Children and young people's mental health and emotional wellbeing (health and wellbeing needs in South Tyneside)

Mental health and emotional wellbeing (MHEW) are a very important part of general health and wellbeing. The mental health and emotional wellbeing of children is especially important as this ultimately can shape the life chances and outcomes for that child into adulthood (Marmot, 2010) [1].

MHEW are highly complex issues. They are difficult to describe, define and measure. They are issues that can be the result of a variety of social, environmental, family and individual factors, but they can also be the cause of additional ill health and even death.

A commonly accepted definitions of MHEW is:

'A state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.' (World Health Organisation, 2014) [2]

The WHO (World Health Organisation) definition of mental health and emotional well-being is particularly appropriate in childhood and adolescence, as mental health is the foundation of healthy development and mental health problems at this life stage can have adverse and long-lasting effects (Murphy and Fonagy, 2012) [3].

We know that South Tyneside has consistently poorer health and wellbeing outcomes across a range of health behaviours, illnesses, disabilities and early deaths when compared with England and other similar areas. We will never precisely know how much of our current health burden is attributable to issues people experienced in childhood, but we are increasingly understanding that it is emotional health and wellbeing of children is a leading priority when trying to improve self-efficacy and the health of the South Tyneside Population, reduce health inequalities, and reduce demand now and in the future for health and social care services. In particular, healthy social and emotional development in babies and toddlers is important as it is the "building block(s) for healthy behaviour and educational attainment" in the future and helps to prevent behavioural problems and mental illness (NICE, 2012)[4].

We do know, for example, that people with mental ill health use more emergency hospital care than those without mental ill health; over three times more accident and emergency (A&E) attendances and nearly five times more emergency inpatient admissions (Dorning, Davies and Blunt, 2015) [5].

South Tyneside has recognised MHEW of children and young people for some time and there is a local strategy to help prevent the development of MHEW issues and support children and families as appropriate with evidence-based services. South Tyneside has also produced a partnership transformation plan in line with the ambition set out by the Department of Health and NHS England in Future in Mind [6]. Future in Mind clearly sets out the standards and services that must be in place to promote, protect and improve our children and young people's mental health and wellbeing.

South Tyneside Council People Select Committee held a Commission on the Mental Health and Emotional Wellbeing of Children and Young People. The final Commission Report was published on 27 April 2015 and presented to South Tyneside Council's Cabinet on 17 June 2015 [7]. The People Select Committee report recommended a further needs assessment is conducted to understand the mental health needs of children and young people in South Tyneside for inclusion in the Joint Strategic Needs Assessment for 2016 / 17.

This needs assessment has been conducted in partnership with South Tyneside CCG (STCCG), Northumberland Tyne and Wear NHS Trust (NTW), South Tyneside Foundation Trust, Third Sector organisations, South Tyneside Council and the Young People's Parliament.

This needs assessment attempts to draw together the most up-to-date information on:

• population risk factors and indicators that relate to causal or contributory factors for MHEW problems in children and young people, including issues around use of the internet/ social media and Self Harm.
• the prevalence and incidence of mental health conditions in children and young people and the resulting harms,
• local service provision and support for MHEW, not just in specialist Child and Adolescent Mental Health Services (CAMHS) but across the range of universal and targeted settings available to children and their families,
• The local views of children and young people on the local approach to MHEW and the services that are available to them.

This information will be used by the Health and Wellbeing Board and Children and Families Board to inform the development of the local prevention and early help services, implement the MHEW strategy, transform local services, and inform Commissioning Plans for 2016 / 17 and beyond.

• Measuring the actual levels of MHEW need in children and young people is very difficult to do in practice and risks drawing attention to complex (and diagnosed) needs, and thus missing undiagnosed/ unidentified needs and diminishing the role of prevention. In addition to this, when children and young people are supported by mental health services there is very little information on associated needs, such as being looked after, gay, lesbian, bisexual, or transgender, having a chronic health condition, or being in contact with youth justice services,
• Work conducted by the Young Person's Parliament clearly highlights that young people in South Tyneside recognise the importance of mental health and want it to be considered as a priority,
• Children and young people feel very distant from, and therefore do not always access, the services that are available to them locally. Issues cited including a lack of confidence in the level of confidentiality of services,
• Children and families do not understand what services are available to them locally and how these services work together,
• The continuity of care for children and their families between mental health services has been identified as an area that needs improvement,
• Children and young people have identified that there is a clear gap in help and support for "low-level" mental health and wellbeing support at times of stress and anxiety - such as during family difficulties or exams. This includes a lack of awareness in children, parents / carers, and professionals around understanding MHEW issues, and ways of offering simple support or promoting self-care,
• Self-harm is cited by professionals and young people as an issue in South Tyneside. The statistical data available do potentially support this finding. However, further anecdotal reports from teaching staff, school nurses, educational psychologists and young people themselves point towards more of a hidden harm issue in South Tyneside,
• Locally the attention of statutory organisations is on the provision and quality of more specialist services, rather than clear programmes to improve prevention and early help, and therefore resources are disproportionately weighted towards treatment,
• Need to improve the use of champions for positive MHEW in children and young people, which are currently identified in every school. Young people cited a number of good example of help and support in the schools setting, but they also cited where support is lacking,
• This needs assessment has a number of limitations that should be address over time by the Children and Young People's MHEW Strategy Group. These include:
  • A lack of views by clinical professionals and parents/ carers on the needs of children and young people, and the local provision of services. Some excellent work has been conducted with schools, but we must expand the conversation to other professional groups and families,
  • A lack of specific quantitative data on the level of self-harm that doesn't result in a hospital admission in children and young people. A further survey of schools pastoral leads and/ or children, young people and / or families would be beneficial in understanding the scale of the local issue.
  • Clarity on meaning and interpretation of performance data from tier 2 and 3 child and adolescent mental health services in South Tyneside

This needs assessment has illustrated the important link between mental health problems and many of the social and deprivation risk factors that are present in South Tyneside. We know that socioeconomic deprivation is particularly associated with multiple long term conditions, specifically mental health disorders (Barnett et al., 2012) [8]. Strategic action to reduce deprivation and improve economic prosperity for all communities in South Tyneside should be a system-wide priority.

The specific additional priorities identified by this needs assessment are:

• To ensure that the promotion, protection and improvement of the mental health of children and young people is seen as a key priority in local health and wellbeing strategies and commissioning plans,
• For commissioners to take an integrated, system-wide view of MHEW in children and young people to ensure that prevention is resourced appropriately to avoid an increase in more expensive demand,
• Ensure that risk factors of mental health and emotional wellbeing are recognised and recorded as part of children service delivery - this includes training for staff and changes to contracts to ensure that risk factors are recorded consistently,
• A structured and well promoted offer of evidence-based parenting programmes is needed in South Tyneside to work as part of the universal and targeted support offer,
• A clear skills development and training strategy is required to ensure that all frontline workers in contact with children and young people have the appropriate skills to offer low-level support and provide help in accessing appropriate services (recommended by NICE); these skills should include identifying and supporting young people who are (or at risk of) self-harming,
• Ensure that all local services offering MHEW support to young people meet the 'You're Welcome standards' and activity promote confidentiality,
• Commissioners and providers must prioritise continuity of care for children and families in specialist mental health services as a measure of quality and performance, and ensure that data-sharing and risk management do not become a barrier to providing a quality service,

To produce, publish and actively promote a map of local services available to prevent, identify and manage MHEW problems in children and young people, using appropriate media and feedback from young people, families and professionals.

There are a number of risk factors for mental health and emotional wellbeing that have been identified through research. These include:

• Poverty,
• Maternal and infant health,
• Learning disabilities,
• Ethnicity, gender, and sexual orientation,
• Work, education and early years development,
• Family breakdown or social issues (including when children require care and support),
• Lifestyle and behaviours (although these can be a result of MHEW need as well as a cause),
• Offending,
• Chronic disease.

On many of the areas above South Tyneside is shown in routinely collected (and publicly available) data to be worse than the England average, and often regional peers.

Using the Children and Young People Mental Health Profile Tool 'Those at Risk' are outlined in the following profile - Primary Prevention - Adversity and Primary Prevention - Vulnerability

Using the Children and Young People's Health Benchmarking Tool we can see South Tyneside's absolute and relative position on a number of key risk factors:

Poverty

• There are over 6,500 children under 16 living in poverty in South Tyneside (2013), which at 25.9% is significantly higher than the national (18.6%) and regional averages (23.3%),

Maternal and infant health

• South Tyneside has the worst smoking in pregnancy rate in the country at 25.9% (2014 / 15),
• Locally breast feeding initiation and maintenance rates are low at 53% for initiation and only 24.4% at 6 - 8 weeks. These rates are significantly lower than national averages,
• Evidence clearly illustrates the importance of reducing the exposure of babies to second-hand smoke, and promoting breast feeding to improve the health of the baby and promote a strong bond between the mother and child. These both lead to improved MHEW in the child over their lifetime,
• Although South Tyneside has made great progress on reducing under 18 conceptions (down by half since the early 2000s) they are still higher than the national average.

Learning disabilities

• People with learning disabilities are more likely to experience mental health problems (Emerson, E. et al, 2008)[9]. Estimation of the population prevalence of learning disability is problematic and should be treated with caution. The estimated number of children with a learning disability in South Tyneside are:
  • 80 5 - 9 year olds,
  • 175 10 - 14 year olds,
  • 240 15 - 19 year olds,
• These rates for different age groups reflect the fact that as children get older, more are identified as having a mild learning disability. The Foundation for People with Learning Disabilities (2002)[10] estimates an upper estimate of 40% prevalence for mental health problems associated with learning disability, with higher rates for those with severe learning disabilities.The estimated total number of children with learning disabilities with mental health problems in South Tyneside are:
  • 35 5 - 9 year olds,
  • 70 10 - 14 year olds,
  • 95 15 - 19 year olds.

Ethnicity, gender, and sexual orientation

• South Tyneside has a predominantly white population with over 93% of the 0 - 19 population recognised as White British, leaving around 2,000 non-white children. The largest non-white population group is the Asian / Asian British: Bangladeshi at around 2% of the 0 - 19 population which is largely found in the Riverside / Ocean Road areas of South Tyneside.
• The Government estimates put the numbers of LGB between 5 - 7% of the population. At an approximate rate of 6%, this would equate to 9,167 LGB people in South. [11]
• There are no data around LGBTQ young people or those who don't identify as cisgender. There are no comprehensive data about LGBTQ young people who accessed MHEW services.

Work education and early years development

• The percentage of children achieving a good level of development at the end of reception is significantly worse than the national average, at 60% locally (2014 / 15). This is even lower for children who are eligible for free school meals at 46%,
• South Tyneside (in 2014) has a significantly higher proportion of 16 - 18 year olds not in education employment or training (6%) when compared to the national average (4.7%),

Family breakdown or social issues

• South Tyneside had 180 families in 2013 / 14 recorded as homeless (number of applicant households with dependent children or pregnant women accepted as unintentionally homeless or eligible for assistance) - this give South Tyneside a significantly higher rate than the national average.
• Looked-after children are more likely to experience mental health problems (Ford, T. et al, 2007)[12]. It has been found that among children aged 5 to 17 years who are looked after by local authorities in England, 45% had a mental health disorder, 37% had clinically significant conduct disorders, 12% had emotional disorders, such as anxiety or depression, and 7% were hyperkinetic (Meltzer, H. et al, 2003)[13].
• In 2014 South Tyneside was recorded as having 310 children in care which gives a significantly higher rate than the national and regional average.
• There is a clear association between domestic violence, abuse and substance misuse and mental health problems in mothers, and also children. There can also be an impact on child emotional and cognitive development.
  • Around 10% of South Tyneside's 900 substance misuse clients (who are known to service) are living with a child, another 40% of clients have a child but don't live with that child.

Lifestyle and behaviours

• South Tyneside has over a third of year 6 pupils classified as being overweight or obese (significantly higher than the national average). This could have significant implications for the emotional health of many children in South Tyneside,
• There are also a significantly higher proportion of children aged 15 smoking regularly in South Tyneside (7.7%) compared to the national average of 5.5%,
• Locally there are also significantly higher rates of hospital admissions due to alcohol specific conditions and substance misuse than England.
• In 2014 - 15 there were 154 young people (<18) in specialist substance services in the South Tyneside community. There has been a steady decline in numbers in treatment since 2012-13 (then 173 per year). The majority of children in service are males (68%).

Offending

• South Tyneside has a significantly higher rate of 10 - 17 year olds receiving their first reprimand, warning or conviction per 100,000 population when compared to the national rate. This equated to 78 children in 2014 in South Tyneside. This has increased year on year in South Tyneside since 2012, but not statistically.

Chronic disease

• All children will likely have many different health problems during infancy and childhood, but for most children these problems are mild, they come and go, and they do not interfere with their daily life and development. For some children, however, chronic health conditions affect everyday life throughout childhood. [1]
• Chronic condition is an "umbrella" term. Children with chronic illnesses may be ill or well at any given time, but they are always living with their condition. Some examples of chronic conditions include (but are not limited to) asthma (the most common), diabetes, and cancer.

To reduce the risk of mental health problems there is a suggested Five-a-Day for Health and Happiness:

• Connect - how to connect with people around you
• Be active - exercise, move about, change your surroundings
• Keep learning - try something new, learn to cook, read
• Take notice - ask questions, notice positive things in your life
• Give - do something for someone else, say thank you, volunteer

Health Related Behaviour Questionnaire

• In 2006 and 2012 / 13 there was a health related behaviour questionnaire completed in schools in South Tyneside (conducted by the SHEU at Exeter University). HRBQ 2006 and 2012 / 13 HRBQ 2012/13 reports.
• The 2012 survey showed that in year 4 - 6 (aged 8 - 11 year olds in primary school) 72% were worried about at least one of the items listed in the questionnaire:
• 41% worried about exams / tests, 30% about crime, 28% about family problems.
• The table below illustrates the emotional wellbeing results results for years 8 and 10 from both the 2006 and 2012 / 13 surveys:

• The main issues of concern cited by pupils continue to be exams and "The way I look". This also corresponds with qualitative data collected from the Youth Parliament.

[1] chronic health condition as a health problem that lasts over three months, affects a child's normal activities, and may require hospital admissions, outpatient appointments and / or home health care

The levels of MHEW need in children and young people is very difficult to measure accurately as many mental health and emotional wellbeing problems go undetected and unrecorded in a format that is useful for needs assessment. Therefore much of the need information below is derived from estimates and bespoke studies.

Population

There are around 32,900 children aged 0 - 19 years in South Tyneside (2014, taken from PHE Child Health Profile, 2016). One in four of the under 20 population is classified as living in poverty. Every year there are around 1,600 births. More information on prevalence rates of mental health and wellbeing indicators in children and young people can be found here.

Maternal and Pre-school

• Maternal mental health is a particular topic of concern because of the effect they can have on the foetus, baby, wider family and mother's physical health and the fact that problems often are not disclosed, recognised or treated during this period. Mental health problems in women can occur during pregnancy (the antenatal period) and the postnatal period, which is defined as up to one year after childbirth. The antenatal and postnatal periods are often called the perinatal period, when referring specifically to mental health. There are a range of mental health problems that can affect women during perinatal periods including depression, anxiety, post-traumatic stress disorder (PTSD), postpartum psychosis and adjustment disorders and distress.
• Based on the number of women giving birth in South Tyneside, the figures below show how many women we would expect to have certain mental health problems in pregnancy and the postnatal period.[1] These estimates are based on national estimates of these conditions and local delivery figures only, and have been rounded up to the nearest five. They do not take into account socioeconomic factors or anything else which is likely to cause local variation. We are not aware of any data or research on exactly how maternal mental health differs by socioeconomic status that would allow us to take this into account in the estimates.

• Adding all these estimates together will not us an overall estimate of the number of women with antenatal or postnatal mental health conditions in South Tyneside, as some women will have more than one of these conditions. It is believed that overall between 10% and 20% of women are affected by mental health problems at some point during pregnancy or the first year after childbirth.
• There are relatively little data about prevalence rates for mental health disorders in pre-school age children. A literature review of four studies looking at 1,021 children aged 2 to 5 years inclusive, found that the average prevalence rate of any mental health disorder was 19.6% (Egger, H et al, 2006). Applying this average prevalence rate to the estimated population within the area, gives a figure of 1,320 children aged 2 to 5 years inclusive living in South Tyneside who have a mental health disorder.

School Age Children

Mental and Behavioural Disorders

• Prevalence estimates for mental health disorders in children aged 5 to 16 years have been estimated in a report by Green et al. (2004). Prevalence rates are based on the ICD-10 Classification of Mental and Behavioural Disorders with strict impairment criteria - the disorder causing distress to the child or having a considerable impact on the child's day to day life.
• Prevalence varies by age and sex, with boys more likely (11.4%) to have experienced or be experiencing a mental health problem than girls (7.8%). Children aged 11 to 16 years olds are also more likely (11.5%) than 5 to 10 year olds (7.7%) to experience mental health problems.
• The estimated number of children in South Tyneside with mental health disorders are:
  • 800 5 - 10 year olds,
  • 1,170 11 - 16 year olds,
  • Out of the estimated total 1,970 5 - 16 year olds with a mental health disorder, around 60% are boys,
• These prevalence rates of mental health disorders have been further broken down by prevalence of conduct, emotional, hyperkinetic and less common disorders (Green, H. et al, 2004). These estimates are
  • 515 5 - 10 year olds and 700 11 - 16 year olds with conduct disorders,
  • 2455 - 10 year olds and 530 11 - 16 year olds with emotion disorders,
  • 1805 - 10 year olds and 150 11 - 16 year olds with hyperkinetic disorders (around 90% of these are estimated to be boys),
  • 1405 - 10 year olds and 125 11 - 16 year olds with less common disorders,

Neurotic Disorders

• A study conducted by Singleton et al (2001) has estimated prevalence rates for neurotic disorders in young people aged 16 to 19 inclusive living in private households.
  • Males aged 16 - 19 years;
    • Mixed anxiety and depressive disorder 190
    • Generalised anxiety disorder 60
    • Depressive episode 35
    • All phobias 25
    • Obsessive compulsive disorder 35
    • Panic disorder 20
    • Any neurotic disorder 320
  • Females aged 16 - 19 years;
    • Mixed anxiety and depressive disorder 435
    • Generalised anxiety disorder 40
    • Depressive episode 95
    • All phobias 75
    • Obsessive compulsive disorder 35
    • Panic disorder 25
    • Any neurotic disorder 670

Autistic Spectrum Disorder (ASD)

• A study of 56,946 children in South East London by Baird et al (2006) estimated the prevalence of autism in children aged 9 to 10 years at 38.9 per 10,000 and that of other ASDs at 77.2 per 10,000, making the total prevalence of all ASDs 116.1 per 10,000.
• A survey by Baron-Cohen et al (2009) of autism-spectrum conditions using the Special Educational Needs (SEN) register alongside a survey of children in schools aged 5 to 9 years produced prevalence estimates of autism-spectrum conditions of 94 per 10,000 and 99 per 10,000 respectively. The ratio of known to unknown cases is about 3:2. Taken together, a prevalence of 157 per 10,000 has been estimated, including previously undiagnosed cases.
• The European Commission (2005) highlights the problems associated with establishing prevalence rates for Autistic Spectrum Disorders. These include the absence of long-term studies of psychiatric case registers and inconsistencies of definition over time and between locations.
• The numbers of children with autistic spectrum disorders if the prevalence rates found by Baird et al (2006) and by Baron-Cohen et al (2009) were applied to the population of South Tyneside are:
  • Autism in children aged 9 - 10 years old 15,
  • Other ASDs (9 - 10 year olds) 25,
  • ASDs in children aged 5 - 9 years 130.

Suicide and Self Harm

• Looking at suicides in the UK between 1997 and 2003, one study has made the following observations (Windfuhr, K., 2008):
  • Three times as many young men as young women aged between 15 and 19 committed suicide
  • Only 14% of young people who committed suicide were in contact with mental health services in the year prior to their death, compared with 26% in adults.
  • Looking at the difference between sexes, 20% of young women were in contact with mental health services compared to only 12% of young men
• Levels of self-harm are higher among young women than young men. The rates of self-harm in young women averaged 302 per 100,000 in 10 to 14 year olds and 1,423 per 100,000 in 15 to 18 year olds. Whereas for young men the rates of self-harm averaged 67 per 100,000 in 10 - 14 year olds and 466 per 100,000 in 15 to 18 year olds (Hawton, K., 2012). Self-poisoning was the most common method, involving paracetamol in 58.2 % of episodes (Hawton, K., 2012).
• In comparison with the 2009 / 10 - 2011 / 12 period, the rate of young people aged 10 to 24 years who are admitted to hospital as a result of self-harm in South Tyneside is higher in the 2012/13-2014/15 period. The admission rate in the 2012 / 13 - 2014 / 15 period is higher than the England average. Nationally, levels of self-harm are higher among young women than young men.

(Data source: Hospital Episode Statistics, Health and Social Care Information Centre).

• In 2014 / 15, this meant that there were 134 admissions as a result of self-harm in the 10 - 24 year old age group. It's important to note that these admissions may represent the tip-of-the-iceberg with regards to self-harm as much may go unreported/ undetected.

Estimated need for services at each tier

• Estimates of the number of children and young people who may experience mental health problems appropriate to a response from CAMHS at Tiers 1, 2, 3 and 4 have been provided by Kurtz (1996).
• Estimated number of children / young people who may experience mental health problems appropriate to a response are;
  • Tier 1 4,400
  • Tier 2 2,055
  • Tier 3 545
  • Tier 4 25

[1] Definitions of the conditions can be found in the glossary at the end of this report.

It is clear from this needs assessment that many of the key services and support are in place in South Tyneside. What does appear to be lacking is work on promotion, awareness raising and self-care relating to MHEW, and the clarity of pathways and access routes for more specialist services, for professionals, parents / carers and children themselves.

The needs of parents are largely unmet in terms of information and advice about how to support young people with MHEW issues. Family Therapy is now being offered by the Lifecycle Service; however more could be done to support families who are not in formal services.

Support for young people will low level emotional health issues is not consistent across the board. Young people tell us that they do not have 'someone to talk to' in Universal setting. Low level support provided at the right time can prevent young people from suffering from more complex serious mental illness.

From the needs assessment, it is not clear if Resilience skills are being built by Universal staff such as GP's, school staff, school nurses, health visitors, practice nurses, sport coaches and youth workers. A clearer training offer is needed for the borough outside of the schools setting.

Support for women pre and perinatal needs to be met through good quality psychological support. In particular the needs of women with personality disorder are largely missing.

A comprehensive robust program of support is needed for young people in crisis which is currently not being provided.

The needs young people who are referred to mental health services are not consistently being met in a timely manner. Waiting times for young people are a concern and they are being closely monitored as part of service contracts. The target outlined in the CAMHS Transformation Plan is 4 week standard wait by 2020 and a 25% less waiting time for vulnerable young people such as those who are looked after.

The needs of young people who are diagnosed with an eating disorder are also not being met. This is a specific target of the CAMHS transformation plan.

The future mental health and emotional wellbeing needs of children and young people are difficult to outline accurately and quantitatively. The 0 - 19 population in South Tyneside is set to rise from 32,900 in 2014 to 33,600 in 2025 (PHE, 2016). This relatively small increase in the CYP population is unlikely to lead to any significant increase in demand for services, however we do know that the costs (and expenditure) on mental health services are rising. This is recognised by the Future in Mind as an issue, hence the increased emphasis on intervening early and promoting universal wellbeing as opposed to simply treating mental health problems.

Locally, there is a general shift toward prevention and early identification of mental health and emotional wellbeing issues, as the recognition of these needs increase. However, increasingly local children's services will have to continue to adapt and incorporate emotional health and wellbeing as a cross-cutting issue, as well as developing bespoke interventions where the need arises.

There are a range of assets and services available in South Tyneside that seek to prevent, identify, and manage/ treat MHEW issues in South Tyneside. These services extend from those that are universally available to all, through to those that are either targeted at particular populations or groups, or those that are specialist services for children and young people meeting particular criteria. There are a number of PHE Indicators related to protective factors in young people.

Universal

General Standards and Confidentiality

Our Healthy Schools Award has been achieved by all schools in South Tyneside. It also extends to the Early Years with all of our Children Centres, who are also signed up to the award. All of our Children Centre and Daycare settings staff are trained to use Growth Mind-sets with children and their families. The Outreach staff are also trained in Dino-school, Incredible Years and Solihull parenting programmes.

Many of our schools have Emotional Health / Mental Health Champions; this role could be developed to act as a bridge to clinical services.

As part of the Healthy Schools and Change4Life Programme in South Tyneside there has been a further work on confidentiality and the rights of young people when accessing services. This is now promoted though some printed information and a confidentiality statement that is available on the Change4Life website.

Further work is needed on promoting confidentiality in children's services. This should include a structured approach to ensuring local services reach the You're Welcome standards, and that services actively promote confidentiality in all of their materials and websites.

Training for Children and Young People

The Young People's Parliament have taken part in Young Minds training and Mindfulness training. Our Young Peoples Parliament has a Mental Health Subgroup which looks specifically at Mental Health Issues for young people and feeds back into the CAMHS and Emotional Resilience Groups.

Workforce Development and Resources

A Primary School Risk Taking Behaviour / Emotional Resilience resource was launched in September. The impact of this resource is not yet understood. This was adapted from the Evidence based SEAL programme.

Through the Healthy Schools Programme, resources have been provided to schools (primary, secondary and special) to encourage them to do sessions on stress, mental health, and emotional wellbeing. It is not clear how these have been used in practice, and what the impact of the resources has been. Clear and structured feedback on these resources needs to be collected to determine the benefits of this approach. This is now being collected through the Healthy Schools programme.

We have a number of generic services which have staff trained in Mental Health First Aid, however this does not form part of a local structured approach to workforce development at this stage. Likewise, we have a number of staff trained in the PENN resilience programme.

We have a high number of school based staff who are trained in bereavement support.

Our Sports Development Team and Outdoor Education team have all had training in positive discipline, emotional resilience techniques and basic mental health.

Targeted

Early Help Service

Services for Young People listened to the views around positive activities needed for young people with emotional / self-esteem problems. So they have set up groups (called Participa8) exclusively for young people who have confidence / esteem issues, may have Special Educational Needs and/or struggle to access mainstream positive activities. Children / young people can only join the group on a referral basis, age range is 8 plus.

Our Emotional Resilience Service offers 1-2-1 support for young people to ease transition or for young people who school refuse. The service has now extended to offer bereavement support.

Specialist

Youth Justice Service

The Youth Justice Service is a multi-agency team, which means that it is made up of staff from all the main local authority departments and agencies all working together. Its main aim is to prevent offending and anti-social behaviour by young people in the communities of South Tyneside. In terms of Mental health, there is a Senior Mental Health Practitioner that employed within the YOS to provide consultation, advice and support to YOS colleagues. They also provide an assessment service for young people referred by YOS staff. The Practitioner is part of the wider CAMHS (Child and Adolescent Mental Health Service), acting as a link between the YOS and Mental Health Services.

Leaving Care

South Tyneside leaving care service supports young people who are looked after with a variety of issues from employment, education, health and wellbeing. They act as a gateway to mental health support and health services.

Child and Adolescent Mental Health Services

Tier 2 Lifecycle Service - Commissioned by South Tyneside CCG; started on 1 October 2015 as part of a phased roll-out and full introduction in March 2016.

The Lifecycle Service provides a whole person tier 2 therapeutic and non-therapeutic services to young people of any age and their families. Tier two supports young people who have difficulties with attachment, behaviour, eating disorders, development, emerging OCD, anxiety and depression. A key role for the Lifecycle Service is providing the children and young people's IAPT programme (Increasing Access to Psychological Therapies). The lifecycle service collapses the age boundaries associated with young people service to ensure there are no issues with transition.

The Lifecycle service sees between 10 and 20 new children and young people cases per week with a constant case load of between 150 and 200 children. As well as holding a case load of children the service works closely with schools and children's professionals on training and education.

Children and Young People's Service (CYPS) - Provided by Northumberland Tyne and Wear and commissioned by South Tyneside CCG

The service consists of a multidisciplinary team of mental health practitioners including psychiatrists, nurses, social workers, psychological therapists and psychologists, occupational therapists and administrative staff. The integrated team operates to meet the tier 3 specialist mental health needs of all children and young people regardless of their circumstances or other needs. They operate within a multi-agency framework and undertake the delivery of the specialist mental health element a specific plans for a young person. The service can also provide consultation, advice and support directly to families but also to other agencies working with children and young people presenting with mental health.

NTW produces a monthly performance report for STCCG (who then also share this with partners). There is separate report on LAC referrals as a result of some challenges by People Select Committee on how the children and young people's services work together with Children's Social Care.The CYPS service sees around 100 referrals per month.

There have been some historical waiting time issues with CYPS, and this was highlighted by People Select in 2015. There has been significant progress against waiting time targets for accessing CYPS, with all historical long-term waiting time patients (prior to October 2014) now in treatment. Data for quarters 1,2 and 3 of 2015 / 16 also demonstrate that overall the number of young people waiting longer than 12 weeks for treatment has reduced, with 71% of children now waiting less than 12 weeks for treatment and 61% waiting less than 9 weeks.

Matrix

The MATRIX works with young people under 18 in South Tyneside, their families and carers. The service provides help, support and advice to those whose lives have been affected by drug and alcohol misuse or those who are at risk of developing drug and alcohol problems. Young people who access this project have access to a trained counsellor as well as robust signposting and referral pathway to mental health Services. The service is also a good example of a confidential, accessible and trusted service for young people.

In 2014-15 there were 154 young people (<18) in specialist services in the community (PHE, 2015). There has been a steady decline in numbers in treatment since 2012-13 (then 173 per year). Service users are largely males (68%), 65% in South Tyneside use two or more substances and 100% started using before the age of 15 - an absolutely crucial role for prevention here.

Key vulnerabilities include:

• Involved in offending/ ASB 44%
• Affected by domestic abuse 29%
• Affected by other substance misuse 22%
• NEET 19%
• LAC (5%) CIN (8%) CP (4%)

Gaps:

• Structured (evidence-based) training offer to young people and families in South Tyneside,
• Data and evidence of impact of the workforce development approach (and associated resources) in South Tyneside,
• A clearer estimate on the scale and impact of the current prevention offer needs to be understood. Is the current offer likely to have a significant impact on population outcomes?
• The local diagnostic pathway for Autistic Spectrum Disorder needs to be improved in line with NICE guidance, and input from children and their families.

Third Sector

Relationships Works

Relationship Works, based in Ocean Road Community Association, provides young people with advice about family and sexual relationships through a number of drop-in sessions and educational intervention at schools, to educate teenagers about healthy relationships.

Escape

Escape is a third sector charity which exists to promote the emotional, social, educational and vocational competence of children and young people, by offering a range of therapeutic interventions, including counselling, advice, guidance and support, to enable them to reach their potential and remove the barriers to personal success.
 

Bright Futures

Bright Futures works with young women aged 11 - 25 around a range of issues to raise their self-esteem and confidence around a range of issues which affect them including alcohol and substance misuse, sexual health and relationships, homelessness, family relationships, friendships, school, education, training, crime and anti-social behaviour. Bright Futures offers young women the opportunity to take part in educational group work sessions using interactive and engaging resources to make the sessions we deliver fun and suitable for all abilities.

There is compelling evidence of the cost benefit of early intervention using evidence-based programmes and methods. Key examples are suggested below.

Conduct disorder is the most common mental disorder in childhood. By the time they are 28 years old, individuals with persistent antisocial behaviour at age ten have cost society ten times as much as those without the condition. Parent education and training programmes can have good medium to long term effects at relatively low cost. (SERVICE, 2011)

• If services had intervened early for just one in ten of the young people sentenced to prison each year, public services could save over £100 million annually.
• The cost to society of adult mental health problems is currently estimated at more than £100 billion.
• The savings associated with providing an early intervention service approach rather than standard mental health care for patients with psychosis have been conservatively estimated at £50 million per year in the short term and more than £20 million in the long term. The savings relate to increased work, decreased suicide and decreased homicide. (SERVICE, 2011)

The current spend for Children and Young People Mental Health can be found here.

Looked after children

Around half of looked-after children in England are reported to have emotional and behavioural difficulties. Boys are more likely than girls to have higher scores on the strengths and difficulties questionnaire (SDQ), which indicates emotional difficulties (40.9% compared with 33.2%). Looked-after children also have poorer educational outcomes than children who are not looked after. (NICE, 2010)

This guideline also states that Looked after children should be one of the priorities for the local authority.

• The services that are commissioned should focus on health promotion, early identification and prevention of physical and emotional health problems, access to specialist services, including child and adolescent mental health services and also access to professional advice for the looked-after children and young people's care team.
• Transition from children's to adults services should also be a priority.
• 'Ensure that equal priority is given to identifying the needs of those children or young people who may not attract attention because they express emotional distress through passive, withdrawn or compliant behaviour' (NICE, 2010)

Early Years Provision

Nice guidelines on the Emotional Wellbeing in the Early Years stress the importance of the mother-child bond. (NICE, Social and Emotional Wellbeing: the early years, 2012). It advises that vulnerable families are identified. Health visitors or midwives should offer a series of intensive home visits by an appropriately trained nurse to parents assessed to be in need of additional support. The trained nurse should visit families in need of additional support a set number of times over a sustained period of time (sufficient to establish trust and help make positive changes) Activities during each visit should be based on a set curriculum which aims to  achieve specified goals in relation to: maternal sensitivity (how sensitive the mother is to her child's needs), the mother-child relationship, home learning (including speech, language and communication skills), parenting skills and practice.

Amongst other recommendations, its states that the greatest cost savings could be achieved by intervening during the early years of life. It was judges that, if effective evidence-based interventions are systematically implemented, then cost savings are likely to be achieved over 3 to 4 years and also in the longer term.

Older Children

A 'whole schools based approach' is recommended by Public Health England (England, 2015) based on eight principles.

• Leadership and management eg having a senior leaderships for emotional health and wellbeing
• School ethos and environment- promoting and respecting diversity
• Curriculum, teaching and learning eg is focus is given within the curriculum to social and emotional learning and promoting personal resilience, and how is learning assessed-
• Student voice eg ensuring all students have the opportunity to express their views and influence decisions
• Staff development, health and wellbeing eg how are staff supported in relation to their own health and wellbeing and to be able to support student wellbeing
• Identifying need and monitoring impact eg How does the school or college assess the needs of students and the impact of interventions to improve wellbeing
• Working with parents/carers eg How does the school or college work in partnership with parents and carers to promote emotional health and wellbeing
• Targeted support eg How does the school or college ensure timely and effective identification of students who would benefit from targeted support and ensure appropriate referral to support services?

Key findings of the Review of Emotional Health and Wellbeing by South Tyneside Public Health Team found the following

1. lack of cohesion between programmes and services
2. lack of awareness of emotional health and wellbeing services for young people
3. training is required for all people who work with or look after young people
4. no consistent educational programmes or use of resources
5. gaps in anti-bullying provision
6. self harm is a common problem
7. training should incorporate social media

It recommended the following:

1. annual Emotional Health and Wellbeing training incorporating all local prevention programmes, referral processes
2. raising awareness including the School Nurse drop in, identify a champion in EHWB
3. consistent educational programme
4. provide and promote quality assured resources with young people
5. look at other provision in the borough
6. anti-bullying provision
7. address self harm including training, school nurse recording pathways
8. social media

Health Visiting and School Nurse Programme: Supporting implementation of the new service offer: Promoting emotional wellbeing and positive mental health of children and young people

The five steps provide the framework for Health Visitors and School Nurses working with children, young people and families, as well as an organisational tool to effect cultural change (PHE and DH).

Connect... Enable young people to spend time with friends and family.

Be active... Urge young people to exercise regularly, either on their own or in a team.

Take notice... Encourage awareness of environment and feelings.

Keep learning... Keep young people's world as large as possible, encouraging their natural curiosity.

Creativity and play... Encourage children's imagination and creativity as they grow

Recognising Diversity and Risk

The diversity of children should be identified and addressed. Core assessments should contain an accurate and comprehensive picture of the child or young person's needs relating to their cultural, religious and ethnic identity, and pay particular attention to race, sexual orientation, language, faith and diet.

There are a number of sources of information that we can draw on when considering the views of young people and their families both locally and nationally.

• Nationally speaking, there have been a few major consultations undertaken recently. The 'Young Minds Taskforce Report Consultation' and 'Youth Select Committee Call for Evidence about Children, Young People's Mental Health' was undertaken with young people and their families.
• In 2013 the Department of Health (with other partners) led a significant engagement exercise on improving CYP outcomes (DH, 2013).
• Young people talked about mental health information still not being readily available. They understood the value of good quality information stating that they wanted more information online to be endorsed by professionals. They stated that campaigns about mental health need to be as prevalent as physical health campaigns with schools being the main vehicle for this as 82% of the 5,600 surveyed stated that school needs to educate them to look after their mental health and prepare them for real life.
• Both young people and parents recognised school staff training as an area for development as a gateway to services ,this is echoed by our local Mental Health Question Time Panel which highlighted a need to treatment services to be more linked into schools.
• In addition to the nationally understood views of children and young people on MHEW there have been a number of consultation exercises conducted in South Tyneside.
• In 2015, the South Tyneside Young People's Parliament organised a Borough-Wide School Council Health project. The project included hosting three events focussed on health and wellbeing (South Tyneside Young People's Parliament, 2015). The events brought together 2 to 3 members of each Secondary School Council together to discuss a range of topics including emotional wellbeing. The project did bring in a broader range of view as each school council took consultation questions back to their respective schools to include all children.
• The results from the consultation identified that mental health and sexual health are the joint top issues for young people in South Tyneside. The consultation also highlighted that confidentiality was the biggest barrier for young people when it came to accessing support, followed by not having enough information.
• Young people identified that they'd most like to receive information at Schools and education settings, followed by Health care services.
• Following the Borough-Wide School Council Event the Young People's Parliament hosted a workshop during Mental Health Awareness Week (commencing 11 May 2015)
• The Young People's Parliament have also taken the opportunity to shape the services delivered as part of the South Tyneside Clinical Commissioning Group's new Mental Health Lifecycle Service. The Youth Parliament were consulted on the specification and the services offered.
• However, despite the YPP's involvement in the commissioning of the Mental Health Lifecycle Service and a good overall knowledge of mental health in South Tyneside, young people still struggle to understand what services are available to them locally and how to access help. On 9^th December, members of the Public Health Team met with the South Tyneside Youth Parliament to discuss levels of awareness of MHEW in young people, the approach to MHEW taken by schools and other universal services, and local services for MHEW. At this session it was clear that the local offer of help for MHEW was too complicated and not widely understood.
• This is a reoccurring theme in all of the consultations; young people want transparency in terms of how services work and to have an understanding of how services fit together. This was further reinforced by our second round of consultation with our Youth Parliament, Young people completed a 'SWOT (strength, weaknesses, opportunities and threats) analysis of both CAMHS and school based support services'. There were a number of reoccurring themes that came from this exercise. The main theme was a lack of understanding across the board about what support was available or what would happen when they got there. Most of the young people's comments were about accessing the service and not the quality of the service itself which it useful in understanding future work direction.

The young people in this exercise as well as the Young Minds report also highlighted the issue of trust when receiving treatment. They explained that continuity of staff is essential to the service they received. They also discussed lack of partnership working as a concern with only 42% stating that multiple services had worked well together.

A massive issue raised in a number of reports was that of confidentiality. Clear boundaries and information for young people about what should or should not be shared needs to be present for service delivery to be effected. This was reinforced by our local Borough Wide School Council where confidentiality came out as the top barrier to support that young people face.

• An updated JSNA topic on Looked After Children and Child Protection is required.
• A more detailed needs assessment on self-harm in children and young people may be needed given the levels of anecdotal feedback received on the issue.
• There is a gap in our understanding with regards to parental and wider (non-school staff supporting children and young people e.g. social workers, GP's etc._ professional views and options with regards to mental health and emotional wellbeing of children and young people.

References from Sections 1 to 11

[1] Marmot, M. (2010) Fair Society Healthy Lives: The Marmot Review

[2] World Health Organisation (2014) Mental health: a state of wellbeing

[3] Murphy, M., Fonagy, P. (2012) "Chapter 10 Mental health problems in children and young people, Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays", England: Department of Health

[4] NICE (2012) Social and emotional wellbeing: early years. NICE guideline (PH40). London: National Institute for Health and Clinical Excellence

[5] Dorning, H., Davies, A., Blunt, I. (2015) "Quality Watch: Focus on: People with mental ill health and hospital use: Exploring disparities in hospital use for physical healthcare", England: The Health Foundation and the Nuffield Trust

[6] Department of Health and NHS England (2015) Future in Mind: Promoting, protecting and improving our children and young people's mental health and wellbeing              

[7] Report of the People Select Committee (2015) Commission on the Mental Health and Emotional Wellbeing of Children and Young People: Final Report

[8] Barnett, K., Mercer, S.W. Norbury, M., Watt, G., Wyke, S., Guthrie, B. (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, "The Lancet", Published Online 10 May 2012

[9] Emerson, E. and Hatton, C. (2008) "Estimating Future Needs for Adult Social Care for People with Learning Disabilities in England", Centre for Disability Research, Lancaster University

[10] Foundation for people with learning disabilities (2002) Count us in, Foundation for people with learning, London.

[11] The RaRE Research Report: LGB&T Mental Health, Risk and Resilience Explored

[12] Ford, T. Vostanis, P. Meltzer, H. and Goodman, R. (2007) Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households. British Journal of Psychiatry

[13] Meltzer, H. Gatward, R. Corbin, T. Goodman, R. Ford, T. (2003) "The mental health of young people looked after by local authorities in England", Office for National Statistics, London, HMSO

Public Health England (2016) Child Health Profile

Department of Health, Care Quality Commission, Department for Education, Health Education England, Healthwatch England, Medicines and Healthcare products Regulatory Authority, Monitor, NHS Commissioning Board, NHS Information Centre, NHS Trust Development Authority, National Institute for Health and Clinical Excellence, Public Health England, Royal College of General Practitioners, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Psychiatrists (2013) Improving Children and Young People's Health Outcomes: a system wide response

NICE. Looked-after children and young people. NICE guidelines (PH28). London: National Institute for Health and Clinical Excellence, 2010 (cited 2015 Jun 17).

South Tyneside Young Person's Parliament (2015) "South Tyneside's Borough Wide School Council Health Events", accessed from laura.kate.johnson2@southtyneside.gov.uk on 15.12.15

PHE (2015) Young people's substance misuse data: JSNA Support Pack, PHE North Region

Local Strategies and Plans

South Tyneside Partnership Children and Families Board (updated 2015) Children and Families and Child Poverty Strategy 2014 - 2017

South Tyneside Partnership (2014) Mental Health and Emotional Wellbeing Strategy for Children and Young People 2014 - 16

South Tyneside Partnership (2011)

National Strategies and Plans

Davis, S (2013) "Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays", England: Department of Health

Department of Health and NHS England (2015) Future in Mind: Promoting, protecting and improving our children and young people's mental health and wellbeing

Additional Resources

National Child and Maternal Health Intelligence Network

Public Health Profiles, Fingertips

Glossary

Adjustment disorders

Adjustment Disorder is a state of mixed emotions such as depression and anxiety which occurs as a reaction to major life events or when having to face major life changes such as illness or relationship breakdown. Source: Royal College of Psychiatrists

Mild-moderate depression and anxiety

The main symptoms of depression are losing pleasure in things that were once enjoyable and losing interest in other people and usual activities. A person with depression may also commonly experience some of the following: feeling tearful, irritable or tired most of the time, changes in appetite, and problems with sleep, concentration and memory.  People with depression typically have lots of negative thoughts and feelings of guilt and worthlessness. Sometimes people with depression harm themselves, have thoughts about suicide, or may even attempt suicide.

Mild depression is when a person has a small number of symptoms that have a limited effect on their daily life. Moderate depression is when a person has more symptoms that can make their daily life much more difficult than usual.

Mild anxiety is experienced as feelings of being overwhelmed by responsibilities and unable to cope. People with depression may have feelings of anxiety as well. Source: NICE27, Best Beginnings

Postpartum psychosis

Postpartum psychosis (or puerperal psychosis) is a severe episode of mental illness which begins suddenly in the days or weeks after having a baby. Symptoms vary and can change rapidly. They can include high mood (mania), depression, confusion, hallucinations and delusions. Source: Royal College of Psychiatrists

Post-traumatic stress disorder

Postnatal Post Traumatic Stress Disorder (PTSD) is experienced as nightmares, flashbacks, anger, and difficulty concentrating and sleeping. It may be a pre-existing condition or be triggered by a traumatic labour. Source: Best Beginnings

Serious mental illness (severe mental illness)

Serious mental illness includes diagnoses which involve psychosis. The most common disorders which are associated with psychotic symptoms are schizophrenia, bipolar disorder and psychotic depression.  Psychosis is used to describe symptoms or experiences that happen together. Each person will have different symptoms, but the common feature is that they do not experience reality like most people. A person with psychosis may have: hallucinations, delusions, muddled thinking, lack of insight.  Source: Mental Health Wales, Royal College of Psychiatrists

Severe depressive illness

Severe depression is when a person has many symptoms that can make their daily life extremely difficult. Sometimes a person with severe depression may have hallucinations and delusions (psychotic symptoms). Source: NICE27

Last updated: July 2017