This independent article from Alison Jeffery, Director for Children’s Services for East Sussex County Council is part of the LGA children and young people's mental health think piece series. Alison has written this piece in a personal capacity and explores the question 'what would a good 'whole system' set of services and policies to support mental health and wellbeing look like?'.
Children’s mental health has been a focus of public and public service concern for many years. In a survey for the House of Commons Library publication series in June last year Katherine Garratt, Judy Laing and Rob Long began their account with the 2011 strategy document- no health without mental health published by the 2010-2015 coalition government which went on to publish a major review on children and young people, 'Future in Mind'. The survey ran through to the 2019 NHS Long Term Plan and most recently the 2021 and 2022 announcements of additional funding as the country came out of the pandemic and the associated lock down, whose negative impact on children and young people has been widely recognised.
So, no shortage of policies and plans. Council children’s services were very much written into the Future in Mind exercise with local “whole system” plans having to be signed off by Directors of Children’s Services (DCS). That was a high point; supported by DCSs several area partnerships took the opportunity at that point to develop strong, whole system strategies encompassing services ranging from health visitors and early years settings to youth justice.
Since 2015 it has been harder for councils to advocate for those whole system approaches against a narrower set of “must do” investments for the NHS (mainly around eating disorders), combined with national Government initiatives such as Mental Health Teams in Schools. There has also been a growing sense that the conventional model of delivery of specialist Children and Adolescent Mental Health Services (CAMHS), comprising in the main the offer of appointments with consultants in NHS buildings, many of which fail to be attended, is out of date. The ADCS has called for a review of children’s mental health support comparable with the independent review of children’s social care.
What would a good “whole system” set of services and policies for the public sector look like in 2023? Here are a few considerations...
First, we need strategies which get onto the front foot, which are proactive rather than reactive. We can no longer afford simply to “respond to need” where we identify it. We know that for children to have good mental health there are some fundamentals which need to be in place:
- A strong attachment to primary care givers based on a secure sense of being unconditionally loved and cherished.
- For as many children as possible, good physical health based on regular exercise. A healthy mind in a healthy body
- Engagement in continuous development of understanding, knowledge and skills, education for shorthand.
This means our early childhood services - maternity, health visiting and early years care and education - need to pay the strongest possible attention to emotional attachment.
Education, for all ages, must include regular physical exercise for as many children as possible. And we must recognise the impact which exclusion from education and personal development, for whatever reason, will inevitably have on the mental wellbeing of the young. For our most vulnerable young people, we cannot take the view that a young person needs somehow to have their mental ill health “cured” before they can engage in education. Good education as children and teenagers develop into adults is profoundly therapeutic and no consultant or counsellor, however good, can ever substitute for it any more than they can substitute for lack of love in a child’s life.
Second, we must work with families to tackle, much more effectively, two key issues which drive the poor mental health of some children: social media and sleep.
Prolonged unthinking exposure to social media and lack of good sleep (including because of over stimulation/excessive on-line socialising) both have a pernicious impact if they are left unchecked. Tackling them means equipping both children and their parents with the best possible critical thinking skills to resist social media manipulation/distortion and, in the case of parents and carers, encouraging a steely determination to provide at least a minimal routine structure around sleep. (Reasonably) healthy nutrition is a good idea too ideally through regularly eating and socialising together with other people. Some people will think guidance here is a symptom of a “nanny state” and not the business of public services. Consistent messaging using shared concepts and language could make a difference, however, as it has on smoking, or seat belts. It won’t solve all problems; it is important we don’t minimise the issue of children’s mental health, or victim blame in any way. But some attention to these issues ought to help, in a “marginal gains” approach.
Third, we must help all families 'renormalise' distress and anxiety for children. Distress and anxiety are part of the human condition; they are what give meaning to joy and calm. Part of growing up is about managing distress and anxiety, recognising that we will all feel them, knowing that it is absolutely OK to express them, and that they will be temporary not permanent. We must help families all understand that distress and anxiety cannot and should not be either avoided or managed out of a child’s life. Again, shared language and messaging could be powerful. The best schools and services already do this well but their impact could be amplified by wider public/civic leadership and councils could and arguably should be part of this.
That does not of course mean ignoring distress which we can and should do something about, including the distress felt by neurodivergent children when we do not help to make their world more autism-friendly or to help them find coping mechanisms. This needs an essay of its own, but it is vital we respond to children’s needs as soon as we can and do not make any of our actions, except perhaps the prescription of drugs, dependent on detailed clinical assessments, particularly if, as now in England, that could take three years.
Fourthly and by no means least, we should provide high quality, joined up, targeted and graduated support for the many who really do need that support. Proactive promotion of the conditions for good mental health, tackling forces which work against it, and understanding it correctly, are all necessary but by no means sufficient to deal with the genuine crisis we are now experiencing. We need to think through a whole system approach to responding to the very real difficulties so many children are experiencing. Schools need link workers in CAMHS and other external services to give them advice and guidance. Early help and social care also need to be able to access expert advice and residential care services need to include specialist inputs of different kinds. Beyond support for wider services, specialist mental health services then need to offer group work/peer support to children/families as an appropriate first step, with individual psychiatric assessment and treatment at the apex of the offer. A whole family approach is critical, as is providing support when and where families need it rather than offering inflexible consultant appointments.
Finally, taking the helicopter view, we must take a life course, all age approach to our strategic planning for mental health support. Too often there is a rigid barrier between services for children and services for adults. Given that so many adult mental health conditions begin in the teenage years, we must take a preventative, strategic approach, and look at how we shift our profile of spend, over time, in that direction.