Joint strategic needs assessment

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Emotional health mental health needs of children and young people aged 0 – 18 years old living in Nottingham City (2015)

Topic titleEmotional health mental health needs of children and young people aged 0 – 18 years old living in Nottingham City (2015)
Topic ownerLynne McNiven
Topic author(s)Sarah Quilty
Topic quality reviewed23/04/2015
Topic endorsed byCAMHS Exec
Topic approved byCAMHS Exec
Current versionApril 2015
Replaces version2011
Linked JSNA topicsMental health, Domestic Violence
Insight Document ID123274

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Executive summary

Introduction

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Good mental and emotional health is essential to enable children and young people to fulfil their potential. Mental and emotional health problems are an important and common group of disorders affecting about 1 in 10 children and young people living in the UK (1). Mental health is best seen as a continuum, ranging from mental wellbeing, to severe and enduring mental disorders that cause considerable distress and interfere with relationships and daily functioning. Mental health problems vary in their nature and severity, and affect individuals differently over time. The factors that affect mental and emotional health are complex, ranging from individual biological factors to complex societal issues. Mental health conditions in childhood and adolescence are particularly important due to the far reaching consequences on health, social and educational outcomes. Mental health problems unlike other health problems tend to start early and persist into and throughout adulthood. It is recognised that by the age of 14 about half of all lifetime mental health problems start (2). This highlights the long term nature of mental illness and the importance of intervening early to prevent mental illness alongside early recognition and treatment.

In terms of children and young people’s emotional mental health and well-being, according to the National CAMHS review (2008), children and young people state that it’s not just about children being ‘happy’ but feeling ‘in control’ or ‘feeling balanced,’ It’s about children and young people “having the resilience, self-awareness, social skills and empathy required to form relationships, enjoys one’s own company and deal constructively with the setbacks that everyone faces from time to time,” (1) .  The term ‘wellbeing’ is a broad concept encompassing emotional, psychological and social wellbeing.

Unmet needs and gaps

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Needs of children and young people

  • Increasing referrals to tier 2 and tier 3 CAMHS for children and young people who are self-harming
  • An increasing number of presentations to the Emergency Department (ED) at Queens Medical Centre by children and young people who are self-harming.
  • An overall increase in the complexity of cases presenting both to ED and CAMHS.
  • A significant number of children in Nottingham City are exposed to domestic violence either as part of their family life or within their own relationships.
  • School nurses are seeing an increasing number of children and young people who are experiencing emotional and mental health problems.
  • School nurses are seeing an increasing number of children who are self-harming. Due to waiting time into be seen within tier 2, school nurses are holding and ‘counselling’ children who may be at significant risk to themselves.
  • Some stakeholders stated that Schools needs to take greater responsibility for raising awareness of self-harm. This will hopefully be ameliorated by the development of the Kooth counselling services being placed within the City schools and the SHARP team self-harm specialist team within tier 2.
  • The age of children and young people presenting to services with regards to self-harm is lowering to age 7.
  • There are a significant number of children in Nottingham who are witnessing/experiencing domestic violence with an estimated 3 children in every classroom.  Research states that children who experience DV have a 4 fold increased risk of experiencing mental and emotional health issues. Therefore there are a substantial number of children in Nottingham who may be experiencing/witnessing DV however their emotional and mental health needs are not being catered for.
  • A number of high profile suicides of young people in the city where previous self-harm was a prominent feature.Behavioural Issues/ ASD/ADHD
  • A significant number of referrals to CAMHS are related to behaviour which is taking up significant time and resources. It is anticipated that the new emotional health and wellbeing pathway commissioned by the NHS Nottingham CCG will help to divert these referrals away from CAMHS, if appropriate.
  • A significant number of referrals from GPs to community paediatricians for behaviour and suspected ASD/ADSD. However there is a view that there is limited resources within community paediatricians to cope with the sheer number of referrals being made on a weekly basis (again this should be alleviated with the development of the Emotional Wellbeing Pathway) and that community paediatricians do not have a wide source of opportunities to refer onto to support parents, therefore pharmacological treatment is used as a first line of treatment rather than parenting and psychological support.
  • Stakeholders expressed care of children with behavioural issues should be multidisciplinary and focused on the child’s needs rather than medical diagnosis
  • A recognition that many of the referrals coming through to both community paediatricians and CAMHS tier2 are caused by attachment issues. Therefore work should be focused on parenting programmes.

Early Intervention

  • Stakeholders felt that there needs to be a greater emphasis on early intervention, identifying emotional and mental health problems early in order to ‘break the cycle’.
  • It is also recognised that resilience needs to be systematically promoted within the school setting starting within primary schools.
  • Some stakeholders felt there is a perceived gap around teaching young people to work through and manage issues themselves.
  • There needs to be more emotional and mental health training and support provided to universal services due to sheer numbers of children and young people accessing these services.
  • Schools needs to take on a greater role in promoting emotional health and wellbeing as well identifying children who are at risk of emotional and mental health problems.

Issues related to the provision of CAMHS Services

Overall stakeholders recognised there are blockages at every tier of CAMHS and there is no step up step down approach within Nottingham City which allows children to move up and down the tiers of CAMHS depending on their level of need. It is also recognised by stakeholders the children and young people are not at the heart of the service in terms of the development and care and this needs to be developed further.

Universal Services (tier 1)

  • The numbers of pupils seen by school nurses for emotional and mental health problems are increasing (557 from April until October 2013).
  • There is still a need for tier 1 services to be trained in dealing with young people self-harming (despite the new services coming on line). In particular there needs to be recognition by schools and school governors that self-harm is a public health challenge.
  • GPs are referring to community paediatricians rather than into CAMHS services due to being ‘bounced’ around the existing CAMHS provision.

Tier 2 Services

  • Neither universal services nor community paediatricians currently receive any feedback from the CAMHS services with regards to the children and young people they refer into the SPA.
  • There is a lack of knowledge within clinical children’s services of the skills and competences of the tier 2 work force.
  • The community paediatricians currently do not receive feedback from the SPA on the care plan and outcomes of the children/ young people they have referred.
  • There is a lack of knowledge from referrers into the CAMHS service on the outcome of referral through the SPA process.
  • A number of referrals made into the SPA (tier 2) by the community paediatrician have been ‘bounced back’ to them instead of being placed within tier 2.
  • It was reported that there are increasing waiting times for children to be seen in tier 2 after a referral has been made into the SPA due to the numbers of referrals being made into CAMHS. In some cases children and Young people are waiting up to 8 weeks to be seen initially within CAMHs after a referral has been made. However this issue is now being dealt with, with the introduction of the CAPA model within tier 2.
  • There appears to be reduced capacity within tier 2 due to an increase in the number of referrals.

Tier 3 Services

  • The Head to Head service are not filling all their numbers of planned sessions for Nottingham City. However the cases that they are working with are extremely complex and taking up significant time.
  • There is a significant waiting time for tier 3 services.
  • Tier 3 services including the special self-harm team work office hours Monday to Friday, which does not cater to the demand for the service as the majority of ED presentations which would warrant a special tier 3 intervention are at an evening or weekend.
  • The self-harm team are only able to see a small proportion (2 assessments per professional per day) of those young people who are admitted to a paediatric bed in QMC for self-harm due to the sheer number of admissions. This is causing an increase in bed stays within the paediatric wards for the young people until the young people can be assessed and having a knock on effect and increasing pressure in paediatric care.

Looked After Children

  • The CAMHS Looked after Children team has seen an increase in the number of referrals which is a reflection of the increasing number of children and young people entering into care.
  • There is currently no monitoring system to assess the emotional and mental health of all children who are in care. The SDQ questionnaire is only used for children who have been referred into the team to assess their emotional and mental health.

Tier 4 Services

  • There is recognition locally and nationally that there are a limited number of inpatient beds within tier 4 (12 beds locally for all children and young people who live in Nottinghamshire and Derbyshire).
  • There are issues that local children and young people have been placed out of area due to impatient capacity.
  • In patient unit at Thorneywood is mainly occupied by long term stay patients. There is currently no step up step down pathway for children and young people who no longer require inpatient care but require intensive support.

Secondary Care- Queens Medical Centre

  • There are an increasing number of children who are presenting and admitted to ED at QMC with emotional and mental health issues.
  • Children and Young People who present to ED with self-harm on a Friday afternoon or over the weekend are not assessed by the CAMHS self-harm service until a Monday morning. The consequence of this is that children and young people have to stay over the weekend in a paediatric bed which again causes pressures on paediatric care.
  • If a young person is admitted to QMC over the weekend, it will not be the specialist self-harm team that undertakes the assessment, a Registrar Psychiatrist or a Consultant Psychiatrist will undertake the assessment using a different risk assessment tool from the self-harm team and will only assess and not refer onto appropriate CAMHS services.

Transition to Adult Services

  • Stakeholders expressed mixed views about transitioning from child to adult mental health services. Many reported that in general, transitioning appeared to work ok. Where it did not work well, cases were complex or had been out of area. It was felt in these cases; transitions weren’t always planned far enough in advance, particularly where there were complex needs.
  • Transitions were reported to work well when young people have significant mental health disorders that clearly map onto adult services. For example, it was felt there was a good match between child and adult psychosis services.
  • Several stakeholders however reported that adult and child services are configured differently with some young people not necessarily meeting criteria to be seen in adult services, particularly for emotional or behavioural conditions.
  • Linked to the above, it was felt that transition was a vulnerable time for the young person, potentially having left school, losing other support networks and potentially losing support from CAMHS.
  • Young people who present with emotional and mental health issues on the cusp of transition into adult services may not necessarily be placed with the most appropriate level of care.

 

Recommendations for consideration by commissioners

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Antenatal

  • Antenatal and perinatal health needs to focus more on emotional and mental health of mothers with the development of specialist mental health midwives to support mothers with post natal depression. This is due to the link between antenatal anxiety at 32 weeks and the link to behavioural and emotional problems in children. This recommendation will be fed into NHS Nottingham City CCG midwifery review.
  • Develop universal programmes which address how to parent effectively as part of antenatal care for example based on the Family Partnership programme in the USA. This recommendation will be fed into the Nottingham City Emotional, Mental Health and Wellbeing pathway which is in development.

Early Years

  • Utilise the school readiness check at age 4 to undertake an emotional and mental wellbeing check of the child and pass on any information to the school and school health.

Parents/Family

  • Systematic support should be provided to families with children and young people who are experiencing domestic violence at all risk levels as assessed by DART. There needs to be recognition the impact of DV on children’s emotional and mental health.
  • Ensure all services are linked into Nottingham City Council’s Family Support Strategy.
  • All adult mental health services should have a Key Performance Indicator to support the emotional and mental health needs of children particularly when parents are diagnosed with a mental health condition.
  • All children’s services to consider parental mental health, substance misuse and domestic violence as a factor affecting child emotional and mental health and to signpost/refer to appropriate services.

Training

  • All primary care (GPs, school nurses and health visitors) and schools (all teachers) should have comprehensive training in the skills and knowledge required to recognise children and families who may be experiencing emotional and mental health issues.
  •  A comprehensive self-harm training programme should be developed and delivered to all GPs, schools (both primary and secondary including teachers) and school nurses.
  • Roll out the Public Health England Tool Kit for emotional health in schools.

Children and adolescent mental health services and proposed pathways

  • Identify resources to develop a new CAMHS pathway in light of the increased number of referrals and improve partnership working with adult mental health services
  • Utilise tier 2/3 service usage data to deliver a multi-disciplinary and skilled community CAMHS pathway provision where the child and young person is at the centre of delivery. This includes appropriate venues for meeting families and children and young people, suitable waiting times to the point of invention and length of intervention time.
  • Ensure that the CAMHS pathway systematically supports universal services after the point of referral.
  • Undertake a whole CAMHS workforce review to ensure there are the right skills and competences in relation to working with children and young people who are experiencing emotional and mental health problems. Develop a skills and competences quality standard for all CAMHS workforce.
  • Develop a multi-agency assessment process with a single point of access which is inclusive of all appropriate referrers into the CAMHS service.
  • Support the workforce and service users to smooth transition of patients between tiers and transition to adult services to minimise duplication of assessments.
  • Develop an appropriate pathway for children and young people who attend emergency department (ED) for self-harm
  • .All young people who are admitted to QMC over the weekend with self-harm should have the standardised self-harm risk assessment tool undertaken as done by the specialist tier 3 self-harm team.
  • Provide a responsive CAMHS service which works into the evenings and weekends to minimise the number of admissions to QMC by young people and the need for inpatient beds.

Waiting times

  • All referrals should work towards a standardised waiting times and all interventions should be standardised to ensure children and young people are at the heart of the service.

CAMHS specific services

  • All looked after children (LAC) undertake a strengths and difficulties questionnaire SDQ) every 6 months as part of their LAC review. This will ensure that all LAC will be monitored for changes in their emotional and mental health state and subsequently be referred into the CAMHS looked after children team to appropriate interventions.

Improving local data on children and young people’s mental health

  • Develop a core dataset to be reviewed at the CAMHS Executive, taking account of the development of a national CAMHS minimum dataset and the use of outcome measures such as The health of the nation outcomes scale for children and adolescents (HoNOSCA), for more information please go to http://www.liv.ac.uk/honosca/faq.htm.
  • A systematic change needs to be implemented across the CAMHS which focuses on the outcome of the child/young person rather than the process.   Investigate the possibility of a newly commissioned data system or that existing data systems talk to each other to ensure a smooth referral or transition between tiers of CAMHS children and young people.

What do we know?

1. Who is at risk and why?

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There are numerous risk factors which can affect the emotional and mental health of children and young people. Table 1 below outlines data taken from the Department of Health (DH), the Mental Health Review and from the Office of National Statistics (ONS) survey (2004) (3) (2). Many children who for example live in families with low income, with one parent or with no parent are more prone to emotional and mental health problems, however according to the CAMHS Review (4) it is stated that it is important to emphasise that these are associations and not necessarily direct causes as the majority of children and young people in these circumstances grow and develop without difficulties

 

  TABLE 1: RISK FACTORS FOR MENTAL ILLNESS IN CHILDREN AND YOUNG PEOPLE , (2) (3)

CHILD RISK FACTORS

 

Male

 

Increasing age

 

Child abuse

15.5 fold increased risk of minor depression as a child

8.9 fold increased risk of suicidal ideation

8.1 fold increased risk of anxiety

7.8 fold increased risk of recurrent depression as adult

9.9 fold increased risk of adult post-traumatic stress disorder (PTSD)

5.5 fold increased risk of substance misuse/ dependence

4 or more adverse childhood experiences (e.g. abuse, neglect, parental divorce, domestic violence)

12.2 fold increased rate in attempted suicide as an adult. 10.3 fold increased risk of injecting drug use

7.4 fold increased risk of alcoholism

4.6 fold increased risk of depression in past year

 

 

 

 

Low birth weight

4-5 fold increased risk in onset of emotional/conduct disorder in childhood

Adolescent dating violence (i.e. physical or sexual abuse by a dating partner)

8.6 fold increased risk of suicidality

High level use of cannabis in adolescence

 

 

6.7–6.9 fold increased risk of developing schizophrenia

PARENTAL RISK FACTORS

 

Poor parental mental health

 

Parental unemployment

2-3 fold increased risk of emotional/ conduct disorder in childhood

 

 

Lone parent

Prevalence of mental health disorders 16% (lone parent) compared to 8% (2 parent family)

Reconstituted families (a family was defined as ‘reconstituted’ if stepchildren were present)

Prevalence of mental health disorders: 14% if the child had stepbrothers or stepsisters, compared to 9% if they had no stepbrothers or stepsisters

Receipt of disability living allowance

Prevalence of mental health disorders 24% (member household receiving disability allowance) compared to 8% (no one receiving DLA in household)

Parents with no educational qualifications

4.25 fold increased risk of mental health problem in children

Use of alcohol, tobacco or drugs during pregnancy

Increased risk of long-term neurological and cognitive-emotional development problems

Maternal stress during pregnancy

Increased risk of child behavioural problems. Impaired cognitive and language development

Poor parenting skills

4-5 fold increased risk of conduct disorder in childhood

HOUSEHOLD RISK FACTORS

 

Low household income

Prevalence of mental health disorders 16% (gross weekly income <£100) compared to 5% (gross weekly income ≥£600)

Living in deprived areas

3 fold increased risk of mental health problems between highest and lowest socioeconomic groups

Living in social or privately rented accommodation

Prevalence of mental health disorders 17% (social housing) compared to 7% (private ownership)

 

 

There are also children and young people who are significantly more likely to experience emotional and mental health problems than the general population.

  • Nearly 50% of children in local authority care have a clinically diagnosable mental health disorder, compared with 10% in the general population (5). This increases to nearly 70% among children living in residential care.
  • Children in special schools for behavioural, emotional and social difficulties (BESD schools) or pupil referral units (PRU) are significantly more likely to experience mental health difficulties than the general population (6).
  • Over a third of children young people with an identified learning disability also have a diagnosable disorder.
  • Approximately 40% of children and young people within the youth justice system have a mental health problem (7). This rises to more than 90% for those in custody (8).
  • Children and young people with a physical disability are twice as likely to develop psychological problems as those without (9).
  • Teenage mothers are three times more likely than older mothers to suffer post natal depression and mental health problems in the first three years of their baby’s life (10).
  • Young lesbian, gay, bi-sexual, transgender (LGBT). There is a 7- fold increased risk of suicide attempts in young lesbians and an 18- fold increased risk of suicide attempts in young gay men (11) .
  • Children of prisoners – there is a 3 fold increased risk of antisocial-delinquent outcomes (12).

Several data sources have been used to assess the prevalence of these risk factors in Nottinghamshire. Further detail can be found in a health needs assessment of ‘The Emotional and mental health needs of children and young people aged 0 – 18 years old living in Nottingham City (Quilty 2014).

  • The total number of children and young people aged 0 – 18 living in Nottingham City is 68,424
  • Aspley ward has the highest number of children and young people residing there (6,590) followed by Bilborough (4,506) and Berridge (4,480). Children and young people in Nottingham City account for 22.4% of the population in the city.
  • 35.1% (CI 95%, 34.8-35.6) of Nottingham City children are living in poverty which is significantly worse that in Nottinghamshire County and in England
  • The prevalence of lone parent families within Nottingham city is 9.5% (taken from the 2011 consensus), this is higher than the East Midlands average (6.7%) and England (7.1%) average. Some wards within Nottingham have significantly higher prevalence than the overall average in Nottingham city, for example; Aspley ward has 23.5% of lone parents residing there whereas in contrast Dunkirk and Lenton ward only has 2.5% of lone parents residing there.
  • Aspley and St. Ann’s has the highest proportion of households in socially rented houses (48.3% and 46.8% respectively) with Nottingham as a whole having 29.7% of all citizens residing in socially rented accommodation compared to 17.7% in England.
  • The percentage of households with no parent working in Nottingham City is 6.9%, higher than the average for the East Midlands (0.8%) and England (4.2%). 
  • Aspley (9.7%) and Bilborough (7.0%) have a higher prevalence of this risk factor for parents who have a long term illness or disability than the average for East Midlands (4.6%) and England (4.6%).
  • There are between 7,000 – 10,000 children in Nottingham at risk from domestic abuse. This means at least 3 in every class of 30 children are at risk or experiencing domestic violence.
  • The importance of good perinatal mental health is increasingly recognised. NICE estimates that about 10-15% of new mothers suffer some perinatal mental health difficulties (13). Applying these estimates to the numbers of new mothers in Nottingham City in 2012 suggests that of the 4,408 new mothers, between 441 and 661 may have had a perinatal mental health problem.
  • National estimate 7% of children will see fathers imprisoned in their school years. This equates to around 2,500 children of school age in Nottingham City (age 5-15 years).

2. Size of the issue locally

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Prevalence of mental health problems in children and young people

Regarding prevalence, the most comprehensive statistical surveys in Great Britain have been carried out by The Office for National Statistics in 1999 and again in 2004.  The first survey (1999) obtained information about the mental health of 10,500 5-15 year olds living in private households in England, Scotland and Wales.  The second survey (2004) included 7,977 children and young people aged 5 – 16 living in England, Scotland and Wales. Both surveys found that one in ten children in Great Britain had a clinically recognisable mental disorder.  These were classified in 2004 as shown in TABLE  2 and demonstrate that overall boys were more likely than girls to have a mental disorder with highest prevalence amongst 11-16 year olds.  Conduct and hyperkinetic disorders are much more likely in boys than girls, although girls are slightly more liable to suffer from emotional disorders.  1 in 5 children with a mental health problem were found to have more than one clinically recognisable mental disorder (3). 

The Child and Maternal Health Observatory (CHiMAT) provide local estimates of mental health problems in the UK and uses an average prevalence of 9.6%. 

There is no local survey which collects information and data on the emotional health and wellbeing of children and young people who live in Nottingham therefore national prevalence data is used and estimates are calculated for the local population.

TABLE 2: PREVALENCE OF CHILDREN’S MENTAL DISORDERS (CHiMAT) 2004, GB

 

5-10 Year Olds

11-16 Year Olds

All 5-16 Year Olds (%)

Boys (%)

Girls (%)

Boys (%)

Girls (%)

Emotional Disorders

2.2

2.5

4.0

6.1

3.7

Conduct Disorders

6.9

2.8

8.1

5.1

5.8

Hyperkinetic Disorders

2.7

0.4

2.4

0.4

1.5

Less Common Disorders

2.2

0.4

1.6

1.1

1.3

 

Any Disorder

10.2

5.1

12.6

10.3

9.6

Source ONS: (2004). Survey of Psychiatric Morbidity among Adults Living in Private Households

Pre-school Children

According to Gardner and Shaw (2008) (14) the evidence for stability and prognostic significance of preschool problems is not particularly strong especially in the under three’s as co-morbidities are very high and there are also concerns about distinguishing normal from abnormal behaviours in this period of rapid change in development and maturation that takes place from birth to age 5.  However the author further states that there may be also a disadvantage in not defining disorders in young children, including failure to recognise distress and provide appropriate help. Therefore the estimates discussed in relation to this age group need to be treated with some caution.

Using the DSM-IV criteria, generated from structured interviews with parents in the USA, the prevalence of preschool oppositional defiance disorder (ODD) was estimated at 5%, and attention deficit hyperactivity disorder (ADHD) at 6% (15). Further studies of pre-school children using DSM-III and DSM-IV criteria have estimated prevalence of emotional disorders; these tend to be low for each category: separation anxiety (0.3-5%), social phobia (2-4%) and depression (0-2%). An estimate by the Mental Health Foundation gives a prevalence of mental health problems among the 2 – 5 year olds as 10% (16).

School Aged Children

In 1999 ONS carried out a large survey of 10,500 children and young people aged 5-15 years old living in private households. The subsequent survey in 2004 included 7,977 children and young people aged 5-16. Data were collected from young people, parents and teachers to identify if the child or young person met the ICD-10 criteria of a clinically diagnosable mental disorder. These surveys provide the most robust and comprehensive data on the prevalence of mental disorders among children in the UK. Both surveys found that 1 in 10 children (10%) had a clinically diagnosable mental disorder with variation seen according to age, sex and ethnicity.

The four main groups of disorders considered by the survey were:

  • Emotional disorders, which includes conditions such as separation anxiety, phobias, generalised anxiety and depression.
  • Conduct disorders, which includes oppositional defiant disorder and socialised and unsocialised conduct disorders.
  • Hyperkinetic disorders, such as ADHD.
  • Less common disorders which includes autistic spectrum disorder, eating disorders and tics.

The key findings were:

  • 1 in 10 children had a diagnosable mental disorder associated with distress and interference with personal functions such as social and family relationships.
  • 4% of children had an emotional disorder such as anxiety or depression.
  • 2% had a hyperkinetic disorder.
  • 1% had a less common disorder (e.g. autism, tics, and eating disorders).
  • 2% had more than one type of disorder.
  • More boys than girls had a diagnosable mental disorder.
  • Mental disorders were more common among children aged 11-15 than children aged 5-10.
  • Boys were more likely to suffer from a conduct or hyperkinetic disorder than girls.
  • Girls were slightly more likely to have an emotional disorder than boys.

According to the Charity Young minds (17) it is estimated that 850,000 children have mental health problem

  • Three children in every classroom have a diagnosable mental health disorder (and that’s just the ones that have been diagnosed).
  • One in five young adults show signs of an eating disorder.
  • One in 12 deliberately harm themselves (and 25,000 of them are hospitalised each year because of this).
  • Nearly 80,000 children and young people suffer from severe depression.


The charity states that children and young people are often demonised by society, thousands of children and young people are isolated, unhappy, have eating disorders and self-harm; some even commit suicide. Many are likely to become victims of crime, grow up in dysfunctional families, or left to cope with illness, drugs and/or alcohol issues

Young People Aged 16-19 years

A further ONS survey was carried out between March and September 2000. A two-stage approach to the assessment of mental disorders was used. From this survey, the prevalence of mental health disorders for 16- 19 year old young people can be identified. Table 3 shows the prevalence of certain neurotic disorders for males and females aged 16 – 19.

Table3.JPG

From TABLE 3 it can be seen that females have a high prevalence rates of mixed anxiety and depressive disorder and generalised anxiety disorder (124 per 1000 compared to 51 per 1000) and a higher prevalence rates of any neurotic disorder (192 per 1000 compared to 86 per 1000).

Compared to neurotic disorders, psychotic and personality disorders were less common. Among females aged 16-19, 5 out of 1000 reported a probable psychotic episode in the last year. The number of males reporting a psychotic episode in the last year was too small to publish.

The prevalence of any personality disorder was presented for people aged 16-34 with male having a higher prevalence (52 per 1000) than females (17 per 1000).

It is estimated that one in 12 young people in the UK have self-harmed at some point in their lives, although the figure could be much higher with many people suffering in silence, according to research carried out for Young Minds last year (18). In addition, ChildLine has reported a 167 per cent increase in counseling sessions where the main concern was self-harm (19).

ChildLine has also found that self-harm is affecting younger children. In 2011/2012, ChildLine reported that self-harm was in the top five concerns for 14-year-olds for the first time. However in the first six months of 2012/2013, this age dropped further with 13-year-olds citing self-harm as one of the top five concerns (19).

The Mental Health Foundation’s report (20)  found that there is relatively little research or other data on the prevalence of self-harm among young people in the UK or on the reasons why young people self-harm. The report states that the inquiry found that self-harm is a symptom rather than the core problem. It masks underlying emotional and psychological trauma and a successful strategy for responding to self-harm must be based on this fundamental understanding

From Figure 1 it can been seen that females aged between 15 and 17 years have the highest rate of admissions in the City with the North Locality and South Locality having the higher rates than the overall average for Nottingham City. Females aged between 11-14 years have the next highest rate of admissions with the South Locality being significantly worse than the other locality and the Nottingham City average. Overall it can be seen that self-harm is an emerging public health priority within the city.

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Suicide

Numbers of suicides are small among children and young people. Figure 2 shows the rate of suicides in Nottingham City, the East Midland and ONS Clusters according age for 2008-2010. As it can be seen the crude rate of suicide is low in the 5- 14 years but rises steeply in the 15-35 years old age group.

An image

ONS Cluster includes: Barking and Dagenham, Birmingham, Leicester, Manchester, Sandwell, Wolverhampton.

 

3. Targets and performance

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State the relevant PHOF, NHSOF and ASCOF outcomes.

Add details of any other local strategy targets which could be used to measure effectiveness and outcomes for this topic.

Details of performance against the above, where available.

Include links to more detailed performance reports as appropriate (supporting documents can be held in the JSNA library).

Despite there not being an indicator specific to child and adolescent mental health within the Public Health Outcomes Framework, there are several related indicators as listed below (Department of Health, 2012):

Indicator 1.01 Children in poverty

Indicator 1.04 First time entrants to the youth justice system

Indicator 1.05 16-18 year olds not in education not in training

Indicator 2.08 Emotional wellbeing of looked after children

Indicator 2.23 Self-reported wellbeing (measured for those 16 years and over).

Indicator 4.10 Suicide rate (all ages, adults and children)

Locally NHS Nottingham City Clincal Commissioning Group (CCG) has a target to reduce A and E admissions by 5%.   Preventing young people who self-harm  and who are admitted after an attendance at A and E is a significant work steam as part of an overall programme of measures to reduce A and E attendances and admissions.

 

4. Current activity, service provision and assets

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Universal Services/tier 1 is provided by practitioners working in universal services (such as GPs, Health Visitors, teachers and youth workers), who are not necessarily mental health specialists.

Tier 2 CAMHS offers an effective early intervention service to prevent emotional and behavioural difficulties emerging into more complex ones. It is a jointly commissioned service by Nottingham City Council and NHS Nottingham City CCG. In 2012/2013 there were 1301 referrals into tier 2 with the most common reasons for referral being challenging behaviour, low mood and self-harm. Referrals are highest in the north of the city which reflects a larger population of children and young people. There has been a significant increase in the numbers referred for self-harm in 2012/2013 – 2013/2014 and indications for this financial year suggest there has been an increase in the number of children and young people referred for suicidal thoughts.

Tier 3 CAMHS provides specialist multi-disciplinary services for severe and complex child and adolescent mental health problems. In 2012, 163 children and young people were seen in tier 3 CAMHS, of which 113 (69%) were male and 50 (31%) were female. The main reason for referral was self –harm, followed by challenging behaviours and eating disorders.

A self-harm audit conducted on 15 cases of young people who were admitted to Queens Medical Centre (QMC) for self-harm demonstrated some preliminary risk factors, the main ones being poor parental mental health and low attachment. It is anticipated this will be an ongoing audit over 2014 to identify trends and emerging themes in order to implement early intervention.

Tier 4 CAMHS includes highly specialised inpatient care. Between 1st Jan 2010 and 31st December, 2012, 23 young people completed 25 hospital spells. The most common reasons for admission were non mental health diagnoses such as behaviour which require a psychiatric assessment, history of self-harm and eating disorders.

Data

Information from school nurses within Nottingham City illustrates the scales of the issue. Since April 2013 and October 2014 school nurses have seen a total of 557 children with emotional health problems.  Out of the 557 children the reasons for emotional support were:

 

  • Emotional Health – Behaviour = 203
  • Emotional Health – Bullying = 24
  • Emotional Health – Eating Disorder = 33
  • Emotional Health – Low Mood = 130
  • Emotional Health – Self Esteem = 106
  • Emotional Health – Self Harm = 172

Single Point of access data

Between 1st April 2012 and 31st March 31st 2013, 1301 referrals were received by the CAMHS SPA. Figure 18 shows the three most common sources of referrals were from GPs (48.3%), other health (which includes school nurses) (23.50%) and education (15.60%). At the SPA weekly meetings, referrals are made to the most appropriate services.

Tier 2 CAMHS Service Data (2012-2013)

Numbers of referrals

1301 referrals were received by the CAMHS. Figure 17 shows the proportion of referrals made by each locality with the North Locality making the most referrals (38.5%), followed by the South Locality (36.7%) and then Central Locality (24.7%).  From 2011-2012 there has been increase in referrals from 1293 to 1301 in 2012-2013. It can be seen in Figure 18 that more males are referred into tier 2 than females (699 males and 602 females) and most children and young people are between the ages of 11 – 15 years who are referred (Figure  3).

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Reason for Referral and Outcome of referral

Table 4 shows the initial reasons for referrals and Table 5 show the outcome of the referral.  It can be seen from Table 4 that referrals for challenging behaviours were the most common, followed by low mood and then self harm. It must be noted that these reasons for referrals are symptoms children and young people are referred with, not a diagnosis or issues that are revealed when a child or young people is seen in CAMHS. Table 5 shows the outcome of the initial referral. Working with the family is the most common outcome, followed by working within a children’s centre then referral into Tier 3. Only 4.38% of children are referred into tier 2/3 and 7.3% are referred into Tier 3 CAMHS therefore CAMHS tier 2 are holding a significant number of cases within the service.

 

TABLE 4: REASON FOR REFERRAL (2012-2013)

 

Central

South

North

ADHD

18

25

14

ANXIETY

34

50

45

ASD

11

37

31

ATTACHMENT

Small Number

0

Small Number

BEREAVEMENT

4

15

9

CHALLENGING BEHAVIOUR

105

144

207

EATING DISORDER

9

11

8

EMERGING PSYCHOSIS

0

5

Small Number

FAMILY RELATIONSHIP

21

17

18

LEARNING DISABILITY

7

10

9

LOW MOOD

37

62

59

LOW SELF ESTEEM

10

17

9

OCD

6

8

Small Number

NEUROLOGICAL DIFFICULTIES

Small Number

0

Small Number

PHYSICAL HEALTH

0

0

0

SCHOOL ATTENDANCE

Small Number

5

6

SELF HARM

46

52

51

SOILING / ENURISIS

Small Number

Small Number

Small Number

SEXUAL ABUSE

Small Number

Small Number

6

SEXUALISED BEHAVIOUR

0

0

Small Number

SUBSTANCE MISUSE

0

0

Small Number

SUICIDAL THOUGHTS

5

16

8

TRILOGY OF RISK

Small Number

0

5

YOUNG CARER

0

0

0

Source: Nottingham City Council, Targeted Family Support Teams- CAMHS 2013

NB: any number 5 and under within the tables have been changed to ‘Small Number.’

From the referrals for 2012 to date it can be seen that a significant number of young people are worked with within Tier 2 and a only a small number (96 children and young people in 2012/2013 and so far for 2013/2014 78 children and young people) are referred upwards into tier 3, this equates to only 7.3% of the total number of referrals (see Table 38 for outcome of referrals from quarters 1, 2 & 3). 

TABLE 5: OUTCOME OF REFERAL FROM QUARTERS 1, 2 & 3 FROM 2013/2014

Outcome of Referral

 

Total

 

Direct with YP / Child

6

 

Direct with family

757

 

Consultation

53

 

Drop in

20

 

REF - TIER3 CAMHS

78

 

Joint TIER2 / TIER3

31

 

REF - Children's Centre

155

 

Signpost to other Agency

46

 

Inappropriate referral

10

Community Paediatricians

The role of Community Paediatricians

 Children are referred to the service for a huge variety of reasons that generally fall into three main categories

  • medical/physical health concerns including growth concerns
  • developmental concerns  e.g. developmental delays, ASD, motor co-ordination difficulties
  • emotional /behavioural concerns including ADHD

Referrals are now managed centrally via a SPA.  The vast majority (>90% estimate) of referrals come from Primary Care via the GP, although they may have been initiated by the school nurse or by a health visitor (HV).  Some referrals come direct to the service from CAMHS, usually tier 2 requests for assessment of ASD/ADHD.   Some referrals come from hospital colleagues (usually children at risk of or with a long term disability or children with medical conditions that do not require the facilities of the hospital).  The service does not accept self-referrals.  

Community Paediatricians also see children at the request of social care for safeguarding concerns but these are not dealt with via the SPA and are not included in the figures below.

Between 1 Nov 2012 and 31 October 2013 a total of 1493 referrals were received for the City, of which 17.5% were rejected as inappropriate for the service, leaving a total of 1232 accepted referrals.

Of these, 716 (58%) were for developmental, behavioural or emotional concerns including

  • 447 referrals for possible ASD/ADHD (36% of all referrals)
  • 161 referrals for general developmental concerns including delay, LD or motor co-ordination difficulties (13% of all referrals)
  • 80 referrals for emotional & behavioural difficulties including anxiety, low mood, self- harm but excluding those where ASD/ADHD queried (6.5% of all referrals)
  • 27 ‘Other’ – including sleep, tics, school/learning issues (2 % of all referrals)

The other 516 referrals (42%) were for general medical problems including growth concerns, continence issues, musculoskeletal problems, vomiting/GI problems, headaches, pubertal concerns etc.

With regards to referrals for emotional and behavioural difficulties including anxiety and self- harm (but excluding those where ASD or ADHD were queried); a total of 179 referrals were received but of those 99 (55%) were rejected as not appropriate for the service.  The majority of referrers were advised to redirect the referral to Children’s Centres or CAMHS. Of those accepted, many had been previously rejected by CAMHS and were accepted to prevent further ‘bouncing’ of referrals

Tier 3 CAMHS

Tier 3 CAMHS is commissioned by NHS Nottingham City CCG and it provides a specialised multi-disciplined service for severe and complex child and adolescent mental health problems and neurodevelopmental disorders. The team provide assessment and treatment to patients and advice to tiers 1 and 2.

In the 2 year period 2011/12 & 2012/13 872 children and young people in tier 3 CAMHS (Table 41).s.).The most common age group was 11-15 for boys and 16-17 for girls. At all ages there were greater numbers of males seen within tier 3 CAMHS.  Table 32 that 66.3% of the Children and Young People referred into CAMHS were of White British Origin followed Multi Ethnic Groups.

Referrals

For the 2 year period 2011/12 & 2012/13, there were 872 patients referred.  Table 6 shows the number of referrals by service team.

TABLE 6: REFERRALS 11/12 & 12/13 BY SERVICE TEAM

Service Team

Number of Referrals

% total

CAMHS - County CLA

31

2.6

CAMHS - EDT

121

10.2

CAMHS - Head 2 Head

168

14.2

CAMHS - NDT

Small Number

0.1

CAMHS - Nice ADHD

32

2.7

CAMHS - North

Small Number

0.1

CAMHS - South

378

31.9

CAMHS Day Unit

35

3.0

CAMHS Looked After

141

11.9

CAMHS Paediatric Liaison

71

6.0

CAMHS Paediatric Neurology

26

2.2

CAMHS Psychotherapy

13

1.1

CAMHS Self Harm

168

14.2

All Services

1186

100.0

Source: Nottingham Healthcare Trust Commissioning dataset (NHIS DWH)

CAMHS EDT –Eating Disorder team

NDT – Neuro developmental team

County CLA – Children Looked After

The majority of referrals were to CAMHS – South followed by Head 2 Head, Self-Harm and Looked After Children.  It can be seen in Figure 3 the main source of referrals into tier 3 derive from other internal clinical and non-clinical services followed by social services, the probation services and primary care.

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Figure 22 shows the number of referrals into tier 3 mapped by electoral ward in Nottingham City. Table 42 shows the age / sex standardised rate per 1000 population by ward. Sherwood ward has the highest rate per 1000 (8.8-10.1 per 1000), followed by Aspley, Mapperley, Clifton South, Bulwell Forest, Bestwood (7.3-8.8 per 1000). Figure 23 shows the relationship between deprivation and referral rate at ward level. There is only a weak correlation between deprivation and referral to CAMHS in Nottingham City.

Audit of self-harm admissions to Queens Medical Centre (QMC)

An audit was undertaken of admissions to QMC in January 2014 for self-harm for Nottingham City.  In total there were 39 admissions to QMC of children and young people in January and of those 21 were from city children and young people, however only 15 patient’s clinical notes were analysed.  Information from the self-harm risk assessment tool, which is utilised by the self-harm team, was used to provide the audit information. Analysis was undertaken to identify common risk factors and information which may contribute towards the reasons for the admission for self-harm. The following information was sought from the clinical notes of the 15 admissions:

  • Gender.
  • Age.
  • Previous contact with CAMHS service.
  • Bullying.
  • Sexual exploitation.
  • If there was any one in school the young person would talk to.
  • Interest/Hobbies.
  • Accessing Social Media Self-harm sites.
  • Domestic Violence (witnessed in family or inter-relationship).
  • Parental Mental Health issues.
  • Where did they get the idea of self-harm.
  • Any cultural issues.
  • Observed relationship with parent.
  • Attachment rating.
  • Did the young person inform any one after they self-harmed.
  • The hopefulness score.
  • How could things be improved for the young person.

As only 15 cases were analysed preliminary results need to be interpreted with some caution however some common risk factors and other relevant information was found  which could be used to support children and young people who self-harm.

  • 12 out of the 15 cases were female.
  • The age range of admissions were from 11 to 16 years of age.
  • Some cases mentioned there was someone in school who they could talk to.
  • A minority of case were looked after children.
  • Sexual exploitation was apparent.
  • Some young people had experience of domestic violence.
  • The main idea for the self-harm derived from peers, family and internet sites.
  • A significant number of young people were being or had been bullied.
  • The majority of cased did not inform any one immediately after the event.
  • The hopefulness score ranges from 2 (very little hopefulness) to 10 (very hopeful regarding the future).
  • There was a range of statements with regards to improving their future from no future at all; this coincided with a low hopefulness score and the desire form better mental health.

The most significant findings from the audit were:

  • The significance of parental mental health in particular mothers mental health and this created a parallel with the low attachment rating.
  •  14 out of the 15 had previously self-harmed and some of the young people had been admitted numerous times into QMC.
  • 12 out of the 15 cases had current or previous involvement of CAMHS services.

Tier 4 Services

Tier 4 services are commissioned by NHS England and comprises of the Highly Specialised Adolescent Unit and the Neuropsychiatry Team.

Between 1st Jan 2010 and 31st December, 2012, 23 young people completed 25 hospital spells.

TABLE 7: NUMBER OF ADMISSIONS TO TIER 4 CAMHS, NOTTINGHAM CITY

 

Number of patients

Number of admissions

2010

Small Numbers

6

2011

8

9

2012

10

10

Source: Nottinghamshire Healthcare Trust 2010-2012, Nottingham City Residents

Table 7 shows that patients can be admitted more than once and patients can be admitted in more than one year and so at more than 1 age. From Figure 4 it can be seen that the gender split into Tier 4 are relatively even. 

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5. Evidence of what works (what we should be doing)

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NICE have published a number of guidelines on the management of mental health disorders among children and young people which include:

CG9. Eating Disorders. (2004).

Figure 5 provides an overview of NICE guidelines related to child emotional and mental health. Those shown in pink are guidelines currently in development, with their anticipated publication data shown.

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A matrix of evidence based interventions according to Tier of CAMHS and the age of child is included in Appendix 1.

 

6. What is on the horizon?

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Population projections for 0-19 year olds living in Nottingham City

Population projections for Nottingham City have been produced for 0- 19 year olds based on the 2011 census. Please note that as the projections in Table 7 are taken from the 0-19 age group, the population numbers are larger than the population numbers than in Table 6.

Children and young people in Nottingham City account for 22.4% of the population in the city.

TABLE 8: POPULATION PROJECTIONS FOR 0 – 19 YEAR OLDS LIVING IN NOTTINGHAM CITY

 

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

% change 2011-2021

Nottingham

77,268

77,545

77,509

77,276

77,495

77,676

77,702

77,916

78,111

78,521

78,998

2.2%

East Midlands

1,076,055

1,080,539

1,086,353

1,091,647

1,098,674

1,105,679

1,112,438

1,120,390

1,128,158

1,138,026

1,149,316

6.8%

England

12,710,562

12,773,167

12,860,162

12,947,314

13,050,904

13,148,143

13,240,080

13,343,916

13,451,835

13,575,943

13,713,157

7.9%

 

7. Local views

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User feedback from CAMHS Services

Service user and carer feedback from July 2012 – March 2013 for tiers 3 and 4 CAMHS was supplied by Nottinghamshire Healthcare Trust. In this time  298 responses were received however friend and family scores are not included as the number of responses within the reporting periods does not meet the requires threshold. Figure 6 shows the overall responses to a series of questions about patient/carer experiences. Most questions about care received high proportions of ‘excellent’ or ‘good’  only one question with regards to Involved in care receive a ‘poor’ or ‘very poor’ response.

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Figure 6 show service user feedback to the question “if you could improve just one thing about the care you received and what would it be?” and what was the best thing about the care you received?” The main themes coming out of the feedback was improved waiting times and more staff. Positives aspects of care related to listening skills of the staff, having someone to talk to and care from the staff.

What does this tell us?

8. Unmet needs and service gaps

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  • Welfare reform is contributing towards increasing pressures on families in terms of financial support particularly on those families living in social/private rented accommodation and who are claiming a wide range of benefits from the Government.
  • There are an increasing number of children in Nottingham City from within the city boundaries entering into care.
  • School pupils are under increasing pressure to attain in Nottingham City.
  • Education attainment within Nottingham City is below the England average (there has been a year on year improvement), low educational attainments has a knock on effect in terms of obtaining a job which leads to a cycle of poor adult mental health.
  • There is a recognition that increasing birth rate within the city may contribute towards an increasing number of children particularly within the deprived wards of Nottingham which in turn is a risk factor to emotional and mental health issues.
  • The recognition that Nottingham City is an Early Intervention City and if successful with the Big Lottery Small Steps Big Changes this could impact on changing the way families work together by the provision of universal approach to improve families across the city.
  • Domestic violence is a significant issue within the City.

Needs of children and young people

  • Increasing referrals to tier 2 and tier 3 CAMHS for children and young people who are self-harming
  • An increasing number of presentations to the Emergency Department (ED) at Queens Medical Centre by children and young people who are self-harming.
  • An overall increase in the complexity of cases presenting both to ED and CAMHS.
  • A significant number of children in Nottingham City are exposed to domestic violence either as part of their family life or within their own relationships.
  • School nurses are seeing an increasing number of children and young people who are experiencing emotional and mental health problems.
  • School nurses are seeing an increasing number of children who are self-harming. Due to waiting time into be seen within tier 2, school nurses are holding and ‘counselling’ children who may be at significant risk to themselves.
  • Some stakeholders stated that Schools needs to take greater responsibility for raising awareness of self-harm. This will hopefully be ameliorated by the development of the Kooth counselling services being placed within the City schools and the SHARP team self-harm specialist team within tier 2.
  • The age of children and young people presenting to services with regards to self-harm is lowering to age 7.
  • There are a significant number of children in Nottingham who are witnessing/experiencing domestic violence with an estimated 3 children in every classroom.  Research states that children who experience DV have a 4 fold increased risk of experiencing mental and emotional health issues.  Therefore there are a substantial number of children in Nottingham who may be experiencing/witnessing DV however their emotional and mental health needs are not being catered for.
  • A number of high profile suicides of young people in the city where previous self-harm was a prominent feature.

Behavioural Issues/ ASD/ADHD

  • A significant number of referrals to CAMHS are related to behaviour which is taking up significant time and resources. It is anticipated that the new emotional health and wellbeing pathway commissioned by the NHS Nottingham CCG will help to divert these referrals away from CAMHS, if appropriate.
  • A significant number of referrals from GPs to community paediatricians for behaviour and suspected ASD/ADSD. However there is a view that there is limited resources within community paediatricians to cope with the sheer number of referrals being made on a weekly basis (again this should be alleviated with the development of the Emotional Wellbeing Pathway) and that community paediatricians do not have a wide source of opportunities to refer onto to support parents, therefore pharmacological treatment is used as a first line of treatment rather than parenting and psychological support.
  • Stakeholders expressed care of children with behavioural issues should be multidisciplinary and focused on the child’s needs rather than medical diagnosis
  • A recognition that many of the referrals coming through to both community paediatricians and CAMHS tier2 are caused by attachment issues. Therefore work should be focused on parenting programmes.

Early Intervention

  • Stakeholders felt that there needs to be a greater emphasis on early intervention, identifying emotional and mental health problems early in order to ‘break the cycle’.
  • It is also recognised that resilience needs to be systematically promoted within the school setting starting within primary schools.
  • Some stakeholders felt there is a perceived gap around teaching young people to work through and manage issues themselves.
  • There needs to be more emotional and mental health training and support provided to universal services due to sheer numbers of children and young people accessing these services.
  • Schools needs to take on a greater role in promoting emotional health and wellbeing as well identifying children who are at risk of emotional and mental health problems.

Issues related to the provision of CAMHS Services

Overall stakeholders recognised there are blockages at every tier of CAMHS and there is no step up step down approach within Nottingham City which allows children to move up and down the tiers of CAMHS depending on their level of need. It is also recognised by stakeholders the children and young people are not at the heart of the service in terms of the development and care and this needs to be developed further.

Universal Services (tier 1)

  • The numbers of pupils seen by school nurses for emotional and mental health problems are increasing (557 from April until October 2013).
  • There is still a need for tier 1 services to be trained in dealing with young people self-harming (despite the new services coming on line). In particular there needs to be recognition by schools and school governors that self-harm is a public health challenge.
  • GPs are referring to community paediatricians rather than into CAMHS services due to being ‘bounced’ around the existing CAMHS provision.

Tier 2 Services

  • Neither universal services nor community paediatricians currently receive any feedback from the CAMHS services with regards to the children and young people they refer into the SPA.
  • There is a lack of knowledge within clinical children’s services of the skills and competences of the tier 2 work force.
  • The community paediatricians currently do not receive feedback from the SPA on the care plan and outcomes of the children/ young people they have referred.
  • There is a lack of knowledge from referrers into the CAMHS service on the outcome of referral through the SPA process.
  • A number of referrals made into the SPA (tier 2) by the community paediatrician have been ‘bounced back’ to them instead of being placed within tier 2.
  • It was reported that there are increasing waiting times for children to be seen in tier 2 after a referral has been made into the SPA due to the numbers of referrals being made into CAMHS. In some cases children and Young people are waiting up to 8 weeks to be seen initially within CAMHs after a referral has been made. However this issue is now being dealt with, with the introduction of the CAPA model within tier 2.
  • There appears to be reduced capacity within tier 2 due to an increase in the number of referrals.

Tier 3 Services

  • The Head to Head service are not filling all their numbers of planned sessions for Nottingham City. However the cases that they are working with are extremely complex and taking up significant time.
  • There is a significant waiting time for tier 3 services.
  • Tier 3 services including the special self-harm team work office hours Monday to Friday, which does not cater to the demand for the service as the majority of ED presentations which would warrant a special tier 3 intervention are at an evening or weekend.
  • The self-harm team are only able to see a small proportion (2 assessments per professional per day) of those young people who are admitted to a paediatric bed in QMC for self-harm due to the sheer number of admissions. This is causing an increase in bed stays within the paediatric wards for the young people until the young people can be assessed and having a knock on effect and increasing pressure in paediatric care.

Looked After Children

  • The CAMHS Looked after Children team has seen an increase in the number of referrals which is a reflection of the increasing number of children and young people entering into care.
  • There is currently no monitoring system to assess the emotional and mental health of all children who are in care. The SDQ questionnaire is only used for children who have been referred into the team to assess their emotional and mental health.

Tier 4 Services

  • There is recognition locally and nationally that there are a limited number of inpatient beds within tier 4 (12 beds locally for all children and young people who live in Nottinghamshire and Derbyshire).
  • There are issues that local children and young people have been placed out of area due to impatient capacity.
  • In patient unit at Thorneywood is mainly occupied by long term stay patients. There is currently no step up step down pathway for children and young people who no longer require inpatient care but require intensive support.

Secondary Care- Queens Medical Centre

  • There are an increasing number of children who are presenting and admitted to ED at QMC with emotional and mental health issues.
  • Children and Young People who present to ED with self-harm on a Friday afternoon or over the weekend are not assessed by the CAMHS self-harm service until a Monday morning. The consequence of this is that children and young people have to stay over the weekend in a paediatric bed which again causes pressures on paediatric care.
  • If a young person is admitted to QMC over the weekend, it will not be the specialist self-harm team that undertakes the assessment, a Registrar Psychiatrist or a Consultant Psychiatrist will undertake the assessment using a different risk assessment tool from the self-harm team and will only assess and not refer onto appropriate CAMHS services.

Transition to Adult Services

  • Stakeholders expressed mixed views about transitioning from child to adult mental health services. Many reported that in general, transitioning appeared to work ok. Where it did not work well, cases were complex or had been out of area. It was felt in these cases; transitions weren’t always planned far enough in advance, particularly where there were complex needs.
  • Transitions were reported to work well when young people have significant mental health disorders that clearly map onto adult services. For example, it was felt there was a good match between child and adult psychosis services.
  • Several stakeholders however reported that adult and child services are configured differently with some young people not necessarily meeting criteria to be seen in adult services, particularly for emotional or behavioural conditions.
  • Linked to the above, it was felt that transition was a vulnerable time for the young person, potentially having left school, losing other support networks and potentially losing support from CAMHS.
  • Young people who present with emotional and mental health issues on the cusp of transition into adult services may not necessarily be placed with the most appropriate level of care.

 

9. Knowledge gaps

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There needs to be more information gathered with regards to number of young people attending Emergency Department (ED) for self-harm and suspected mental health problems including documenting the journey of the young person from presentation at ED to Discharge.

What should we do next?

10. Recommendations for consideration by commissioners

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Antenatal

  • Antenatal and perinatal health needs to focus more on emotional and mental health of mothers with the development of specialist mental health midwives to support mothers with post natal depression. This is due to the link between antenatal anxiety at 32 weeks and the link to behavioural and emotional problems in children. This recommendation will be fed into NHS Nottingham City CCG midwifery review.
  • Develop universal programmes which address how to parent effectively as part of antenatal care for example based on the Family Partnership programme in the USA. This recommendation will be fed into the Nottingham City Emotional, Mental Health and Wellbeing pathway which is in development.

Early Years

  • Utilise the school readiness check at age 4 to undertake an emotional and mental wellbeing check of the child and pass on any information to the school and school health.

Parents/Family

  • Systematic support should be provided to families with children and young people who are experiencing domestic violence at all risk levels as assessed by DART. There needs to be recognition the impact of DV on children’s emotional and mental health.
  • Ensure all services are linked into Nottingham City Council’s Family Support Strategy.
  • All adult mental health services should have a Key Performance Indicator to support the emotional and mental health needs of children particularly when parents are diagnosed with a mental health condition.
  • All children’s services to consider parental mental health, substance misuse and domestic violence as a factor affecting child emotional and mental health and to signpost/refer to appropriate services.

Training

  • All primary care (GPs, school nurses and health visitors) and schools (all teachers) should have comprehensive training in the skills and knowledge required to recognise children and families who may be experiencing emotional and mental health issues.
  •  A comprehensive self-harm training programme should be developed and delivered to all GPs, schools (both primary and secondary including teachers) and school nurses.
  • Roll out the Public Health England Tool Kit for emotional health in schools.

Children and adolescent mental health services and proposed pathways

  • Identify resources to develop a new CAMHS pathway in light of the increased number of referrals and improve partnership working with adult mental health services
  • Utilise tier 2/3 service usage data to deliver a multi-disciplinary and skilled community CAMHS pathway provision where the child and young person is at the centre of delivery. This includes appropriate venues for meeting families and children and young people, suitable waiting times to the point of invention and length of intervention time.
  • Ensure that the CAMHS pathway systematically supports universal services after the point of referral.
  • Undertake a whole CAMHS workforce review to ensure there are the right skills and competences in relation to working with children and young people who are experiencing emotional and mental health problems. Develop a skills and competences quality standard for all CAMHS workforce.
  • Develop a multi-agency assessment process with a single point of access which is inclusive of all appropriate referrers into the CAMHS service.
  • Support the workforce and service users to smooth transition of patients between tiers and transition to adult services to minimise duplication of assessments.
  • Develop an appropriate pathway for children and young people who attend emergency department (ED) for self-harm
  • All young people who are admitted to QMC over the weekend with self-harm should have the standardised self-harm risk assessment tool undertaken as done by the specialist tier 3 self-harm team.
  • Provide a responsive CAMHS service which works into the evenings and weekends to minimise the number of admissions to QMC by young people and the need for inpatient beds.

Waiting times

  • All referrals should work towards a standardised waiting times and all interventions should be standardised to ensure children and young people are at the heart of the service.

CAMHS specific services

  • All looked after children (LAC) undertake a strengths and difficulties questionnaire SDQ) every 6 months as part of their LAC review. This will ensure that all LAC will be monitored for changes in their emotional and mental health state and subsequently be referred into the CAMHS looked after children team to appropriate interventions

Improving local data on children and young people’s mental health

  • Develop a core dataset to be reviewed at the CAMHS Executive, taking account of the development of a national CAMHS minimum dataset and the use of outcome measures such as The health of the nation outcomes scale for children and adolescents (HoNOSCA), for more information please go to http://www.liv.ac.uk/honosca/faq.htm.
  • A systematic change needs to be implemented across the CAMHS which focuses on the outcome of the child/young person rather than the process.  Investigate the possibility of a newly commissioned data system or that existing data systems talk to each other to ensure a smooth referral or transition between tiers of CAMHS children and young people.

Key contacts

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Sarah Quilty- Public Health Manager

Lynne McNiven- Consultant in Public Health

Deb Hooton- Head of Commissioning Children and Families

References

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1. Greeb, H. McGinnity, A., Meltzer., Ford, T. & Gooddman, R. Mental health of children and Young people in Great Britain. London : s.n., 2004.

2. Department of Health. Department of Health NO HEALTH WITHOUT MENTAL HEALTH: A cross- Government mental health outcomes strategy for people of all ages. Annex B - Evidence Base Supporting document to: No Health without Mental Health: a cross-Government mental health outcomes . 2011.

3. Office for National Statistics. Mental health of children and young people in Great Britain, 2004. . London : HMSO, 2004.

4. Department of Children, Schools and Families. Children and young people in Mind: The final report of the National CAMHS Review . London : s.n., 2008.

5. Meltzer, Gatward,Corvin et al. The Mental Health of Young People Looked After by Local Authority in England. London : TSO, 2003.

6. Hatton, Emerson and. The Mental Health of Children and Adolescents with Learning Disabilities in Great Britain. Lancaster : Institute of Health Research Lancaster University, (2007).

7. Healthcare Commission. A Review of Healthcare in the Community for Young People who Offend. London : Commissioning for Healthcare Audit and Inspection, 2006.

8. Department of health. Promoting Mental Health for Children in Secrure Settihgs: A Framework for Commissioning Services. London. DH. London : Department of Health, 2007.

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