National Assembly for Wales

Children, Young People and Education Committee

CAM 19

Inquiry into Child and Adolescent Mental Health Services (CAMHS)

Evidence from : Royal College of Paediatrics and Child Health Wales

Key points

· Significant and growing numbers of children and young people are affected by diagnosable mental health disorders and by more general mental health ‘difficulties’.

· Early intervention is critical to ensure the best mental health outcomes for a child or young person and to reduce the future prevalence of adult mental health problems.

· Lack of CAMHS capacity in community services and inpatient facilities can lead to children and young people spending periods of time inappropriately on paediatric or adult wards.

· Welsh Government leadership is needed to refocus services on prevention, to expand capacity and to support workforce training.

1.0       Introduction

1.1       RCPCH Wales welcomes the opportunity to respond to the Children, Young People and Education Committee inquiry into child and adolescent mental health services. Mental disorders in children and young people are increasing and represent a hidden epidemic.  This has significant implications for society as whole, both today and in the future.

1.2       Statistics covering Great Britain show:[1]

· 1 in 10 children and young people aged between 5 and 16 have a diagnosable mental health disorder.

· More than 3 per cent of children and young people have an anxiety disorder.

· 1 per cent of children and young people are seriously depressed.  The bulk of children and young people are in the 11+ years age category

· Among 5 to 10 year olds, 10 per cent of boys and 5 per cent of girls had a mental disorder while among 11 to 16 year olds the prevalence was 13 per cent for boys and 10 per cent for girls.  The prevalence of anxiety disorders was 2–3 per cent, depression 0.9 per cent, conduct disorder 4.5–5.0 per cent, hyperkinetic disorder (severe ADHD) 1.5 per cent and autism spectrum disorders 0.9 per cent.

· Rarer disorders including selective mutism, eating disorders and tics disorders occurred in 0.4 per cent of children.  Conduct disorders, hyperkinetic disorder and autism spectrum disorders were more common in boys, and emotional disorders were more common in girls.

1.3       Significantly more children have mental health ‘difficulties’ which have a long-term impact on education, family function and life chances.  There are strong links between mental health problems and adverse life circumstances (parental substance misuse, parental mental health, abuse and neglect, and poverty).  Early and appropriate intervention minimises the mental health challenges for children and young people and the potential lifelong impact.

1.4       CAMHS services in Wales face pressure as the part of their budget that is supported by local authorities comes under budgetary constraints.  To ensure that provision meets demand it is therefore imperative that data are collected on the prevalence and incidence of mental health conditions and an annual audit of services and expenditure in the area undertaken.

1.5       We have focused our response on the availability of, access to and priority given to CAMHS services as this is where our expertise and knowledge in relation to the care and treatment of children and young people with mental disorders lies.

2.0 Availability of early intervention services for children and adolescents with mental health problems

2.1       Children and young people with mental health problems can become adults with mental health problems. Early intervention is crucial to ensure the best possible outcomes for a child or young person.  Early intervention and mental health provision in schools and clinics have been shown in some studies to improve outcomes and life chances for children and young people into adulthood and might be an opportunity to prevent and reduce mental health disorders in adulthood.

2.2       A study quoted by the YoungMinds charity found that more than half of all adults with mental health problems were diagnosed in childhood but less than half were treated appropriately at the time.[2]

2.3       There are many costs to not intervening early:

· Individual children and young people and their families continuing to suffer with no support or inappropriate support.

· Resources in NHS acute services used at crisis point to treat children and young people who could have been helped earlier.

· Financial costs in the criminal justice system, social care, welfare and voluntary sector support.

3.0 Access to community specialist CAMHS at tier 2 and above for children and adolescents with mental health problems, including access to psychological therapies

3.1                   RCPCH Wales draws the committee’s attention to the recent Healthcare Inspectorate Wales and Wales Audit Office report (December 2013) that said:

“There is a divergence between the Welsh Government’s policy on inappropriate admissions to adult mental health wards and how young people presenting in crisis who are in need of an initial assessment are being dealt with.  In the absence of comprehensive services in the community, young people in crisis are being admitted to adult mental health or paediatric wards for an assessment.  This is because the alternative of admitting to a CAMHS inpatient unit is deemed by clinicians in the units to be inappropriate.”[3]

3.2       Further to this quote RCPCH Wales believes there are not enough CAMHS inpatient facilities across Wales to accommodate the demand for inpatient beds.  Children and young people who cannot access these services also end up in paediatric wards – as the next best option – which can be inappropriate both for the child and for other children on the acute paediatric ward.

3.3       One paediatrician consulted by RCPCH Wales reported having one or two admissions per day that require CAMHS and believes other hospitals in Wales are “likely to face the same issues”.  Paediatric staff in these cases have knowledge and experience of treating children and young people but do not necessarily have the specialist skills to address mental health problems.

3.4       These admissions can also lead to children and young people spending longer periods of time in hospital care because they cannot be referred to more appropriate care or discharged if the paediatrician is still concerned about their mental health. Children and young people can be passed between professionals and services repeatedly because of a lack of certainty about the most appropriate healthcare professional or care setting.  RCPCH Wales is concerned that this may lead children and young people to feel poorly valued and unclear about their care, which in turn impacts on their mental health.

4.0       Whether CAMHS is given sufficient priority within broader mental health and social care services, including the allocation of resources to CAMHS

4.1       Although there had been considerable investment in services more recently there is anecdotal evidence that suggests variation in access to services and in implementation of evidence-based interventions.  There are also anecdotal reports of services having long waiting lists and of thresholds for access being too high, which leads to children and young people with less severe problems not being accepted.

4.2       The multi-agency nature of services allows the potential for lack of co-ordination between agencies which, particularly at a time of shrinking budgets, may mean that children and young people fall through the gaps.  There may also be reluctance for agencies to invest in interventions when they themselves may not benefit from any savings, e.g. by providing early intervention.

4.3       Strategic leadership is required to recognise the long term benefits and potential savings of ensuring all children and young people are offered appropriate early intervention and access to high quality evidence based treatments.  This requires commitment from the Welsh Government to resource services at all levels through:

· Preventative services and prioritising these programmes within universal services as part of a commitment to ‘invest to save’.

· Ensuring that paediatric and specialist CAMHS services have sufficient capacity to meet the needs of children and young people.

· Efforts to support the delivery of effective CAMHS by addressing workforce and training issues and shortfalls in resources.

5.0       Any other key issues identified by stakeholders

5.1       Transitions: young people can fall between the gap of children’s and adult’s mental health services, especially for those with neurodevelopmental, severe emotional or emerging personality disorders.  Improved liaison, collaboration and joint working between children’s and adult’s mental health services and primary care are required to ensure genuine pathways of care that meet the needs of the young person and their family.  We note the potential of the individual-level care planning system brought about by the Mental Health Measure 2010 and suggest the committee continues to monitor implementation.

5.2       Supporting health and other professionals: RCPCH is involved in the creation of MindEd (http://www.rcpch.ac.uk/minded), a resource for the many adults who are in regular contact with children and young people but who have little or no idea how to recognise or respond to emotional or behavioural problems.[4] MindEd launches in March 2014 and will offer free resources for all professionals who interact with children.  We would welcome the opportunity to demonstrate this resource to members of the committee.

About the RCPCH

The Royal College of Paediatrics and Child Health is a UK organisation which comprises over 15,000 members who live in the UK, Ireland and abroad and plays a major role in postgraduate medical education, as well as professional standards.

The College's responsibilities include: 

· setting syllabuses for postgraduate training in paediatrics

· overseeing postgraduate training in paediatrics

· running postgraduate examinations in paediatrics

· organising courses and conferences on paediatrics

· issuing guidance on paediatrics

· conducting research on paediatrics

For further information please contact Nick Morris, External Affairs Manager, RCPCH Wales at nick.morris@rcpch.ac.uk or 02920 455414

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[1] Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young people in Great Britain 2004. London: Palgrave

[2] Kim-Cohen, J., Caspi, A., Moffitt, TE., et al (2003): Prior juvenile diagnoses in adults with mental disorder. Archives of general psychiatry, Vol 60, pp.709-717

[3] WAO and HIW, Child and Adolescent Mental Health Services: Follow-up Review of Safety Issues, 11 December 2013, p.5

[4] Also involved: British Association for Counselling and Psychotherapy, Royal College of Psychiatrists, National Children’s Bureau, YoungMinds, Royal College of General Practitioners, British Psychological Society and the Royal College of Nursing