Children and Young People Promoting Emotional Health and Well-Being by vsb11259

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									                                            Children and Young People
                                         Promoting Emotional Health
                                                      and Well-Being




Information Series - Updated June 2008
    CYP Facts


    Please send comments:       This fact sheet has been compiled by the Regional Public
    Linda.Wollam@csip.org.uk    Health Group based in the Government Office of the
    or Jo.Nurse@dh.gsi.gov.uk   South East and published with the support
                                of the Children and Learners team. It aims to summarise
                                key public health issues based upon evidence, in order
                                to facilitate good practice and improve health at local
                                and regional levels. This is NOT a policy document. This
                                factsheet is available to download at : www.sepho.org

                                Audience
                                Head Teachers, Healthy Schools leads, Community Paediatric
                                Teams, Public Health and Health Visitor Leads, Children’s Service
                                Leads and Commissioners in Local Authorities and PCTs, CAMHS
                                service leads, Youth Offending Team leads, and the VCS and all
                                professionals working with Children and Young People.

                                Vision
                                To promote the well-being and mental health of all children and
                                young people, especially those at greater risk of mental health
                                problems, by working in partnership to address need, reduce the
                                impact of risk factors and promote protective factors.

                                Well-Being
                                In order to develop well being, it is important to address risk
                                factors and promote protective factors at an individual mental,
                                physical and social level. These aspects are summarised in the
                                model below, (Nurse, 2006)




2
                                                                                  CYP Facts


Why Its Important:
                                                   Definitions - Mental Health Problems
•	 UK	comes	bottom	of	the	rank	for	children’s	     in Children & Young People,
   well-being	in	a	recent	UNICEF	study	in	         (BMA, 2006)
   comparison with North America & 18
   European	Countries;	(UNICEF	2007)               Conduct Disorders: 6% of 5-16 year
                                                   olds have a conduct disorder, they are
•	 It’s	a	common	problem:	At	any	one	time,	        more common in boys and includes
   one in ten children and young people have       challenging behaviour for more than 6
   a mental health problem, the majority           months or challenging behaviour that
   of which are either emotional disorders,        is extreme or at an inappropriate age.
   (depression or anxiety), or conduct             Characteristics include: frequent or severe
   disorders.                                      temper tantrums; severe and persistent
•	 It	affects	educational	achievement:	poor	       disobedience; defiant provocative
   mental health is associated with low            behaviour; excessive levels of fighting or
   educational performance and absenteeism;        bullying; cruelty to animals and offending
   additionally, conduct and hyperkinetic          behaviour.
   disorders disrupt the educational               Emotional Disorders: 4% of 5-16 year olds
   environment for other children.                 have an emotional disorder. They are more
•	 Inter-relationship	with	risk	behaviours	and	    common in girls and include anxieties,
   physical health: poor mental health is often    depression and phobias. Characteristics
   the underlying factor behind risk behaviours    include sadness, irritability and loss of
   (including smoking, substance abuse,            interest in activities. Associated features
   risky sexual activity) and health outcomes,     include tiredness, sleep disturbance, loss of
   (including teenage pregnancy, eating            appetite, difficulty concentrating, feelings
   disorders, injuries, bullying and violent       of guilt, worthlessness and suicide.
   behaviour).                                     Hyperkinetic Disorders: 2% of 5-16 year olds
•	 Poor	mental	health	can	be	a	symptom	of	         have a hyperkinetic disorder. They are more
   a child at risk: children and young people      common in boys, and include Attention
   frequently express their internal distress      Deficit Hyperactivity Disorder (ADHD)
   in the form of mental disorders. A history      and Attention Deficit Disorder (ADD).
   of abuse or family violence frequently          Characteristics include impaired attention
   underlies symptoms of behavioural               and overactivity, which affect the ability to
   problems and mental distress.                   concentrate and disruptive behaviour.

•	 Increased	offending	and	anti-social	            Less Common Disorders: 1% of 5-16 year
   behaviour: conduct disorders in particular      olds have a less common disorder, including
   are associated with anti-social and offending   autism, eating disorders, tics and selective
   behaviour which impact on the safety and        mutism;
   well-being of the wider community. The          •	 Autistic	Spectrum	Disorders:	more	
   average cost to society of an individual with      common in boys and range from mild
   untreated	conduct	disorder	is	£70,000.	            forms, e.g. Asperger’s Syndrome,
•	 Long-term	impact	and	cost	to	society:	Not	         to more extreme forms of learning
   addressing poor mental health in childhood         disability, with difficulties in interacting
   results in a proportion of young people            and communicating with others;
   who continue to have: mental health             •	 Eating	Disorders:	(more	common	in	
   problems including self-harm and increased         young women, with) up to 1 per cent of
   suicide; low educational and employment            women	in	the	UK	between	the	ages	of	
   achievement; increased violent, anti-social        15 and 30 suffer from anorexia nervosa,
   behaviour and offending behaviour.                 and between 1 and 2 per cent suffer
                                                      from bulimia nervosa. The average
                                                      age of onset of anorexia is 15 and of
                                                      bulimia, 18.




                                                                                                     3
    CYP Facts



     Key National Drivers                                                                  Choosing Health 2004
     http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
     DH_4094550 supporting the public to make healthier and informed choices to improve emotional
     wellbeing and improving access to services so that healthy choices are easier to make
     Every Child Matters: Change for Children, 2004, specifies five outcomes for local authorities and partners:
     www.everychildmatters.co.uk
     •	   Being	Healthy		                            •	 Staying	Safe
     •	   Enjoying	and	Achieving	                    •	 Making	a	Positive	Contribution
     •	   Achieving	Economic	Well-Being	

     Everyone delivering children and young people’s services has a role in improving outcomes and reducing
     inequalities.
     The Children Act, 2004 provides legislation for a duty to co-operate and bring local partners together in
     the form of Children’s Trusts. All organisations need to be responsive to the diverse needs of children,
     young people, their families and communities, and recognise that safeguarding children and young people
     from harm must be everyone’s business.
     National	Service	Framework	for	Children,	Young	People	and	Maternity	Services,	2004,	has	Eleven	
     Standards; www.dh.gov.uk
     •	   Promoting	Health	and	Well-Being,		         •	   Children	and	young	people	in	hospital
          identifying	needs	and	intervening	early	   •	   Disabled	children	and	young	people	with	complex	needs
     •	   Supporting	Parents	                        •	   Mental	health	and	psychological	well	being	of	children	
     •	   Child,	young	person	and	family	centred	    	    and	young	people
     	    services	                                  •	   Medicines	for	children	and	young	people
     •	   Growing	up	into	adulthood	                 •	   Maternity	services
     •	   Safeguarding	and	promoting	welfare	of	
          children and young people
     •	   Children	and	young	people	who	are	ill

     The CAMHS NSF Standard states: “All children and young people from birth to their eighteenth birthday,
     who have mental health problems and disorders have access to timely, integrated, high quality, multi-
     disciplinary mental health services to ensure effective assessment, treatment and support, for them and
     their families”
     The Public Service Agreement CAMHS target for 2008/09 requires that improvements in CAMHS are
     secured and maintained by measuring the percentage of PCTs and local authorities who together provide
     a	comprehensive	service	for	their	area.	Four	proxy	measures	will	be	used:
     •	 24	hour	cover	available	for	urgent	needs	and	specialist	assessments	undertaken	within	24	hours	or	
          during the next working day
     •	 Full	range	of	CAMHS	available	or	accessible	for	children	and	young	people	with	learning	disabilities
     •	 Services	available	for	all	16	and	17	year	olds	appropriate	to	their	age	and	level	of	maturity
     •	 Joint	commissioning	of	early	intervention	support	
     An outcome measure for use from 2009 being piloted and there are plans to use a broader measure of
     children’s	EWB.
     Common Assessment Framework 2005 a standardised approach to assessing and communicating children
     and young people’s needs for services. www.everychildmatters.gov.uk/deliveringservices/caf
     The Children and Young People’s Plan - a statutory requirement from the Children Act, that all local areas
     produce a single, strategic and overarching plan for all services affecting children and young people.
     Joint Area Reviews – assess quality of council services and judge how well services work together to
     improve the well-being of children and young people www.everychildmatters.gov.uk/strategy/inspection
     Youth Matters: Next Steps, 2006: www.dfes.gov.uk/publications/youth
     •	 Youth	opportunities	fund	to	increase	young	peoples	decision	making	regarding	local	priorities
     •	 Youth	Capital	Fund	–	to	develop	facilities	for	young	people
     •	 The	South	East	has	been	allocated	£8.3	million	for	the	YOF	and	YCF
     •	 Youth	Opportunity	Card	to	support	young	peoples	decision	making
     RESPECT Agenda, 2006 – Six main strands from the Action Plan: www.respect.gov.uk
     •	   supporting	families	                                •	   Activities	for	children	and	young	people
     •	   A	new	approach	to	the	most	challenging	families	    •	   Strengthening	communities
     •	   Improving	behaviour	and	attendance	in	schools	      •	   Effective	enforcement	and	community	justice

     Commissioning	framework	for	health	and	well-being	2007	
     http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_072604
     Help for commissioners to work with partners to commission services that focus on promoting physical and
     mental health and well-being for all, rather than just treating people when they are ill
     Care Matters 2007 - http://www.dfes.gov.uk/publications/carematters/index.shtml sets out a package of
     proposals for transforming the lives of children in care




4
                                                                                      CYP Facts


Current Situation

Prevalence Of Mental Health Problems In Children And
Young People:
Over 1 in 10 five to sixteen year olds have a mental disorder
(mainly emotional or conduct disorders) in the South East. These
                                                                    Figure 1
rates are not statistically significant from England or other
regions. Rates increase with age and are higher for boys compared   Prevalence of children and
to girls, especially in the 5-10 year age group. See figure 1 for   young people with a mental
rates of mental disorders by age and sex.                           health disorder, England and
                                                                    the South East, 2004




                                                                    Source: Office for National Statistics,
                                                                    Mental Health of Children and Young
                                                                    People in Great Britain, (Green, 2004)

The most common type of mental health problems in children
and young people are conduct and emotional disorders, both          Figure 2
increase with age. There are higher rates of conduct disorders in
boys and emotional disorders in girls. (See figure 2)               Prevalence of types of mental
                                                                    health disorder in children and
                                                                    young adults by age and sex,
                                                                    England, 2004




                                                                    Source: Office for National Statistics,
                                                                    Mental Health of Children and Young
                                                                    People in Great Britain, (Green, 2004)




                                                                                                              5
    CYP Facts


                                              Self- Harm
                                              Self-harm occurs more in young people compared to adulthood,
                                              and	is	associated	with	a	history	of	abuse.	Figure	3	shows	that	
    Figure 3                                  self-harming behaviour occurs in over 1 in 4 young people with
                                              an emotional disorder, e.g. anxiety, depression or phobia, and
    Children who have tried to                1 in 5 young people with a conduct disorder. A recent National
    harm, hurt or kill themselves             Inquiry	‘Truth	Hurts’	(Brophy,	2006),	highlights	the	importance	
    by emotional conduct or                   of understanding the underlying reasons for self-harm and
    hyperkinetic disorder, England            how many young people were met with ridicule or hostility by
    2004                                      professionals instead of being offered appropriate support.




    Source: Office for National Statistics,
    Mental Health of Children and Young
    People in Great Britain, (Green 2004)




                                              Risk Factors

                                              Socio-Economic Factors:

    Figure 4                                  Figure	4	illustrates	how	child	poverty	(as	measured	by	parental	
                                              income) increases the risk of mental health problems in children:
    Percentage of children with               approximately 15% of children experience mental health
    a mental health disorder by               problems at the lowest income levels compared to 5% of children
    parental income, England 2004.            at the higher income levels.




    Source: Office for National Statistics,   Over 15% of children living with a single parent have a mental
    Mental Health of Children and Young       health problem, compared to 8% living with two parents. There
    People in Great Britain, (Green, 2004)
                                              is no statistical significance between rates in the South East
                                              compared to England. (See figure 5).


6
                                                                                          CYP Facts


                                                                        Figure 5

                                                                        Percentage of children with
                                                                        a mental health disorder by
                                                                        family type, England and the
                                                                        South East, 2004.




                                                                        Source: Office for National Statistics,
                                                                        Mental Health of Children and Young
                                                                        People in Great Britain, (Green, 2004)




Children whose parents have lower educational achievement are
more likely to have a mental health problem. With Less than
5% of children have mental health problems if their parents
are educated to degree level, compared to approximately                 Figure 6
15% for children with parents with no qualification, (see figure
6). Some of this effect will be accounted for by differences in         Percentage of children with
income. There is no statistical difference in rates in the South East   a mental health disorder by
compared to England averages.                                           educational status of parent,
                                                                        England and the South East,
                                                                        2004.




Having a mental disorder as a child has a considerable impact           Source: Office for National Statistics,
                                                                        Mental Health of Children and Young
upon educational achievement, especially for conduct and                People in Great Britain, (Green, 2004)
emotional	disorders,	(see	figure	7).	Some	of	this	difference	will	be	
accounted for by the co-occurrence of learning disabilities with
mental disorders.



                                                                                                                  7
    CYP Facts


    Figure 7

    Percentage of children behind
    in school ability by type
    of mental health disorder,
    England, 2004.




    Source: Office for
    National Statistics, Mental
    Health of Children and
    Young People in Great
    Britain, (Green, 2004)



                                     There is a high correlation between having a mental disorder and
                                     missing school: approximately 25-30% of depressed and anxious
                                     children and 20% of children with conduct disorders truanting
    Figure 8
                                     from school (see figure 8). Additionally, having a mental disorder
    Percentage of children playing   in childhood makes it more likely to miss school due to sickness or
    truant by mental disorder,       school exclusion.
    England 2004.




    Source: Office for
    National Statistics, Mental
    Health of Children and
    Young People in Great
    Britain, (Green, 2004)



                                     Individual Risk Factors:
                                     Risk factors (after adjusting for socio-economic factors), for
                                     developing an emotional disorder, include: increasing age,
                                     physical illness and number of stressful life events; whilst
                                     independent risk factors for developing a conduct disorder
                                     include: being male, having a special educational need,
                                     stepchildren in the family, and poor maternal mental health.

                                     Independent risk factors for persistence of emotional disorders
                                     included only poor maternal mental health; and for conduct
                                     disorder, independent risk factors for persistence included: special
                                     educational needs, maternal mental health and whether the child
                                     was frequently shouted at. (Meltzer, 2003).


8
                                                                                                 CYP Facts


Violence and Abuse
•	 Adverse	childhood	experiences	of	one	of	either:	emotional,	
   physical or sexual abuse, household substance abuse, mental
   illness, incarceration, parental domestic violence, separation or
   divorce; increased the lifetime risk of attempted suicide by 2-5
   fold, compared to no adverse childhood experiences. The more
   adverse experiences the greater the risk. (Dube, 2001)

•	 A	history	of	child	abuse	(emotional,	physical	or	sexual),	
   increases the risk of lifetime prevalence of depression by 1.8-
   2.7	times	for	women	and	1.6-	2.6	times	for	men,	compared	to	
   no history of child abuse, (Chapman, 2004).

•	 Children,	who	have	been	abused	or	witnessed	family	violence,	
   are more likely to show aggressive and anti-social behaviour,
   have low self-esteem and do less well at school, (Dixon, 2006).

•	 Abuse	in	childhood	alters	brain	functions	in	the	limbic	system,	
   producing symptoms of reduced impulse control, hyperactivity,
   withdrawal and dissociative disorders, and Post Traumatic
   Stress Disorder- PTSD (Glaser, 2000). All of which can be
   expressed as emotional, conduct or hyperkinetic disorders in
   childhood, with PTSD, depression and personality disorders in                * In the Ofsted Tell Us Survey 2007
   adulthood.                                                                   30% of children aged 10-15 reported
                                                                                being bullied in the last four weeks.
                                                                                The NCH mobile bullying survey 2005
Prevalence of Violence and Abuse:	Percentage	in	England/	UK	                    found that 20% of 11-19 year olds
from population surveys experiencing violence or abuse at least                 had experienced bullying or threats
once in their lifetime.                                                         via e-mail, internet chatroom or text
                                                                                message.


  Type of Violence                      Female               Male                  Source and location of study
  Child Sexual Abuse                    21% all forms        11% all forms         Cawson, 2000
  (all forms and contact abuse)	        16%	contact	abuse	   7%	contact	abuse	     NSPCC	UK	study
  Child	Physical	Abuse	-		              23%	                 27%	                  Cawson,	2000
  (violent treatment from anyone)	      	                    	                     NSPCC		UK	study
  Child Emotional Abuse-                20%                  16%                   Cawson, 2000
  (Humiliation by parents)	             	                    	                     NSPCC	UK	study
  Bullying	*	                           46%	                 43%	                  Smith,	2000
  (10-14 year olds at school)                                                      England
  Youth	Violence	                       7.6%	                15.5%	                Dodd,	2004
  (16-24 year old victims of violent                                               England & Wales
  crime in last year)
  Sexual Assault and Rape
  (16-59 year olds ever experienced)	   Sex	Assault:	23%	    Sex	Assault:	3%	      Finney,	British	Crime	Survey,
                                        Rape: 5%             Rape: 0.4%            2004/5




Alcohol Misuse: Growing up with one or more adverse childhood
experiences (emotional, physical or sexual abuse, a substance
abuser in the household, mental illness, incarceration, parental
domestic violence, separation or divorce), is associated with a
20-70%	increased	likelihood	of	initiating	alcohol	use	during	
mid adolescence. The higher the number of adverse events, the
stronger this association was found to be. A third of suicides in
young people are linked to alcohol intoxication, (Cornah, 2006).
Approximately 40% of young people report binge drinking,
(Bonomo	2002).




                                                                                                                        9
     CYP Facts


                 Drug Misuse: There is growing evidence from cohort studies
                 that earlier use of cannabis increases the risk of developing
                 schizophrenia, (sole use of cannabis 50 or more times increased
                 the	risk	of	developing	schizophrenia	by	6.7	(CI:	2.1-21.7),	(Zammit,	
                 2002). Cannabis affects dopamine processing in the brain, which
                 biochemically is related to psychosis and can worsen psychotic
                 symptoms. However, the majority of people who use cannabis
                 do	not	develop	schizophrenia,	(Fergusson,	2006).	Approximately	
                 30% of 11-15 year olds have used Cannabis in the previous year,
                 with	10%	using	cannabis	weekly,	(Bonomo	2002).	

                 Adult outcomes of young people with depression and conduct
                 disorder: a follow-up study of children attending the Maudsley,
                 found that young people with depression and conduct disorder
                 were more likely to have been mental health inpatients, used
                 healthcare services and involved with criminal justice services,
                 when compared to adults in the general population;
                 (Knapp,	2002).	




                 Vulnerable Young People

                 Child Protection and Children in Care
                 Children on the Child Protection Register and Children in Care
                 and those on local Child Protection registers are a particularly
                 vulnerable population. They have higher rates of adverse
                 childhood experiences, including physical, sexual and emotional
                 abuse or neglect, compared to children in the general population.
                 The	Figure	below	shows	variations	in	rates	of	children	on	child	
                 protection	registers,	with	higher	rates	in	Portsmouth,	Brighton	
                 and Hove, Medway and Southampton compared to England and
                 the South East.

                 Children in Care are 6-8 times more likely to have a conduct
                 disorder than children in the general population, (36.5% vs 4.6%
                 of 5-10 year olds, and 40.5% vs 6.2% of 11-15 year olds). They are
                 also	2-3	times	more	likely	to	have	an	emotional	disorder,	and	5-7	
                 times more likely to have a hyperkinetic disorder, compared to
                 children in the general population. Girls were more likely to have
                 an emotional disorder with increasing age.




10
                                                                                      CYP Facts


Any of the mental disorders (emotional, conduct or hyperkinetic),
increased the likelihood of truancy or being in trouble with
the police, compared to no mental disorder. All of the mental
disorders, and especially hyperkinetic and conduct disorders,
are associated with poor performance at school. This reflects
that some of the mental disorders are associated with learning
difficulties; however, being distressed also interferes with
learning.

Children in Care with emotional and conduct disorders are several
times more likely to smoke, drink alcohol, take drugs or have
early sexual intercourse, than Children in Care with no disorder or
children in the general population, (Meltzer, 2002). A follow-up
study of Children in Care found they were 4-5 times more likely
to attempt suicide and 4-6 times more likely to be admitted to
hospital with a mental illness as a young person, compared to
their peers. Children in long-term care had the worst outcomes
(Vinnerljung, 2006).




‘What Works’

Promoting Protective Factors in Childhood and Young
Adulthood
Promoting mental well being in childhood is key to addressing
poverty	and	social	inequalities.	By	improving	long-term	
educational and social achievement you can reduce behavioural
and	emotional	problems,	(Stewart	Brown,	2004).	The	following	
section outlines the most important contributions to promoting
mental well-being in childhood.

Good Parenting: In earlier childhood the most protective aspect
promoting mental well-being and reducing the risk of abuse for
children is good parenting skills. Additionally, long term follow-
up of Home Visitor programmes to develop parent skills found
reductions in adolescent anti-social and offending behaviour
as well as improved educational and employment outcomes,
(Olds,	1997).	Table	1	highlights	key	effective	elements	of	good	
parenting skills.

Table 1 Effective aspects of parenting skills

 Parent education programmes for young children    Parent Skills for Later Childhood & Adolescence
 •	   Warmth,	positive	regard,	empathy	            •	   Love	and	connection;
 •	   Clear	boundaries	and	positive	discipline	    •	   Monitor	and	Observe;
 •	   Parental	sensitivity	and	attunement	         •	   Guide	and	Limit;
 	    	                                            •	   Model	and	Consult;
 	    	                                            •	   Provide	and	Advocate.


Emotional Literacy: Social and Emotional Aspects of Learning,
(SEAL) is a primary school programme interwoven and integrated
into the main curriculum. It is voluntary for schools to adopt the
SEAL curriculum, with approximately 30% of primary schools
nationally signed up to it. SEALs programmes bring about an
immediate reduction in self-reported depression, reduction in drug
and cigarette use and improved educational outcomes. Details can
be found on the DfES website at: http://tinyurl.com/ho24l



                                                                                                     11
     CYP Facts


     Figure 9.    Aspects of             A similar programme is being developed for secondary schools.
                  Emotional Literacy.    The key components of emotional literacy programmes are
                                         summarised	in	Figure	9
     Emotional Literacy
                                         Violence and Abuse Prevention: The SEAL programme provides
     Programmes                          many of the skills needs to deal with conflict: learning how to
                                         peacefully problem-solve, calm down strategies, understand
     Goleman 2003
                                         emotions, be assertive and anti-bullying messages. However,
                                         there are additional aspects that are needed to prevent the risk
                                         of child abuse and sexually abusive adolescent relationships
     Five Effective Components           (Krug,	2002).	These	include	the	development	of:	
     1. Teach person to calm down        •	 Mutual	rights	and	respect	in	relationships	(peers,	family	and	
     2. Increase awareness of               dating);
        emotional states of others       •	 Challenge	gender	norms	that	support	partner,	family	and	
                                            sexual abuse;
     3. Learn to describe own            •	 Abuse	awareness	and	protective	skill	development;	
        emotional state to others        •	 Communication	and	conflict	resolution	skills;
     4. Learn planning and               •	 Where	and	how	to	seek	help.
        thinking ahead skills
                                         Youth Suicide Prevention: The HDA Evidence briefing summary,
     5. Empathy - consider how           (2005), recommends the development of school multi-year, multi-
        others feel and how own          component strategies to address high-risk behaviour:
        behaviour affects them
                                         •	 Restrict	access	to	paracetamol	and	responsible	media	
                                            reporting;
                                         •	 Education	on	coping	skills	benefits	depression	and	suicidal	
                                            ideation;
     Four Key Guidelines                 •	 Target	protective	programmes	for	high-risk	groups;
     1. Emotions are important           •	 Problem	solving	skills	and	emergency	contact	cards	for	
        signals                             preventing self-harm.

     2.	Feelings	are	separate	from	      Integrating Substance Misuse And Sexual Health Programmes
        behaviour                        With Mental Health Promotion Programmes: It’s important to
                                         address the underlying risk factors for substance misuse. The
     3. You can’t think until you’re
                                         evidence base to support school based mental health promotion
        calm
                                         and violence prevention programmes is much stronger than
     4. Treat others the way you         for programmes that address substance misuse (alcohol, drugs,
        want to be treated               tobacco) alone, which are largely ineffective. In that some
                                         substance misuse is driven by emotional distress, mental health
                                         promotion and violence prevention programmes, which also
                                         address substance misuse, are likely to be more effective than
                                         substance misuse educational programmes alone, (Stewart-
     Traffic Lights for when
                                         Brown,	2006).	
     upset
     Red         Pause: Deep breath.     There are good opportunities to integrate mental health
                 Identify problem and    promotion and abuse prevention approaches into Sure Start
                 feeling                 programmes, wider Healthy Schools work, including the SRE,
                                         PHSE and citizenship curriculum. Additionally, this needs to be
     Orange	 Find	a	positive	            done in the context of a whole school approach for behaviour
             solution: What can          improvement, including bullying and abuse prevention, with staff
             I do? Does it harm          training on educational and communication styles, prevention
             others?                     policies, including improved nutrition and physical exercise.
     Green       Act and reflect on      Further	information	on	the	wider	aspects	of	the	health	can	be	
                 solution identified:    found	in	the	report	‘Health	and	Well-Being	of	Children	and	
                 Try best idea. Did it   Young People in South East England’ (2005).
                 work?




12
                                                                                      CYP Facts


Developing Protective Skills and Respectful Relationships:

High-risk groups of young people and adults often need
additional input to develop these protective skills. An example of
a Southampton project working in schools and with vulnerable
young people to raise awareness on self-protection of abusive
situations, the development of respectful relationships and where
to	seek	help	is	illustrated	in	the	case	study.	Further	work	of	this	
sort needs to be developed for adults at risk of mental health
problems including those with mental illnesses.

Many people in contact with mental health services already have
a history of abuse. Having been abused in the past, increases the
risk of being abused again, especially for women, whilst men
are more likely to develop offending behaviour and become
perpetrators of abuse. This abuse needs to be recognised
and responded to appropriately with counselling, Cognitive
Behavioural	Therapy	(CBT)	and	the	development	of	protective	
skills include the ability to develop respectful relationships.



Case Study: The Star Project - Southampton Together
            Against Rape


 The	S*tar	Project	is	the	Southampton	Rape	Crisis	(SRC)	
 education and outreach initiative which aims to reduce the
 incidence of rape and sexual abuse and raise awareness of
 support services via creative and innovative workshops with
 young people in Southampton.

 All	S*tar	work	is	framed	by	four	key	aims:

 •	 To	raise	awareness	of	the	issues	surrounding	rape	and	
    sexual abuse;

 •	 To	assist	young	people	in	developing	skills	around	
    negotiating respect and consent within relationships;

 •	 To	provide	information	to	young	people	about	SRC	
    counselling service for young women and young men as
    well as other relevant information, advice and support
    agencies;

 •	 To	develop	targeted	work	with	young	people	identified	as	
    being particularly vulnerable.



 Feedback from young people:

 “Don’t feel under pressure in a relationship, remember, you
 have	a	voice!	Stand	up	and	speak	up!”	(Female,	15).

 “I liked the openness of Star. It was great and I learnt the
 consequences of choices that can ruin the relationship. I learnt
 the values and disadvantages of sex”, (Male, 15).

 If you would like any more information about the work of the          See NICE Guidance under the
 Star Project, please ring, email or visit the website:                References and Resource section
 T: 023 8063 6315      E: michelle@starproject.org.uk
 W: www.starproject.org.uk




                                                                                                         13
     CYP Facts


                                               Ways Forward
                                               Service Provision Appropriate To Need
                                               A recent mapping exercise of Tiers 2-4 Child and Adolescent
                                               Mental Health Services (CAMHS) in England found that although
                                               budgets have increased CAMHS services are still under resourced
                                               and there are relative gaps in service provision. The South East
                                               has relatively less workforce capacity compared to many other
                                               regions. In terms of the balance of services provided, in England
                                               in general and even more so within the South East, there are
                                               gaps in service provision.

                                               There are relative gaps in the provision of Tier I and II services
                                               compared to Tier III and IV services and in early intervention
                                               to prevent mental health disorders and violence and abuse
                                               particularly in high-risk groups for poor mental health and
                                               suicide.

                                               In	the	South	East	Children	in	Care	make	up		7-8%	of	the	Tier	2-4	
                                               caseload, which is comparable to other areas but we know that
                                               Children in Care are five times more likely than their peers to
                                               have a mental health disorder. Young Offenders, who have an
                                               18 fold increased risk of suicide, make up only 6% of the caseload
                                               in	tiers	2-4	,	and	in	Kent	and	Medway	and	Hampshire	and	Isle	of	
                                               Wight in particular they have poor access to specialist CAMHS
                                               services. Across the South East, only 25-50% of CAMHS services
                                               have specialist services for Learning Disabilities, compared to
                                               75-100%	in	many	other	regions,	(Wistow,	2004).	A	BMA	report	
                                               highlights these issues, and also identifies the need to improve
                                               provision	and	transition	to	adult	services	for	17-18	year	olds,	and	
                                               to	ensure	appropriate	services	for	BME	groups	and	refugees	and	
                                               asylum	seekers;	(BMA,	2006).	

     Figure 10                                 Figure	10	illustrates	how	only	23-28%	of	children	with	emotional	
                                               and conduct disorders are seen by a mental health specialist and
     Help Sought by Children and               receive less support from other services, despite these being the
     Young People, England, 2004.              most common forms of mental health problems in children.




     Source: Office for National Statistics,   Early	intervention	saves	money:	By	age	28,	those	with	conduct	
     Mental Health of Children and Young       disorders in childhood, were ten times the cost to society
     People in Great Britain, (Green, 2004)
                                               compared to those with no conduct disorder. Each individual
                                               with	a	conduct	disorder	had	a	total	cost	of	£70,000,	mainly	due	
                                               to crime incurred, followed by extra educational provision, foster
                                               and residential care, state benefits and health costs, (Scott, 2001).

14
                                                                        CYP Facts


Parent skills and education, and day care for young children have
been found to have long-term benefits in reducing neglect, and
abuse, and criminal and anti-social behaviour in young adults.
It also improves protective factors, including maternal mental
health,	educational	and	employment	outcomes,	(Olds	1997,	
Zoritch	2006,	Barlow	2006).	Additionally,	later	intervention	is	also	
effective with family and parenting interventions in child and
adolescent young offenders with conduct disorder, decreasing
time spent in offender units and reducing re-offending rates
(RR 0.66, CI: 0.44-0.98); (Woolfenden, 2006). Parent education/
training programmes cost between £629-£3,839, depending upon
type and intensity. This compares with the long-term costs of
conduct	disorder	of	£70,000,	and	highlights	the	benefits	of	earlier	
intervention, (Dretze, 2005).

Target High Risk Groups:
While there should be a level of service available for people
outside high risk groups it is essential to ensure appropriate and
accessible services are targeted at the following high-risk groups:

The Child or Young Person:
•	 Children	in	Care	/	Child	Protection	Register
•	 Children	experiencing	physical,	sexual,	emotional	abuse	
   or neglect
•	 Children	who	are	victims	of	bullying	
•	 Substance	misuse,	including	alcohol	and	smoking	
•	 Children	with	a	physical	health	problem	and	their	siblings	
•	 Young	Disabled,	LGBT	or	BME	People
•	 School	excludees	and	non	attenders	
•	 Teenage	parents
•	 Young	offenders
•	 Children	who	have	experienced	significant	loss	

The Family:
•	 Children	with	family	members	who	have	mental	health	
   (particularly poor maternal mental health) or substance
   misuse problems, including alcohol
•	 Children	with	family	members	who	are	offenders	or	ex-
   offenders
•	 Children	living	in	families	where	there	is	parental	violence	
   and parental conflict
•	 Homeless	or	disadvantaged	families
•	 Traveller	or	asylum	seeker	families




                                                                                    15
     CYP Facts


     Ways Forward for Children and Young People - School based settings, and target high risk groups;
     Mental Well-Being	     •	 Parenting	education	and	skills	e.g.	via	Children’s	Centres	for	those
                               caring for young children and adolescents, including foster parents and
                               residential care workers ,for general population and high risk groups -
                               address maternal mental health. Ensure fathers included ;
     	                      •	 Violence	and	abuse	prevention	skills	for	self-protection,	ability	to	deal
                               with conflict, and promotion of respectful relationships;
     	                      •	 Emotional	Literacy	adoption	of	Social	and	Emotional	Aspects	of	Learning	in
                               primary schools. Pilots in secondary schools underway. Pre-school being
                               developed.
     	                      •	 Access	to	arts	and	creativity	which	promote	positive	emotions	and	a	sense	of
                               well-being;
     	                      •	 Healthy	whole	school	approach	to	ensure	mental	health	promotion	and
                               violence and abuse prevention programmes (including bullying)
                               underpin Healthy Schools curriculum for Sex and Relationship Education,
                               PHSE, citizenship, including substance misuse and sexual health;
     	                      •	 Appropriate	and	accessible	CAMHS	services-ensure	services	across	the
                               tiers are appropriate to local need and well integrated. and
                               appropriate referral criteria to prioritise high risk groups. Support
                               schools and health professionals in identifying, managing and
                               referring emotional and conduct disorders;
     	                      •	 Access	to	youth	friendly	services	ensure	children	and	young	people
                               have the skills and information of how and where to seek support
                               and information for issues surrounding abuse and mental health.

     Physical Well-Being	   •	 Healthy	Eating	-	promote	in	schools	and	families,	increase	provision	of		 	
                               healthy foods - school meals, tuck shops and vending machines, and reduce
                               unhealthy foods in schools;
     	                      •	 Physical	Activity	-	children	and	young	people	should	have	at	least	60	minutes		
                               of moderate physical activity each day, (e.g. walking, cycling, badminton).
                               Ensure school travel plans support active transport (walking or cycling) to and
                               from schools;
     	                      •	 Substance	Misuse	-	ensure	programmes	for	tobacco,	drugs	and	alcohol	are		
                               underpinned by mental health promotion and abuse prevention work.

     Social Well-Being	     •	 Promote	social,	relationship	and	life	skills	-	mentors	and	buddies	for	high	risk		
                               children;
     	                      •	 Promote	volunteering,	participation	in	community	programmes	and		 	
                               providing places to go and things to do for young people, including inter-
                               generational projects that increase creativity, physical activity, self-esteem
                               and social skills.




16
                                                                               CYP Facts


Local Area Agreements
Children & Young People
Be Healthy
NI 50     Emotional health of children PSA 12
NI 51     Effectiveness of child and adolescent mental health (CAMHs)
          services	DCSF	DSO	
NI	58		   Emotional	and	behavioural	health	of	children	in	care	DCSF	DSO	
Stay Safe
NI	69		   Children	who	have	experienced	bullying	DCSF	DSO	
NI	70		   Hospital	admissions	caused	by	unintentional	and	deliberate	
          injuries	to	children	and	young	people	DCSF	DSO	
Enjoy and Achieve
NI	91		   Participation	of	17	year	olds	in	education	or	training	DCSF	DSO	
NI 99-101 Educational achievement of children in care PSA 11
NI 106    Young people from low income backgrounds progressing to
          higher education PSA 11
Make a positive contribution
NI 110   Young people’s participation in positive activities PSA 14
NI	111		 First	time	entrants	to	the	Youth	Justice	System	aged	10	–	17	PSA	
         14
NI 115   Substance misuse by young people PSA 14
Economic Wellbeing
NI 116   Proportion of children in poverty PSA 9
NI	117		 16	to	18	year	olds	who	are	not	in	education,	training	or	
         employment (NEET) PSA 14
NI 118   Take up of formal childcare by low-income working families DWP
         DSO
Safer Communities
NI 15,29 Serious violent crime and gun crime rates PSA 23
NI 28    Serious knife crime rate HO DSO
NI	17		  Perceptions	of	anti-social	behaviour	PSA	23
NI 19    Rate of proven re-offending by young offenders PSA 23
NI 22    Perceptions of parents taking responsibility for behaviour of their
         children in the area HO DSO
NI 23    Perceptions that people in the area treat each other with respect
         and dignity HO DSO
NI 32    Repeat incidents of domestic violence PSA 23
NI 39    Alcohol harm related hospital admission rates PSA 25
NI 40    Drug users in effective treatment PSA 25
NI 45    Young offenders engagement in suitable education, employment
         or training MoJ DSO
NI 46    Young offenders access to suitable accommodation MoJ DSO
Adult health and wellbeing outcomes:
NI 126    Early access for women to maternity care PSA 19
Tackling exclusion and promoting equality outcomes:
NI 143     (Young) Offenders under probation supervision living in settled
           and suitable accommodation at the end of their order or license
           PSA 16
NI144      (Young) Offenders under probation supervision in employment at
           the end of their order or license
NI	147		 Care	leavers	in	suitable	accommodation	PSA	16
NI 148     Care leavers in employment, education or training PSA 16
Local economy
NI 152    Working age people on out of work benefits PSA 8
NI 156    Number of households living in Temporary Accommodation PSA
          20
NI 158    % decent council homes CLG DSO
NI	173		 People	falling	out	of	work	and	on	to	incapacity	benefits	DWP	DSO	
Environmental sustainability
NI	187		 Tackling	fuel	poverty	-	people	receiving	income	based	benefits	
         living in homes with a low energy efficiency rating Defra DSO
NI 195   Improved street and environmental cleanliness (levels of graffiti,
         litter, detritus and fly posting) Defra DSO



                                                                                           17
     CYP Facts


     Promoting emotional wellbeing and mental health in children and young people
     One in Ten children has a clinically diagnosable mental health disorder before they reach 16.
     Emotional and Conduct disorders are the commonest: they have short and long term negative outcomes and are
     least well addressed by services.
     This is a guide to effective interventions and commissioning for children’s commissioners, service leads and
     practitioners to ensure the best provision of Tier I and II CAMHS services.

      Risk factors and protective factors for emotional well-being in children and young people
      and the long term outcomes of emotional and conduct disorders

       Possible adverse outcomes                     Emotionally healthy             Effective interventions
                                                     and safe children               (see page 3)

      Risk factors                                                                                    Protective factors
      for conduct &             Foetal Alcohol                                  Promote maternal      for wellbeing and
                                Syndrome                                        health
      emotional disorders                                                                             positive mental
                                                             Infant                                   health
      Family
      Alcohol abuse in                                                                                Positive parenting
                                Attachment                                      Universal parenting
                                                                                                      Social network
      pregnancy                 difficulties                                    programmes
                                                                                                      Appropriate housing
      Post natal &
      maternal
                                                          Pre-school                                  Good physical health
      depression
                                                                                Promote protective    Healthy eating
      Mental illness,           Conduct disorder             child              factors and reduce    Physical activity
      substance misuse          6% 5-16 yr olds                                 risk factors          Social and emotional
      Domestic violence &       Boys > girls
                                                                                                      literacy
      parental conflict                                                                               Arts and creativity
      Parent abused as                                                                                Relationship skills
      child                                                                     School based          Conflict resolution
      Offenders in family                                    Child              interventions
                                                                                                      skills
                                Emotional disorder
      Poverty                   4% 5-16 yr olds                                                       Risk management
      Unemployment              Girls > boys                                                          skills
      Homelessness                                                                                    Coping skills
                                                                                Prevent and treat
      Asylum seekers                                                            abuse                 Respectful
      Travellers                                                                                      relationships
                                Poor educational          Adolescent
      Child                     attainment                                                            Tolerant community
      Adverse childhood                                                         Targeted parenting
                                                                                                      Meaningful activity
      events                                                                    programmes for        Access to green
      Prematurity                                                               high risk groups      open spaces
      Separation at birth       Depression                                                            Absence of risk
      Physical health           Self harm/suicide
                                Eating disorders           Teenager                                   factors
      problem
                                                                                Therapeutic
      Sibling with health                                                       interventions
      problem
      Learning Disability
      Significant loss
                                Young offender
      Children in care
      Violence & abuse                                   Long term outcomes of childhood adverse events
      Bullying	                                          & MH disorders
      School excludees                                   Poor physical health; early death
      School non
                                                         Emotional Disorder
      attenders
                                                         Depression/PTSD; Increased risk of self harm; increased risk of
      Alcohol/drugs/                                     abuse; suicide
      smoking                                            Teenage pregnancy; obesity; eating disorders
      Lesbian,gay,bisexual,
                                                         Conduct Disorder
      transgender	(LGBT)
                                                         Low educational & employment attainment
      Black	&	minority	                                  Increased violent, anti-social & offending behaviour
      ethnic	(BME)	groups                                Increased risk of perpetrating abuse
                                                         Substance misuse; injuries



18
                                                                                                 CYP Facts


           Common mental health disorders in children and young people
Unmet need and service gaps

              NEED                    RELATIVE GAPS IN CURRENT                      NATIONAL STANDARDS
                                              SERVICES                              Key policies
                                                                                    Every	Child	Matters	(DCSF)
                                     Relative balance of CAMHS level                Care	Matters	(DCSF)
Conduct disorders                    I & II to CAMHS level III & IV                 NSF	for	children,	young	people	
4% of 5-10 yr olds                   services                                       & maternity services (DH)
6% of 11-15 yr olds                                                                 Choosing Health (DH)
Boys	>	girls                         Interventions for emotional and                Our Health, Our Care, Our Say
                                     conduct disorders                              (DH)
                                                                                    Aiming	High	for	Children	(DCSF)
Emotional disorders                  Interventions to reduce abuse
2.5% of 5-10 yr olds
                                     and therapeutic interventions                  Guidance
5% of 11-16 yr olds                                                                 NICE
Girls	>	boys                         for abused children and young                  Commissioning framework for
                                     people                                         health and wellbeing (DH)
                                                                                    Self commissioning tool for
Learning disability                  Interventions to promote MH in                 services to CYP (DH)
40% develop MH disorder              children & young people with                   Teenage parents –next steps
Children in care                     learning & physical disability,                (DCSF)
6-8 x risk of conduct disorder       children in care, young                        You’re Welcome (DH)
2-3 x risk of emotional              offenders and other high risk
disorder                                                                            Key PSA targets for CYP
                                     groups                                         12 Improve health & wellbeing
Young offenders                                                                     13 Improve safety
40% have history of MH               Integrated accessible services for             14 Increase number on path to
disorder                             young people in transition                     success



The commissioning loop

                            Evidence       National Standards

                          Needs Assessment
Target high risk       e.g. JSNA CAMHS                                                      Key interventions
groups                 needs assessment                                                     Maternal mental health
                              CYPP                                                          Parenting education
Families	with	MH	
                                                                                            Emotional literacy
or substance misuse    Review                                     Joint
problems                                                                                    Violence and abuse
                       current         Strategy                Commissioning
                                                                                            prevention
Homeless &             service                                                              Parenting skills for
disadvantaged          provision                                                            conduct disorder
families                                                                                    Behaviour	therapy	
Children with                                                                               &	CBT	for	emotional	
disabilities                                                                                disorder
& their siblings
                                                    Children,                             Who can deliver?
Families	with	             Seek views of                                  Evidence	Based	 Extended schools,
violence, abuse &      children and families      young people             Interventions  teachers, school nurses,
parental conflict                                  and families                             School governors,
Children in care                                                                            Learning support
Young offenders                                                                             assistants
                                                                                            Health visitors
School excludees and                                                                        Primary care workers
non attenders
                                                                                            Family	support	workers	
Teenage parents                                                                             Youth services
                                                                  Manage demand
BME	groups                       Audit, Governance                                          Voluntary sector
                                                                 & develop capacity
                                   Identify Risks                                           Criminal justice sector
LGBT	groups                                                           delivery
                                                                                            Youth offending team
Young men                                                                                   Educational
                                                                            Workforce
                                                       Training for                         psychologists
                                                                           development
                                                                                            Specialist CAMHS
                                                     universal services




                                                                                                                      19
            What can be done to promote mental health and well-being in children and young people?
                                                         The evidence base for effective interventions                                                               Target High risk groups of young people
                  Intervention                                                   Rationale                                                                                               What works
                                     Poor maternal mental health- independent risk factor for conduct disorder & persistence of           Identify & treat maternal depression whenever child presents with ED/CD.
            Promote                  both conduct & emotional disorders ( Meltzer 2003).                                                  Routine enquiry in pregnancy for MH disorders & use ‘Whooley’ questions at booking & postnatally
            maternal                 1 in 10 women have depression following childbirth. Teenage mothers at increased risk. Can
                                     affect infant attachment & school adjustment - increased behavioural difficulties, especially
                                                                                                                                          to detect depression.
                                                                                                                                          •	Targeted	psychosocial	interventions	for	women	who	have	symptoms	of	depression	and/or	anxiety	
            mental health            boys. (Sinclair & Murray 1996/1998).                                                                   which do not meet threshold for formal diagnosis.
                                     Binge	drinking	in	pregnancy	associated	with	Foetal	Alcohol	Syndrome	–includes	learning	              •	Self	help	strategies,	counselling,	CBT	for	mild/moderate	depression.	
                                     disability & behavioural problems. Leading known cause of non-genetic intellectual disability.
                                     Estimated	incidence	0.5-2/1,000	live	births	(	BMA	guide	2007).                                       •	Antidepressants	for	more	severe	disease.		(NICE	antenatal	&	postnatal	mental	health	guideline	
                                                                                                                                            no.45,	2007)
                                     Current DH guidance is to avoid alcohol in pregnancy.
                                                                                                                                          Screening and brief interventions effective in reducing harmful drinking in pre-natal settings (Chang 2004).
                                     Domestic Violence (DV) under reported -30% starts or escalates in pregnancy. Effects on
                                     children very damaging-increased aggressive & anti-social behaviour, low self-esteem,                Routine	ante-natal	enquiry	for	domestic	violence	increases	number	of	women	disclosing	abuse	(Bristol	
                                     increased risk of suicide & alcohol abuse (Dube 2001;Dixon 2006).                                    midwife	pilot	study)	Appropriate	training	for	professionals	essential	(DH	/Home	office	policy.	NSF	std.	11)
                                     Good parenting skills -best way to promote mental & emotional well being & reduce risk of            Universal	programmes	(primary	prevention	in	communities)	for	common	parenting	problems	&	
            Parenting skills         conduct disorders & abuse in children. Long term follow up of health visitor programmes
                                     to develop parent skills found reduction in adolescent anti-social & offending behaviour &
                                                                                                                                          targeted programmes such as Triple P for high risk groups (including foster & adoptive parents &
                                                                                                                                          residential	care	workers)	&	for	complex	problems.		Early	intervention	most	effective.	(DCFS)	May	also	
            in infancy and           improved	educational/employment	outcomes	(Olds	1997).                                                improve	maternal	psychosocial	health	(	Barlow	2000).
                                                                                                                                          Effective interventions: have strong theory base & clear model of change; are delivered by
            early childhood          Children with learning difficulties & disabilities at greater risk of MH problems & abuse. Early
                                     intervention	&	support	benefits	child	&	family.	NB.	siblings	also	at	risk	of	MH	problems	(NSF	       appropriately trained staff; deliver fact based advice, increase knowledge of child development &
                                     std. 9, Aiming High for children).                                                                   focus on specific parenting skills & practical take home tips.(Moran 2004).
                                     Emotional literacy helps children fulfil social, emotional, educational & employment potential       Whole	school	approach:	integrate	with	extended	schools.		Universal	&	targeted.	
            Emotional                & develop respectful relationships. SEAL programme in primary schools reduces self reported          Emotional	literacy	programmes	e.g.	SEAL	/SEBS-	primary/secondary.	Healthy	Schools.			
            health and               depression, drug & cigarette use & improves educational outcomes. PHSE: Well being
                                     promotes understanding, consequences & management of risks. Physical health and activity
                                                                                                                                          •	Integrated	MH	promotion	&	substance	misuse	programmes	more	effective	than	substance	misuse	
                                                                                                                                            programmes	alone	in	improving	behaviour	&	preventing	bullying	&	violence	(Stewart–Brown	2006).	
            well being               important for mental health. Evidence of link between artificial food colourings & hyper-
                                     activity	in	primary	children	(McCann	et	al	2007).	
                                                                                                                                            Help prevent self-harm/suicidal ideation (HDA 2005)
                                                                                                                                          •	Promote	physical	health-	healthy	diet	&	school	meals,	water,	physical	activity.	Access	to	green	open	
                                                                                                                                            spaces	promotes	mental	wellbeing		(Burls	2007)
                                     Childhood abuse strong risk factor for MH disorders in childhood & adult life.                       Violence prevention and protective skill training to prevent abuse & reduce risk of re abuse –
            Violence                 Vulnerable young people (children in care, children with disabilities, DV)- high risk .              particularly for vulnerable groups. Professionals working with children should be trained to identify
                                                                                                                                          abuse & refer appropriately.
            and abuse                20% of children report experiencing violence or abuse at least once in their lifetime. 20%           Counselling	&	cognitive	behavioural	therapy	(CBT)	-	help	victims	develop	ability	to	form	respectful	
            prevention               females	(16%	contact)	and	11%	males	(7%	contact)	report	sexual	abuse	and	23%	physical	
                                     abuse	(Cawson	2000	NSPCC	UK	study).	
                                                                                                                                          relationships & reduce re-abuse risk. Children with Post Traumatic Stress Disorder should be offered
                                                                                                                                          trauma-focused	CBT	(NICE	2005).
                                     Common:	1	in	17	children	aged	5-16.		Average	cost	to	society	of	an	individual	with	untreated	        Parenting programmes for conduct disorders in children & young offenders -should comply with
            Interventions            CD	is	£70,000	-	10	times	that	of	an	unaffected	individual	-	mainly	due	to	crime.                     NICE 2006 guidance for children 12 & under. Programmes should be evidence based & structured e.g.
                                                                                                                                          Webster Stratton & delivered by appropriately trained, skilled facilitators. Costs/family: £600-£4,000
            for conduct              Early intervention: long term benefits include reduced neglect, abuse & criminal behaviour
CYP Facts




                                     & improved protective factors: maternal MH, educational & employment outcomes. Cost                  depending on type & intensity.                                                             (Dretzke 2005)
            disorders (CD)           effective	:	savings	£150,000	per	case	(Friedli	2007).		Later	intervention	in	young	offenders	with	
                                     CD also effective –reduces time in offender units & re-offending rates (Woolfenden 2006).
                                                                                                                                          Community	based	interventions	to	reduce	substance	misuse	in	vulnerable	young	people	(NICE	2007).
                                                                                                                                          Psychosis-	CBT	/family	interventions	prevent	relapse,	reduce	symptoms,	increase	insight	&	adherence	
                                     Early intervention for first psychotic episode improves long term outcomes. Schizophrenia
                                                                                                                                          to medication (NICE guidance 2002).
                                     may present as CD - commonest psychosis 1 in 100 lifetime risk.
                                     Common: 1 in 25 children aged 5-16 - often undetected & untreated.                                   CBT,	behaviour	therapy	&	protective	skill	training	to	prevent	abuse.
            Emotional                Early intervention reduces long term impact (in 30% MH disorders persist into adulthood /risk        Stepped care approach. Watchful waiting for mild depression.
            disorders (ED)           of self –harm & suicide/ teenage pregnancy).
                                                                                                                                          Specific psychological therapy as first line for mod/severe depression. Severe depression, including
                                     £64,000 per 30,000 5-18 year olds to identify and treat depression.                                  psychotic disorders & eating disorders managed by Tiers 2-4. (NICE guideline 2005).
            (anxiety & depression)




                                                                                                                                                                                                                                                         20
                                                                                                                     CYP Facts


Emotional wellbeing and mental health: a guide for professionals working with
children and young people

                                                    WHAT TO LOOK OUT FOR
Persistent changes in behaviour                      Disruptive, defiant or attention seeking behaviour
Inappropriately familiar/attention seeking           Watchful, frozen, flat affect
Change in educational performance/poor               Absenteeism/school refusal or reluctant to go home
concentration                                        Stressful/adverse life events
Loss of interest in activities                        Sad, withdrawn, anxious
Poor relationships with peers/difficulties in groups Physical symptoms-headaches/tummy ache
Low self esteem
                        EXPLORE UNDERLYING REASONS /SIGNPOST FOR FURTHER HELP


   Refer to LA children’s social care                                                                     RED	FLAGS	
                 team                                                                           Is child seriously distressed?
    (What to do if you are worried                                                            Look for underlying risk factors
   about	a	child	being	abused-DCFS	                          Yes                               Domestic violence and abuse
            guidance 2006)                                                                Alcohol and substance misuse in family
        or urgently to Specialist CAMHS                                                             Self harm/Suicide risk
                                                                                                         Child in care
                                                                                                  Child protection register


                                                         Mild Problem
                                                UNIVERSAL SUPPORTIVE ADVICE
                                  from professionals who work with children and young people
                       PARENTING	SKILLS.		Encourage	warmth	and	                     HEALTHY DIET. Encourage eating more
                       positive feedback. Set clear and consistent                  fruit and vegetables and fewer sugary
 Increasing Severity




                       boundaries. Talk and listen to children.                     foods, biscuits, cake, chocolate, fizzy drinks
                                                                                    and other foods with additives and food
                       Consider referral to local parenting
                                                                                    colourings. Drink plenty of water.
                       programme
                                                                                    TALK	TO	THE	SCHOOL.	Ensure	access	to	
                        PHYSICAL ACTIVITY. Encourage play and
                                                                                    emotional literacy programme, violence and
                       physical activity and access to safe outside
                                                                                    abuse prevention and educational support
                       areas where possible.
                                                                Consider:
                         •	 DRUG	AND	ALCOHOL	MISUSE	IN	CHILD	AND/OR	PARENT-refer	to	local	service
                         •	 PARENTAL	MENTAL	ILL	HEALTH	–	refer	to	GP
                         •	 CHILD	IS	A	CARER-refer	to	social	services	
                         REFER ON FOR ASSESSMENT AND MANAGEMENT IF SYMPTOMS PROLONGED, SEVERE,
                       GETTING WORSE AND /OR SYMPTOMS OF EATING DISORDER/SELF HARM OR COMBINATION
                                                           OF RISK FACTORS




                                 ? Conduct Disorder                                                  ? Emotional Disorder
                                                                      Formal Assessment




                                  Moderate Problem
                            Refer for parenting programme
                           +/- treatment of substance misuse
                                                                                                        Moderate Problem
                                                                                             Primary care worker to assess self harm and
                                                                                                suicide risk and child protection issues
                                                                                                CBT/behaviour	therapy/family	therapy

                              Severe & persistent problems
                         Refer to specialist services (e.g. CAMHS)
                            including investigation for ADHD
                        Problem solving and social skills training,                              Severe and persistent problems
                       individual- based parent training +/- family                           Refer to specialist services (e.g. CAMHS)
                          therapy and sometimes medication /                                         Violence prevention skills
                                 therapeutic foster care                                             Consider anti-depressants

                                                                                                                        Sallie	Bacon	-	2008


                                                                                                                                              21
     CYP Facts


     Resources                                                         •	 Severe	symptoms,	trauma	focused	CBT	offered	in	first	
                                                                          month after traumatic event
     Evidence Base- Summary Of NICE Guidance:                          •	 Drug	treatment	not	first	option,	unless	psychological	
     Below	is	a	summary	of	Evidence	Based	Guidance	from	                  treatment refused (adults)
     the National Institute of Clinical Evidence – NICE, and           •	 Screening	to	be	considered	1	month	after	major	disaster	
     the Health Development Agency (now a part of NICE).                  for high risk individuals
     Implementation of these is one of the standards assessed by       Self harm. Clinical guidance (CG16), NICE, 2004
     the Healthcare Commission.
                                                                       http://www.nice.org.uk/page.aspx?o=213665
     Parent-training/education programmes in the
     management of children with conduct disorders: The                •	 People	who	have	self	harmed	should	be	treated	with	
     NHS now has two years to make the funding available                  care, dignity and respect
     for all patients who are treated in line with this                •	 Training	for	staff,	to	promote	understanding	and	
     guidance. www.dh.gov.uk/PublicationsAndStatistics/                   appropriate care
     Legislation/DirectionsFromSecretaryState/                         •	 Activated	charcoal	available	in	A&E		and	ambulance	staff	
     DirectionsFromSecretaryStateArticle/fs/en?CONTENT_                   to treat poisoning
     ID=4075685&chk=R4/Zyn
                                                                       •	 A	preliminary	psychological	assessment	should	be	offered	
     Guidelines on bipolar disorder in children and adults, NICE,         at triage
     July 2006
                                                                       •	 Patients	waiting	for	treatment	should	be	in	a	safe,	
     Clinical guidelines on the early identification, treatment           supportive environment
     and management of bipolar disorder in children and adults.
     http://www.nice.org.uk/page.aspx?o=CG038                          •	 Treatment	for	physical	harm	should	be	offered	and	pain	
                                                                          relief for painful treatments
     Depression in children and young people. Clinical guidance
     (CG28), NICE, 2005                                                •	 Information	should	be	provided	on	treatment	options	to	
                                                                          enable an informed choice
     http://www.nice.org.uk/page.aspx?o=273073
                                                                       •	 All	should	be	offered	an	assessment	of	the	factors	specific	
     •	 Assessment	should	consider	and	record	potential	                  to the self harm, and a risk assessment
        comorbidities, social, educational and family context and
        interpersonal relationships                                    •	 Referral	decisions	for	further	treatment	should	be	based	
                                                                          on a comprehensive psychiatric, psychological, social and
     •	 Psychological	therapies	should	be	by	trained	therapists/          risk assessment
        trained child and adolescent mental healthcare
        professionals                                                  Eating Disorders. Clinical guidance (CG9), NICE, 2004 http://
                                                                       www.nice.org.uk/page.aspx?o=101239
     •	 Parental	mental	health	needs	to	be	considered,	assessed	
        and treated                                                    •	 Manage	most	with	anorexia	as	outpatients	with	specialist	
                                                                          psychological support.
     •	 CAMHS	to	support	training	needs	for	primary	healthcare	
        staff and schools to improve identification of those at risk   •	 Inpatient	treatment	for	anorexia	to	provide	re-feeding	
        of depression                                                     and psychological interventions
     •	 Antidepressants	should	not	be	used	initially	to	treat	mild	    •	 Family	interventions	to	be	offered	to	children	and	
        depression                                                        adolescents with anorexia nervosa
     •	 Moderate	to	severe	depression	treated	initially	               •	 Initially	management	of	bulimia	a	self	help	programme	
        with psychological therapy for at least 3 months.                 or antidepressant drug
        Antidepressants only offered in combination with a             •	 CBT	to	be	offered	for	Bulimia	Nervosa	or	Binge	Eating	
        psychological therapy.                                            Disorders
     Antenatal and post natal mental health. Clinical guideline        Schizophrenia. Clinical guidance (CG1), NICE, 2002 http://
     (CG45),	NICE,	2007                                                www.nice.org.uk/page.aspx?o=42424
     http://www.nice.org.uk/guidance/index.                            •	 Holistic	care	across	all	stages	with	recovery	approach	
     jsp?action=byID&o=11004
                                                                       •	 Early	Initiation	of	treatment	–	Early	intervention	for	
     •	 Treatment	and	care	should	take	into	account	patient’s	            first episode of psychosis appears to improve long-term
        individual needs and preferences                                  outcomes.
     •	 Enquire	about	history	of/current		mental	illness	at	first	     •	 Treatment	of	acute	episodes	to	include	clinical,	emotional	
        contact with services (antenatal and postnatal)                   and social needs
     •	 Screen	all	women	for	depression	antenatally	and	               •	 Promote	recovery,	eg	with	CBT	and	address	social	needs	
        postnatally                                                       including meaningful activity to reduce symptoms and
     •	 Targeted	psychosocial	interventions	for	women	who	have	           prevent relapse.
        symptoms of depression and/or anxiety which do not             •	 Rapid	tranquillisation	should	not	routinely	be	used.	
        meet threshold for formal diagnosis.                              Identify and reduce risk factors for rapid tranquilisation.
     •	 Self	help	strategies,	counselling,	CBT	for	mild/moderate	      Substance Misuse interventions	(PHI4)	NICE,	2007	http://
        depression.                                                    www.nice.org.uk/guidance/index.jsp?action=byID&o=11379
     •	 Antidepressants	for	more	severe	disease	bearing	in	mind	       •	 Community	based	interventions	to	reduce	substance	
        that safety of drugs not well understood                          misuse in vulnerable young people
     •	 Clinical	networks	should	be	established	for	perinatal	         Evidence reviews from the Health Development Agency:
        mental health services to provide specialist multi-
        disciplinary teams, expert advice , clear protocols for        Youth suicide prevention. Evidence briefing summary,
        referral and management and care pathways                      HDA,	February	2005
     Post-traumatic stress disorder. Clinical guidance (CG26),         http://www.publichealth.nice.org.uk/page.aspx?o=503371
     NICE, 2005
                                                                       Emotional health and wellbeing through the National
     http://www.nice.org.uk/page.aspx?o=248114 for children            School Standard, HDA, May 2004
     and adults
                                                                       http://www.publichealth.nice.org.uk/page.aspx?o=502723
     •	 Single	session	interventions	on	the	traumatic	incident	
        should not be routine practice                                 Drawing on the evidence. Advice for mental health
     •	 Mild	symptoms	<4	weeks,	watchful	waiting	with	1	month	         professionals working with children and adolescents.
        follow up.                                                     CAMHS	Evidence-Based	Practice	Unit.	2006



22
                                                                                                        CYP Facts


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                                                                 This factsheet is available to download at
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                                                                 http://tinyurl.com/38fjh




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