to persist for years to come. Three quarters of teen smokers appear motivated to quit, yet there is no dedicated smoking cessation service for young people in this area, and no national guidance on how to implement one.

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RECOMMENDATIONS 1. The LSP and the Children and Families Partnership Board should make smoking reduction a key priority for action in the Community Strategy and the forthcoming Children’s Plan. 2. The PCT and partner agencies should review their work place smoking policies in preparation for the implementation of the Health Improvement and Protection Bill and should ban all smoking by staff, children and adults in or immediately outside their buildings. 3. Local agencies should work together on preparing for a universal smoking ban and share best practice on how to implement and monitor the outcomes of the forthcoming legislation.

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4. The LEA, PCT and local schools will need to strengthen and extend their commitment to the Healthy Schools Programme if new Government targets are to be met. 5. PHSE co-ordinators should review the content and timing of their health education curriculum, especially in view of the earlier age of smoking initiation in this area and the higher than average smoking rates amongst teenage girls. Those schools with particularly high rates of teen smoking may need to tailor their programmes to meet local needs and may need additional targeted support. 6. Young women may be more susceptible than young men to media messages about body image and may believe that smoking helps them to control weight. This should be challenged and the short-term health, social and financial consequences of smoking reinforced. 7. Preventing the sale of tobacco to children will require continued and concerted local action. Local shopkeepers should be encouraged to engage in proof of age schemes and must be informed of the likely consequences of repeated failures to comply with forthcoming legislation. 8. The PCT should develop an adolescent smoking cessation service in this area, building on the brief intervention-training programme currently being piloted by the Health Promotion Service and Adult Smoking Cessation Service. The role of school nurses, youth workers and Connexions Service in delivering smoking cessation should be considered and targeted at those schools and communities with the highest smoking rates. 9. Young people who are heavy smokers tend to use other substances and have a range of other problems, which may cluster and reinforce each other. Tackling smoking may not be regarded as a priority by professionals compared with other pressing health, social and emotional needs. However, smoking should be always considered alongside other substance misuse issues in any assessment of health needs. 10. School or community based prevention programmes will only be effective if they are underpinned by work that helps to build young people’s skills and resilience and raise their self esteem. This will require a collaborative approach to improving children’s health and well being across all statutory agencies. 3. ALCOHOL HEADLINES  Alcohol is the most widely used recreational ‘drug’ in this country. Most adults drink alcohol and the majority do so without experiencing any problems. However there is growing concern about the amount of alcohol that is currently being consumed by adults and young people in this country. The Government’s Strategy Unit estimates the cost of harmful drinking to public services nationally, including the NHS, at around £20 billion a year. Recent Department of Health data suggest a dramatic increase in cirrhosis deaths during the last 30 years, with an eight fold

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increase in mortality amongst 35-44 year old males and a four fold increase amongst mean aged 25-34 years. Hence the recent publication of a national Alcohol Harm Reduction Strategy.  Most children report having their first taste of alcohol between 10-12 years of age and by the age of 15 most will have had a whole alcoholic drink. This is nothing new. What has changed in the last 15 years is the frequency of drinking, the age at which regular drinking begins and the amount of alcohol consumed. Between 1990 and 2004 the average number of alcoholic units consumed by 11-15 year olds doubled from 5 units of alcohol in the previous week to just over 10 units, making English under 16s some of the heaviest drinkers in Europe. Young people who engage in heavy and prolonged ‘binge’ drinking in their teenage years are at particular risk of alcohol related health problems in later life, and are more likely to develop alcohol dependency as adults. In North East Lincolnshire, as elsewhere, regular weekly drinking is a fairly well established part of teenage leisure time. By the age of 14, more than a third of children report drinking at least once a week, of whom more than half are consuming 10 or more units. There are no differences in drinking rates between girls and boys or between urban and rural populations. Unlike smoking, regular drinking is not associated with low socio economic status. We could find no evidence of a socio economic gradient in teen drinking, although research evidence suggests that problem drinking is more prevalent amongst low income children, who often have other social, emotional and behavioural difficulties. Although most children drink at home, by the time they reach their mid teens, children are more likely to drink outside on the streets or in parks. This raises issues of personal safety and increases the risk of accidental injury, sexual exploitation and exposure to drugs. More than a third of 1314 year olds reported being drunk on at least one occasion in the previous 12 months, 6% report having unprotected under age sex, and 10% admit using drugs whilst under the influence of alcohol. Acute alcohol intoxication is potentially life threatening for children and whilst it is rare, national surveys suggest that the incidence of such events is increasing. In our survey, 2% of under 15s report attending the local Accident and Emergency Department as a result of being drunk in the last year. This is equivalent to at least 160 attendances a year. Young people continue to purchase alcohol illegally. More than a quarter report buying alcohol themselves from shops. More commonly (31%), they ask a friend or stranger to buy their alcohol for them. However the main source of alcohol continues to be the home, for both regular and occasional teen drinkers.

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Young people have developed a culture of inappropriate drinking over the last 10-15 years, prompted by increased availability, higher incomes, and the proliferation of alcoholic products and drinking venues, which are specifically aimed at the youth market. As long as drinking alcohol to excess remains a legitimate and socially acceptable activity, children will continue to mimic others and use and abuse alcohol in much the same way that some adults do. Tackling the culture of drinking will therefore require a long term and whole community approach to alcohol reduction which encompasses availability of alcohol as well as adult drinking attitudes and behaviours. The Public Health Directorate will explore these issues in more detail in a forthcoming alcohol needs assessment which is due for completion in June 2006.

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RECOMMENDATIONS 1. The PCT and other Local Strategic Partnership organisations should review their workplace alcohol and drug policies and consider actions which might help the population move away from a culture of heavy drinking. 2. Alcohol harm reduction should be a key element of the Community Strategy and a priority for the Children’s Plan. 3. Mainstream children’s services should develop drug and alcohol policies which include formal awareness training for all staff, as well as common protocols for responding to harmful drinking amongst children and young people. 4. Each agency should have a lead professional with responsibility for alcohol and other substance misuse issues. They should work together with members of the Children and Families Partnership Board and the Safer Communities (crime and drug) Board to develop and implement a local alcohol harm reduction strategy. This should be informed by the results of the Public Health Alcohol Needs Assessment, which is due for completion in June 2006. 5. Alcohol education is already part of the PHSE/drug education curriculum in North East Lincolnshire and is one of the 10 priority themes within the Healthy Schools programme. This includes awareness raising, skill development, harm minimisation and access to services. Schools may need to review the timing and content of their drug and alcohol education programme, given the younger age at which regular drinking begins in this area. 6. Particular attention should be paid to the increased risk of accidental injury, drug misuse, and unsafe and coercive sex under the influence of alcohol. This should form an integral part of SRE and drugs education in schools.

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7. The DfES expects all schools to have at least one trained designated person with overall responsibility for drug and alcohol issues. This will require ‘skilling up’ a large number of professionals across the area. Local agencies will need to strengthen their investment in training to ensure that these new targets are met. 8. The Children and Young People’s Partnership should undertake an audit of alcohol and substance misuse training needs across children’s services. 9. Positive leisure and diversionary activities for young people should be strengthened and extended. Under-age drinking is as common in rural areas as it is in Grimsby, Cleethorpes and Immingham towns. Any actions to tackle alcohol misuse should be authority wide. Children and young people should be involved in shaping and evaluating local recreational activities and their views taken seriously. 10. Concerted efforts will be required to reduce under age alcohol sales. Other sources of alcohol will also need to be tackled. The development of a responsible code of conduct for shopkeepers, supermarkets and licensed premises may help to tackle the availability of alcohol to young people. 11. Parents will need support and guidance to help them discuss alcohol with their children and promote sensible drinking at home. They should know where to go for advice in the event of a problem. 12. Substance misuse screening and referral is already in place with young offenders and will be extended this year to other vulnerable groups, including Looked After children and those children who are excluded from school. Training on this and other screening and referral processes will be required across a number of agencies to ensure consistent practice. 13. Northern Lincolnshire and Goole Hospital Trust should develop protocols for children who present to A&E with alcohol related conditions and ensure that other presenting physical and mental health needs are addressed. As a minimum, young people and their families should be given information on the local young people’s substance misuse team, and offered a follow up appointment with a member of NEST. 14. NlaG Hospital Trust should monitor alcohol related attendances to help monitor whether harmful drinking amongst children is increasing. 15. Professionals who work directly with children and young people should be alert to any child safety and child protection issues which may be associated with risky drinking and underage sex and ensure that local child protection procedures and guidance are followed. These guidelines apply to children over the age of 16 as well as those under the age of consent. All agencies should be aware that professional discretion must not be exercised in any case where a child is under the age of 13.

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16. Humberside Police and North East Lincolnshire ACPC should develop specific training and guidance on these new protocols and clarify the position of those who offer sexual health services and advice to young people, particularly those working in health settings. 4. ILLICIT DRUGS  Whilst regular or problem drug use is relatively rare at this age, experimental or recreational drug use has increased significantly during the last 20 years and is now more prevalent than either ‘binge’ drinking or regular smoking amongst adolescents. In 2004, more than a third of 15 year olds and approaching half of all 20 year olds in this country had already tried at least one illicit substance, with cannabis leading the way as the most popular drug of choice.  Most children receive drug education from primary school age onwards, and awareness of drugs is high amongst our secondary school population. The vast majority of 11-14 year olds had heard of each of the drugs listed in the survey questionnaire. Exposure to illicit drugs is also common, even at this age. Almost 1 in 4 under 15s report being offered drugs. By the age of 14 more than a third of boys and 47% girls said they had been in drug offer situations, the most commonly offered drug being cannabis. Young people are just as likely to be offered drugs by someone they know as they are by strangers or dealers. Three per cent of all under 15s report being offered drugs by relatives, mainly siblings and other same age relatives. Exposure to drugs is as high in rural communities as it is in urban areas. Experimentation with drugs is extremely rare at 11 years or younger, but rises sharply between 12-13 years of age. By the age of 14, more than a quarter, (27%) will have already experimented with drugs, with equal rates amongst teenage girls and boys. Cannabis use is slightly more prevalent amongst North East Lincolnshire secondary school aged children than nationally and is especially high amongst girls in Year 10. Cannabis use is higher than nationally amongst this age group. Cannabis is by far the most commonly used drug, accounting for almost three-quarters of self reported drug use by young people. ‘Harder’, more physically addictive drugs are rarely used. Less than 3% of 11-14 year olds had tried Class A drugs in the previous year, and less than 2% reported using either crack or heroin. If these self reports are to be believed, it is likely that most of these young people were just beginning to experiment with harder drugs, making early intervention important, as even casual use of these drugs can be extremely damaging. However, as children get older they are more likely to experiment with a wider range of drugs. By the age of 14, more than a half of our cannabis users had tried other illicit substances.

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Traditionally it has been boys rather than girls that have experimented with drugs. However, this gender gap appears to have closed. We found no statistically significant difference between girls and boys, either in exposure to drugs or in recency of drug use. There appears to be no socio economic gradient in adolescent drug use, although problem users are likely to live in poorer communities and have other social, emotional and behavioural problems, including problem drinking. There were recent drug users in every secondary school and in every year group. By the time they reach Year 10 (14 years), anywhere between 12% - 46% of each school’s year group will have experimented with drugs. Most drug use amongst young people is occasional and recreational. The proportion that goes on to develop a drug problem is very small in comparison, and is estimated to be between 2-6%. Although poly drug use is a common antecedent of problem drug use in adulthood, it is impossible to say how many of these young people were dependent on drugs. Given their age and vulnerability, it is likely that many of those with serious drug problems were already known to specialist support services. However, children are clearly putting their health at risk by trying and mixing a range of different illicit and unregulated substances, however infrequent and should be assessed and referred to specialist services as appropriate. A small percentage of young people reported being offered drugs by family members, including siblings, parents and other relatives. Research from elsewhere has shown that having someone in the family who uses drugs, significantly increases the likelihood of young people initiating drug use. Following a recent national inquiry, steps are already being taken at a national and local level to increase support to children affected by parental problem drug use. Less is known about the impact of illicit drug use by other family members, such as siblings and cousins, nor about the impact of parents’ recreational drug use on children. It may be that illegal drug use by same age relatives, as well as adults, greatly increases the risk of illegal drug use on the part of some teenagers. If so, children will require a range of strategies, including how to deal with drug offers from close relatives, as well as more focused support which can encompass other family members who are recreational drug users. The Department for Education and Skills has recently published their revised guidance on drugs for schools, which clearly outlines their expectations for drug education at both primary and secondary school level. The guidance states that drug education should clarify misconceptions about the prevalence of drug use, increase knowledge and understanding of the health risks and social impact of drug use, as well as help young people develop personal and social skills to make informed decisions and keep themselves safe. However, the survey demonstrates that young people will differ markedly in their experiences of drugs. Even at 12 or 13 years of age, a typical year group is likely to encompass children who have no interest or experience of drugs, as well as a small 9

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number who are already experimenting with a range of illegal substances including Class A drugs. The period following transition to secondary school is a particularly vulnerable time for at risk adolescents, especially if there is little parental supervision in the home. The challenge for schools is to provide a drug education programme which is equally relevant to both groups, without alienating or stigmatising some young people. This may involve targeting some children who are already showing signs of behavioural difficulties or disengagement from school to prevent problems from escalating further.  Whilst the scale of adolescent drug use nationally is unprecedented, we should remember that the majority of children and young people have never tried drugs. There is therefore nothing inevitable about drug use amongst young people. Supporting children who are already declining drug offers and presenting such choices in a positive light will also be important.

RECOMMENDATIONS 1 North East Lincolnshire already has in place a number of initiatives to prevent adolescent drug use, reduce harm, and support families and young people with a serious drug problem. However, the new national drugs strategy requires all agencies that work with children and young people to have a drugs policy. This will require the appointment of a substance misuse champion in each of the statutory children’s agencies and should include procedures on how to deal with drugs related incidents as well as a well resourced and continuous programme of staff training. 2 The Children and Families Strategic Partnership will be the lead multi agency body for developing and monitoring policies on child and adolescent substance misuse. In the short term the local authority should join the Young Person’s Substance Misuse Commissioning Group in readiness for this transfer of responsibilities and ensure that the Young Person’s Substance Misuse Plan is embedded in the forthcoming Children’s Plan (2006). 3 Although the prevalence of Class A drug use by adolescents appears to be stabilising nationally, cannabis use is becoming more common and across all social groups. Children and parents will need clarification about the law in relation to cannabis as well as information about the potential harm that can be caused by prolonged use, to prevent this drug from becoming normalised in our youth population. 4 Drugs appear to be readily available to those children who want them. Most children said they knew someone who took drugs and as many children were offered drugs by people they knew as by strangers, including a small but significant number who were offered drugs by relatives. Concerted efforts should be taken to reduce children’s access to drugs, and to provide children with strategies to resist drug offers, especially from family members.

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Reducing harm to children affected by drug misuse within the family should be a main objective of local drug strategies and should encompass exposure to drugs by same age relatives such as siblings, as well as by parents. The Government has made it clear that it expects drugs education to be delivered in all schools and other education settings throughout compulsory school age and has produced guidance on what this should cover. The DfES also expects each school to have at least one trained designated person who has overall responsibility for drug issues. This will require skilling up a large number of professionals across North East Lincolnshire. Agencies should ensure that training opportunities are developed and sufficiently resourced.

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7. Given the scale of recreational drug use amongst teenagers and the relatively early age at which experimentation begins, both primary and secondary schools should review the timing and content of their drugs education. Drugs awareness and harm reduction training should be extended to all staff who work directly with children and young people. Parents will also need support to help them discuss drugs with their children and should be given information on where to go for appropriate specialist advice. 8. Local information suggests that children and young people are reluctant to self refer to specialist services and may not recognise that they have a drug or alcohol problem. Professionals who work with vulnerable children and young people should persist in encouraging and supporting young people to take up the necessary intervention services, even if they are at first, reluctant to do so. 9. Research on peer led education programmes suggest that these may be more effective than other approaches in delivering vital information on how to prevent drug misuse. Programmes which adopt a ‘Life Skills Training’ approach have also been shown to be effective in reducing smoking, alcohol and other substance misuse. Local agencies should develop and strengthen both elements in their drug education programmes. 10.It is vital that prevention programmes and harm minimisation messages address poly drug use, including alcohol, as this appears to be more common here than elsewhere and is already evident amongst children as young as 11 and 12 years of age. 11.Although universal education is important; children at particularly high risk of substance misuse may not be attending school and will need to be targeted for additional support. This will include young offenders, children who are in alternative education settings, children who are looked after, and children and siblings of adult drug users. This education and support will need to be tailored to meet the particular needs and circumstances of these groups and handled sensitively to avoid any stigmatisation.

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12. People working with ‘vulnerable’ children must be alert to signs of substance misuse, (including alcohol) and be confident about how to respond appropriately. This should be an integral part of the local Common and Integrated Assessment Framework implementation and encompass all statutory and voluntary agencies. 13 Children who present to services with alcohol and other substance misuse problems are likely to have other physical and mental health needs as well as social and educational problems. Practitioners will need clear protocols about how and when it is appropriate to refer children for additional and specialist advice. 14 Drug prevention programmes must tackle not only the harms caused by drugs but also the reasons why some young people may choose to take them. Numerous studies report that the vast majority of young people report using drugs to give pleasure and do not worry too much about the long term or even immediate health and social consequences. Providing positive alternative and diversionary recreational activities for children and young people is important to prevent this and other risky behaviours from escalating. Children and young people should be involved in shaping these services and their views taken seriously. 15 For children and young people generally, the best long-term results may come from better education and training opportunities. This is already the focus of existing programmes, such as Positive Futures, which operate in the most deprived parts of North East Lincolnshire. These will need strengthening and extending to prevent problem drug use from escalating further. It should also be extended to children living in more rural areas. Drug use was just as prevalent in the villages and small suburban communities as it was in the towns. Socio-economic deprivation tends to be ‘hidden’ in these areas, although the risks of developing drug problems may be just as acute. 16 Wider social policy initiatives on employment, benefits, housing and child care which ameliorate family poverty and parenting problems may also do much to reduce risk taking behaviour amongst the young. The Children and Families’ Partnership Board and the LSP should continue to tackle these issues as a matter of priority. 5. SEXUAL HEALTH  Whilst teen conception rates have been declining steadily in North East Lincolnshire, rates are still very high compared with other areas. Hence the importance of continuing with a multi faceted approach to sexual health which includes sex and relationships education, accessible and friendly advice services and support to parents in talking to their children about sex and relationships. Sustaining these services long term and continuing to target those young people most at risk of early sexual activity with life skills training will be important if teen conception rates are to fall further.

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Most children in North East Lincolnshire receive some form of sex education and in those schools working towards Healthy Schools Standards the quality of teaching is likely to be high. However in some schools SRE continues to be delivered by form tutors, with little experience specialist knowledge on the subject and no specific timetable to deliver it. Schools should be encouraged to take up specialist training and support to ensure that the messages young people receive are consistent and appropriate to their age and other needs. Schools will also need to ensure that their teaching time for SRE, and PHSE more generally, is not reduced by the demands of the National Curriculum. Although it is likely that most children in this survey had received education on contraception, almost 10% of local 13-14 year olds said they couldn’t remember having any. Whilst there is a specialist multi agency team (MASHT), which enhances the core SRE curriculum in schools, resources are tight and training capacity is already over stretched. Without additional long term investment, raising the skills of local teachers, outreach workers, and other childcare professionals in this area is going to take some time. Some of this shortfall in capacity will be addressed by the recent LDP bid for a new post of Sexual Health Training Coordinator. However, on its own this post is unlikely to be enough to meet all existing professional training needs. Most schools allocate at least 60 minutes a week to PHSE at Key Stage 3 and 4. However we are aware that in some schools no time was dedicated to this at all. A recent national OSTED report on PHSE education described this situation as ‘untenable’. The increasing pressure on schools to deliver targets in National Curriculum subjects means that PHSE is often the first subject to suffer. As young people approach Years 10 and 11 the pressure on timetables is particularly intense. Yet this is just age when young people are most likely to be engaging in risky behaviours, such as binge drinking, experimenting with drugs and ‘risky’ under age sex. All the evidence suggests that the more good quality information young people have, the more likely they are to delay sexual activity. Most young people locally and nationally, rely on schools as their main source of information about sexual health, although this is often supplemented by information and advice from parents and friends. Schools will need to ensure that the information they receive is consistent and equips them with the resources to make safe and healthy choices about their sexual behaviour. As the recent OFSTED report pointed out, this is more than simply giving information and should include a whole range of strategies to explore attitudes and beliefs, and develop young people’s communication and decision making skills. In today’s multi media environment young people are exposed to an array of messages about sex and relationships, some of which may be factually incorrect, unhelpful or at worst offensive and potentially harmful. Hence the importance of a consistent and collaborative approach to sex 13

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education, which encompasses a balance of knowledge, skill development and exploration of attitudes and values.  There is good evidence that including teenagers’ parents in information and prevention programmes is effective and can increase use of contraception. However there is also research that has indicated a possible increase in pregnancies amongst those young people whose parents have positive attitude towards early pregnancy and early parenthood. Engaging parents in training and education, and providing them with the skills to talk about sex and relationships at home may encourage them to take more responsibility for their children’s sexual health. This training will need to be carefully targeted, as currently many of the parents who take up training are already fairly knowledgeable. As far as knowledge about local services goes, young people appear to be fairly well informed about contraceptive services. Virtually all said they knew where to get free condoms and almost half of Year 10s said they had heard of Choices clinics. Whilst this level of awareness is encouraging it falls well short of the 80% reported in neighbouring North Lincolnshire. Local schools and youth agencies will need to strengthen their promotional activities as research evidence from elsewhere suggests that the first visit to a sexual health or young people’s clinic often follows, rather than precedes their first sexual experience. Knowledge of STIs was patchy and for those infections which commonly affect young people, such as Chlamydia, and Gonorrhoea, awareness was particularly poor. As expected almost 9 out of 10 had heard of HIV/AIDs, although 1 in 5 were clearly ill informed about whether it could be treated and cured. This compares with almost 80% of 14 year olds who claimed to know nothing about gonorrhoea. This is of some concern, as by the age of 14, more than a third of young people said they were sexually active, and just over a quarter claimed to have already had sexual intercourse. In our study, 80% of sexually active young people reported always using a condom, 25% claimed to use both the pill and the condom and almost 20% used no form of protection at all. The timing of educational intervention is therefore important as research has shown that young people who are already sexually active at the start of interventions are less likely to change their contraceptive behaviour. According to national survey data, 91% of boys and 67% of girls aged 13 and 14 at first intercourse are not sexually competent, (measured in terms of regret afterwards, willingness to have sex, autonomy over decision and use of contraception). Other international studies have shown increasing rates of coercion the younger the age that sex occurs, with young women in particular being affected. Young people must be provided with the confidence and skills to say no to sex if they feel they are not ready and to protect themselves and their partner from sexually transmitted infections. To be effective, sex education must be underpinned by efforts to raise self esteem and aspirations amongst young people. 14

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In England it is unlawful to have sexual intercourse under the age of 16. This law exists to protect adolescents from engaging in activities that they are not ready for. Whilst the law recognises some need to exercise professional judgement and discretion in reporting under age sex, this only applies to 13-15 year olds and according to local draft guidelines, any decision not to refer to child protection services must be based on an assessment of need and the decision recorded and signed. Under the Sexual Offences Act, 2003, children under the age of 13 are not deemed competent to make decisions about sexual activity. Hence all such cases must be reported to the relevant authorities. All professionals who work directly with children and young people and specifically those who work in health promotion services may need specific guidance and support on how to apply the new legislation and local child protection procedures without compromising children’s rights to free and confidential advice.

RECOMMENDATIONS 1. It is crucial that good quality SRE continues to be delivered in our local secondary schools. Schools should be encouraged to take up specialist training and support to ensure that the messages young people receive are consistent and appropriate to their age and needs. They should also ensure that their teaching time for SRE, and PHSE more generally, is not reduced by the demands of the National Curriculum. 2. Resources for training and supporting SRE teaching in schools are tight and are currently over stretched. Raising awareness, knowledge and skills amongst teachers, youth and children’s workers, and parents will take some time unless additional training resources are committed. 3. Promotional activity for Choices drop-in services needs to continue. The ‘Where to Turn’ directory of service provision has been reviewed and several thousand copies will be disseminated locally. Because the information quickly becomes out of date, a credit card resource is being developed. This will promote the national RUthinking website where details of current services, including Choices clinics are kept up to date. The Teenage Pregnancy Partnership Board and the Media sub group should continue exploring new ways of ensuring that sexual health messages reach young people.

4. Given the association between low income and early sexual experience, and the strong correlation between teen pregnancy rates and socioeconomic deprivation, a neighbourhood focus to tackling deprivation, raising aspirations and self esteem and addressing sexual health issues is crucial. Choices clinics must be accessible to young people living in areas of high deprivation. Raising awareness and aspirations amongst parents of young teenagers will also be important. In some communities, having children under the age of 18 may be regarded as both acceptable and inevitable. 5 Consistent and correct use of condoms (for all sexual acts) is critical to prevent the transmission of STIs. Given the scale and spread of STIs 15

amongst young people over the last decade, promoting condom use amongst sexually active adolescents is essential. Messages about risky sexual activity, especially under the influence of alcohol, should be reinforced at every opportunity, both in school and in college, as well as when young people come into contact with sexual health and emergency contraception services. 6. Poor local knowledge about STIs is disappointing and worrying. The Teenage Pregnancy Partnership Board and the Sexual Health Partnership Board should consider what additional action would be required to address this. It may be necessary to review the timing and content of this element of SRE in schools. A national awareness raising campaign will be launched later this year. It is important that national products are widely disseminated to this age group. 7. Humberside Police and North East Lincolnshire ACPC should clarify the position of professional staff who offer sexual health advice and services to young people. Health staff in particular will need training and guidance on the practical implications of the Sexual Offences Act, 2003 and the draft ACPC Protocols and Guidance. 6. EMOTIONAL HEALTH AND WELL BEING  Whilst most children worry about things from time to time, relatively few are deeply troubled, anxious or depressed. Nevertheless, each of North East Lincolnshire’s secondary schools is likely to contain at least 100 pupils who are significantly distressed, clinically depressed or suffering from some other mental health problem. Standard 9 of the National Service Framework (NSF) for Children, Young People and Maternity Services requires that all children and families should be able to access staff who can help assess, advise and support children who may have mental health difficulties, including emotional and behavioural problems. Work is already in hand to improve capacity shortfalls within specialist local CAMHS services and to develop skills at Tier 1 and 2, including the development of primary mental health care workers. A fuller health needs assessment of Child and Adolescent Mental Health is due for completion in June 2006. This may identify other areas for improvement in response to young people’s emotional and mental health. Children worry to varying degrees about a range of day-to-day issues. In our survey, overwhelmingly it was school that dominated amongst young people’s main concerns, with more than third of 11-14 year olds saying they worried a lot about exams, homework and tests. Running a close second were other seemingly unrelated issues including relationships with friends, how they were perceived by their peers, their health, and money problems. On closer inspection, all of the issues that young people worry about can be seen to be linked to feelings of self worth and a desire to be valued by others. Young people are particularly sensitive and vulnerable to what is

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told to them about themselves and are dependent on good feedback to help them build a healthy and respectful view of themselves. Maybe the reason why exams, homework and ‘doing well at school’ feature so prominently amongst young people’s concerns is because they tend to be the only behaviours that children feel they are rewarded and valued for.  The National Healthy Schools Standards has a specific theme entitled 'emotional health and well-being (including bullying)'. The schools themselves negotiate targets, and many opt to set targets in relation to this theme. However, in many schools the focus continues to be on the physical rather than emotional health of pupils. The profile of emotional competence may need to be raised in some schools as well as within children’s work more generally, particularly as it underpins many of the outcomes for children and young people within the national Every Child Matters framework. As adults we can all help build young people’s self esteem by giving them opportunities to develop the skills required to make safe and positive choices and to understand the likely consequences of engaging in risky behaviour for their own health and well-being. Adolescence is generally a time of varied experimentation and some risk taking is part of normal growing up. Some young people may need to critically examine why they might want to engage in high risk behaviours such as drug taking, binge drinking and under age or unprotected sex and to decide what place such behaviours are going to have in their lives. Standard 9 of the NSF for Children requires that all staff who work with children and young people should be able to recognise the contribution they make to children’s emotional well-being and use their own professional skills to support children when there are concerns about their well-being. It also requires Primary Care Trusts and Local Authorities to have protocols in place for the early identification and referral of children with mental health needs. Both of these requirements raise training and resource issues within local children’s services. Helping young people to be aware of stress and to recognise its effects would be useful and would give them a skill that they could use throughout adult life. This might include task planning, setting and reviewing goals. Traditionally this tends to take place around exam time, or within PHSE as part of mental health promotion. However, this on its own may not be enough. Pupils may also need more one to one support, including peer support as well as access to confidential and therapeutic counselling. Whilst family are a key source of support for many, the young people in our survey were more likely to share their troubles with people their own age, especially close friends. Mentoring and peer support or buddy schemes are already being used in some primary and secondary schools to support children who may have particular emotional needs. These may need extending further.

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Whilst many children and young people find their way through stressful adolescent experiences, with the support of friends, family or other trusted adults, there will be some for whom this support is either not available or is simply not enough. Knowing when it is appropriate to seek professional help as well as how and where is important, for children, families, schools and other professionals. Some forms of aggression and verbal abuse which might be labelled as child abuse in other contexts are relatively common in child peer relationships and may be taken less seriously under the label of ‘bullying’. Almost 1 in 5 of our 11 year olds said they had been hit for no reason either in or just outside school premises, whilst 10% had been threatened for no reason. Bullying from peers (whether in or out of school) can have serious consequences for young people and is a contributing factor in truancy, self-harm and suicide. No less than one in six 11 year old boys in our survey said they had feared going to school because of bullying, as did a fifth of 13 year old girls. Since September 1999, schools have had specific duties to combat bullying, and must have anti-bullying policies and procedures in place. These polices must be constantly revised to ensure that they are tackling new or emerging problems in the school, such as homophobic or racist bullying. The LEA should work closely with schools to help them review their bullying policies and develop best practice. In one secondary school as many as a third of all 11-14 year old girls said they had been afraid of going to school because of bullying, whilst almost a quarter of both boys and girls across all secondary schools said they had been the subject of behaviour which could be described as bullying at school within the last four weeks. Clearly this requires immediate action from the relevant schools and the LEA. Children and young people adopted a range of coping mechanisms to help them deal with problems and negative feelings. Most commonly children turn to their family and friends to share their concerns. Others distract themselves and release tension through games and physical activity. Crying was also a common way of releasing emotions, mentioned by almost a third of 11-14 year olds. More dramatically, 15% said they hurt themselves as a way of coping with bad feelings, although we did not ask them to describe the act of self-harm in any detail. National estimates of the prevalence of self-harm apply strict definition criteria, which this survey did not. According to these national estimates, 13% of 15-16 year olds will have deliberately self harmed at least once during their life time, 8% within the last year, with a higher frequency amongst young people who misuse alcohol or drugs. Deliberate self-harm is also far more common amongst young people who have been bullied and is strongly associated with physical and sexual abuse in both sexes. So whilst this behaviour may be a transient period of distress for some young people, in others it will be an important indicator of mental health problems. Schools and other children’s professionals will need support and training to help them identify those at particular risk. The promotion of help-lines, use of self-referral 18

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agencies and school counselling services are other actions that could be taken. RECOMMENDATIONS 1. The Children and Families Partnership Board should give the development of children’s emotional and social well being a high profile within the forthcoming Children’s Plan, alongside children’s physical health needs. This should include promoting the well-being, development and training of staff. 2 The LEA should review and where necessary, articulate and strengthen the links between the work of the NHSS on health and well-being and bullying and the development of emotional and social competence amongst school pupils. 3 The LEA and local schools should review their anti bullying polices in light of the high proportion of children in this survey, especially girls, who report being fearful of school, and the incidence of racist and homophobic bullying. Bullying is a key priority for action for the North East Lincolnshire Youth and Schools Council. The LEA and local schools should involve young people, parents and the community in any discussions about how best to tackle this issue, and raise bullying explicitly as part of their core PHSE and citizenship education. 4 The LEA and schools should investigate bullying and fear of bullying within their schools, especially where this was reported to be particularly high. 5 The Healthy Schools Programme should embed emotional and mental health promotion in all aspects of the curriculum and facilitate changes in the school environment that promote mental health. 6 Early intervention services for children and young people with identified mental health needs will need to be strengthened and the current shortfall in tier 3 services tackled. Both of these actions will carry significant training and resource implications for the Primary Care Trust and the Local Council. 7 Mentoring and peer support schemes should be developed and strengthened and local help-lines, youth and school counselling services promoted.

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