The mental health needs of children and young people must be addressed, not only for the individual and their family, but society as a whole. Over half of all mental ill health starts before 14 years old, and 75% has developed by 18 years old. The life chances of individuals affected are significantly reduced in terms of physical health, educational and work prospects, life expectancy, and their chances of committing a crime. There is also a personal cost to affected individuals, their families and carers, in addition to a cost to our economy (Department of Health and NHS England, 2015 Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing ).
Evidence tells us that treating health issues separately will not tackle the overall wellbeing of children and young people. Mental and physical health is intertwined, and at the heart of health and wellbeing are relationships with others. Children, young people, and their families would like to see an integrated child, youth, and family friendly approach that recognises their particular needs, makes them feel supported, emphasises the positives, and helps them to cope.
The National Picture
The prevalence of mental health problems in children and adolescents was last surveyed in 2004 (NHS Digital Mental health services data set ). This estimated that:
- 9.6% (850,000) of those aged between 5 and 16 years have a mental disorder;
- 7.7% (340,000) of those aged 5 to 10 years have a mental disorder;
- 11.5% (510,000) of those aged 11 to 16 have a mental disorder.
Children and families are frequently confused by largely fragmented services, and often face delays in getting help. The Missed opportunities: A review of recent evidence into children and young people's mental health report on children and young people's mental health seeks to piece together mental health and wellbeing in the UK. It breaks down findings into four age groups:
0 to 4 years:
Good mental health and wellbeing in under 5 year olds is shaped very early on, determined by a complex interplay between genetic makeup, exposure to risk, and protective factors in the environment. Infants and toddlers facing greater risk of poor mental health include those whose mothers have untreated mental health problems, whose parents misuse substances, who are subject to maltreatment and neglect, and who live in prolonged poverty;
- 5 to 10 years:
During primary school years, family environment remains an important influence on a child’s mental health. Early educational environments have the potential to provide new, nourishing, and potentially protective experiences.
Bullying is a major risk factor for poor mental health during primary school years. This jeopardises mental health and wellbeing at the time, and also has significant negative effects on long term mental health, as well as on a range of other areas of adult life. Children who are both bullied and bully others face higher risks of poor outcomes in adult life, including imprisonment and suicide.
11 to 15 years:
Mental health difficulties increase during teenage years. During secondary school, one child in eight will have one or more mental health conditions at any time. The number of children with severe behavioural problems is higher among this age group, mainly males. Rates of anxiety, depression, and self-harm are also higher. Self-harm is common especially among females, Lesbians Gay Bi-sexual and Transgender (LGBT), and those with diagnosable mental health conditions. It is an important risk factor for suicide amongst older teenagers, particularly when accompanied by depression.
Studies have found rising levels of emotional problems and deteriorating life satisfaction among females in this age group. Recent surveys suggest that females are concerned about media driven pressures to be thin, sexual harassment, harmful content online, and academic pressures.
Misuse of alcohol, smoking, and drug-taking are associated with poor mental health.
16 to 25 years:
During young adult years, there is a significant increase in self harm, depression, anxiety, and eating disorders. Diagnosable mental health difficulties are more common in young women as opposed to young men. Young adults are least likely to recognise that they have a problem that may benefit from treatment. Friends, digital sources, and intimate partners often become frequent sources of help.
Those who do seek formal help, or who need continuity of support from early teenage years, can be faced with frustrating gaps between child and adult services that are counterproductive to recovery and progress. Evidence points to the importance of supporting families and schools to build firm foundations for children’s mental health, offering effective help for any age at the first signs of difficulty. Quality help offered quickly and early on, combined with ongoing support, is essential.
The local picture
Extrapolation from the last Office for National Statistics (ONS) report on Mental Health of Children and Young People in Great Britain (Green et al, 2004: Mental health of children and young people in Great Britain, 2004 ) suggested that 2,867 children 5-16 years in Calderdale had a mental disorder, with conduct disorders being the most prevalent (60%). Local data suggests current numbers are higher. There is a close association between socio economic disadvantage and mental disorder, particularly for conduct disorders. In 2012, 16.3% of households in Calderdale had a yearly income of less than £10,000.
Locally, Calderdale carries out a yearly electronic Health Needs Assessment (eHNA) within our schools, reporting on a number of emotional health and wellbeing statistics for Year 5 and 6 pupils ( electronic Health Needs Assessment (eHNA) survey: key findings ):
Over three quarters of pupils have high / fairly high emotional wellbeing (78.3%), higher in Year 6 than Year 5, and males than females. It is significantly higher in primary schools than in secondary schools. The majority of children (91.3%) have at least moderate self-esteem, which is significantly lower than 2015, a worrying downward trend.
Males are more likely to have positive feelings than females, and Year 6 students are more likely to have positive feelings than Year 5 students.
Males are more likely to have negative feelings, largely relating to anger.
Over two thirds of pupils (71%) think they are ‘just right’ (neither ‘too fat’ nor ‘too thin’), and over three quarters (80.1%) are happy with their appearance.
Almost two thirds of pupils (60.4%) have at least moderate aggression. This is significantly higher across both age groups and genders than last year. Males continue to have significantly higher levels of aggression than females.
Females have more worries than males, particularly about exams and puberty.
Bullying and harm:
Almost two thirds (60.1%) of pupils report ever having been bullied, significantly higher than last year, and the highest it has been since the survey started. The school range is 33.3%-88.2%. Females are much more likely to be bullied than males.
Almost a quarter of pupils (24.4%) report ever cutting or hurting themselves on purpose, similar to last year. Males, and Year 5 males in particular, are significantly more likely to report this.
The 2016 Secondary School eHNA survey ( electronic Health Needs Assessment (eHNA) survey: key findings ) reports on a number of emotional health and wellbeing statistics for years 7 and 10 pupils.
More than two thirds of students have high or fairly high self-esteem (69.5%), higher in Year 7 than Year 10 and higher in males than in females (6???????).
Positive feelings are more likely in males than females and Year 7 than Year 10.
Year 10 females are particularly at risk, with almost a quarter (23.4%) reporting high or fairly high negative feelings, compared to 1 in 14 (7.6%) of Year 10 males.
Over half of students (55.6%) think they are ‘just right’ (neither ‘too fat’ nor ‘too thin’), and two thirds of students (67.5%) are happy with their appearances.
Almost half of students (48.7%) have at least moderate aggression. Males have significantly higher levels of aggression than females.
Year 10 females worry most, particularly about exams and their weight.
Half (50.6%) of young people report they have been bullied, the same as last year.
One fifth (18.8%) of students have ever self-harmed. Self-harm is more likely in Year 10 students who report they are gay and female (66%), gay and male (44%) and bisexual (61%).
1 in 100 (0.9%) experienced sexual harm in 2016 compared to 1 in 30 (2.9%) 2015.
Physical harm and threats:
Verbal insults continue to be the most common threat at home.
Children and young people at greater risk of mental health disorders
Not in education, employment or training:
The Children and adolescent mental health services (CAMHS) surveys of mental health of children and adolescents show that mental disorders are associated with an increased risk of disruption to education and school absence. Research on long term consequences of mental health problems in adolescence has found associations with poorer educational attainment and poorer employment prospects, including the probability of ‘not being in education, employment or training (NEET)’.
Refugee or asylum seeker:
Emotional wellbeing is likely to be challenging, with the likelihood of clinically significant disorders. These include: Post Traumatic Stress Disorders (PTSD), depression and anxiety being very high. Many sources of stress are located outside the control of the young person. These include: contact with the border agency, children’s services, and other state services.
Lesbian, gay, bisexual and transgender (LGBT) young people:
Young LGBT people often experience emotional and mental health problems, often as a result of stigma. Gay and bisexual young men are particularly vulnerable to depression and suicide, compared to heterosexual young men.
Children with learning disabilities are six times more likely to have mental health problems than other children, see Mental health of children and young people in Great Britain, 2004 .
Children looked after and Care leavers:
The Centre for Social Justice (2008) cites that children in care are 4 to 5 times more likely to experience mental health issues than their peers. These can be a cause and effect of other problems, such as substance misuse and low level educational attainment.
Youth justice system:
Evidence suggests that between a third and a half of children in custody have diagnosable mental health disorder, with 43% of children on community orders having emotional and mental health needs. Research studies consistently show that high numbers of children in the youth justice system have a learning disability; over three quarters have serious difficulties with literacy, and over half of those who offend have also been victims of crime.
Parents with mental health problems and low income households:
Children whose parents / carers have a mental health problem, who live in low income households, or who experience domestic abuse, are at greater risk of experiencing poor mental health, as are teenage mothers.
All secondary schools have named leads for emotional health and wellbeing, and have implemented a range of services to support positive mental health of their students. These include in house counsellors and staff training on, for example, mindfulness and peer support.
Youth mental health first aid training:
This has a practical focus on supporting those experiencing mental distress, and is relevant for people who teach, work, live with, and care for those aged 8 to 18 years.
Young peoples’ service:
This includes youth centres, street based youth workers, and mobile youth work vehicles, offering one to one or group work sessions around emotional health and wellbeing.
Voluntary and community sector:
The voluntary sector plays an important role in building resilience and creating supportive environments, including active lifestyles and peer support.
Noah’s Ark offers individual counselling and outreach services, as well as family therapy. The Rainbows peer support programme (age 4-10) is there for those experiencing loss.
Healthy minds – Open minds:
This education project teaches people about emotional resilience and stigma, encouraging a positive approach to help effectively manage mental health.
Northpoint wellbeing 2016:
This focuses on parents of primary school age children and transitioning year groups, benefitting from the strong relationship between parents and school staff. This enables a holistic approach to supporting children's needs.
Tier 2 CAMHS:
This service offers targeted advice and support to professionals working with children and young people. This is where emotional, behavioural, or mental health problems are not responding to preventative or universal services interventions.
Tier 3 CAMHS:
This works with more severe, complex and enduring difficulties and helps where there is a reasonable indication that the child may have neurodevelopmental difficulties, e.g. autistic spectrum continuum, Attention deficit hyperactivity disorder (ADHD), or other difficulties requiring multi-disciplinary assessment. Pathways exist within tier 3 CAMHS for referrals for adopted and children looked after (CLA), learning disabilities, eating disorders, ADHD, and young people with ASD (autistic spectrum disorders).
Tier 4 CAMHS:
A specialised commissioning team, who work with identified lead commissioners in the relevant Clinical Commissioning Groups (CCGs). The vision is for children to be treated as close to home as possible, in community based services wherever safe and appropriate, with access to specialist services where possible.
CAMHS First point of contact (FPoC):
The FPoC has been established as single entry point for all referrals to tier 2 and 3 CAHMS services for all professionals. Referrers are encouraged to phone before making a referral to ensure young people receive the right support early on.
Domestic abuse services:
‘Staying Safe’ started in July 2016 and works directly with children and young people to increase resilience and emotional wellbeing.
Calderdale therapeutic service (CTS):
The CTS team provides a service to children and young people who are looked after, care leavers, and those on the edge of care (Calderdale therapeutic and counselling services for children and young people [PDF 893KB]) .
This focuses on adolescents on the edge of care who can be offered a range of flexible accommodation and support, matching their needs rather than model flows throughout the process.
The ‘Mental health crisis care concordat’ is a national agreement between services and agencies involved in care and support of people in crisis. It sets out how organisations will work together to make sure people get the help they need when they are having a mental health crisis.
Other services in Calderdale:
The Early intervention strategy (EIS) delivers robust services, taking a coordinated approach to multi agency locality working. Weekly panel meetings are held to address the needs of our most at-risk and vulnerable young people to develop and manage support. The Child sexual exploitation (CSE) service offers direct support for victims and those at risk of CSE, males and young men, parents / carers, and healthy relationships support for schools.
Local Transformation plan:
Partners in Calderdale have come together to improve emotional health and wellbeing for children and young people, identifying this as a key priority in our area. There is a strong local commitment to improving access to services, developing innovative ways to meet mental health needs whilst building up resilience in children, young people and their families in their schools and wider communities to improve outcomes ( Transformation Plan for Children and Young People's Emotional Health and Wellbeing - Calderdale ) .
The Youth Council identified emotional health and wellbeing as a key focus. A working sub group of young people, the ‘Tough Times’ group, was formed to work on this issue. All members having personal experiences of accessing related services.
The Tough Times group undertook the following:
- feedback on NHS Choice website on emotional health;
- views on support needed in schools;
- renaming and creating a logo for the Emotional Health and Wellbeing branding;
- commented on proposed funding priorities for the Commissioning team for year 2;
- fed into the development of CAMHS;
- joined NHS England Yorkshire and Humber regional group; and
- developed a questionnaire on why young people miss counselling appointments
There are a number of health school champions in secondary schools, known as Young health watchers. Tasks carried out include surveys with young people and schools on emotional health and wellbeing issues. Surveys include:
- Keep moving – Be healthy;
- How to stay healthy in body and mind;
- Cyberbullying; and
- Exam stress.
Consultations have also taken place with schools, parents / carers, local Safeguarding Children Board young advisors and wider stakeholders. The CCG works closely with children and young people in service development. They aim to encourage children and young people in designing, developing and decision-making of future services. This gives an integrated child and young person led approach to commissioning ( Transformation Plan for Children and Young People's Emotional Health and Wellbeing - Calderdale ) .
- Children and young people do not receive support early enough;
- pathways are not always clear / suitable and waiting lists are too long;
- there is a lack of flexibility in current provisions, restricting choices for young people;
- services have a strong focus on criteria, rather than individual needs;
- issues with data validity;
- communication / signposting must be improved for all stakeholders;
- increased support for parents / carers is required;
- lack of persistence by organisations if an individual does not engage at first attempt;
- there has been an increase in self-harm and acute and / or crisis demand and difficulties in young people accessing tier 4 beds; and
- must improve support for those with eating disorders.
NHS England has commenced a national mental health service review and has established a board to lead on this process. The mental health service review will be directed and driven locally, so that services meet the needs of local populations. (Unmet need is defined as Challenges and priorities, pages 46-47, Transformation Plan for Children and Young People's Emotional Health and Wellbeing - Calderdale ) .
Projected future need
Findings from the 2016 Primary school’s eHNA survey ( electronic Health Needs Assessment (eHNA) survey: key findings ) .
Key considerations linked to the known evidence base (What works?)
The National institute for health and clinical excellence (NICE) has produced a number of guidance documents for promoting social and emotional wellbeing, clinical guidelines for managing mental health disorders in children and young people and for short term and long term management of self-harm. NICE guidance also summarise evidence based treatments for conduct disorders and other mental health conditions in childhood. Psychosocial therapies are regarded as the mainstay of treatment for conduct disorder, and are clinically and cost effective.
A life course approach is needed to support parents / carers during the perinatal phase and in the early years, so that a secure parent / child relationship and positive attachment develops, and helps to build emotional resilience in children (Green et al, 2004: Mental health of children and young people in Great Britain, 2004 ). Colleges and other organisations also play a part in enhancing children and young people’s emotional wellbeing. Evidence based interventions effective in preventing and treating mental health disorders include:
- promoting maternal mental health and reducing depression;
- supporting parents / carers to parent effectively;
- providing education programmes with a focus on disadvantaged families;
- promoting mental health and developing social and emotional skills in schools / colleges;
- reducing risk taking behaviours and identifying early signs of alcohol and substance misuse; and
- early identification of problems, providing access to information and support when needed.
References and further information
- Department of Health and NHS England (2015): Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing ;
- NHS Digital:
Mental health services data set
Guidelines for commissioning of services developing children’s social and emotional wellbeing;
- Centre for mental health (2016):
Missed opportunities: A review of recent evidence into children and young people's mental health :
A comprehensive overview of mental health set out by age groups 0-4 years, 5-10 years, 11-15 years and 16-25 years, the report highlights an average delay of a decade in children receiving help and what interventions might be considered to help prevent problems multiplying and getting progressively worse, eventually escalating into a crisis in adulthood;
- Calderdale Council:
electronic Health Needs Assessment (eHNA) survey: key findings
The key findings for eHNA surveys carried out in primary and secondary schools;
- Health and Social Care Information Centre (HSCIC):
What about YOUth survey
The ‘What About YOUth? (WAY)’ survey is a lifestyle study of 15 year olds in England, collecting data on risky behaviours, health and wellbeing. The Warwick Edinburgh mental wellbeing scale (WEMWBS) measures wellbeing using responses to 14 positive statements, giving a score between 14 and 70, where positive answers result in a higher score. In Calderdale, the mean score is 47.6, similar to the England mean score of 47.6. In 2012, the average WEMWBS score for 16-24 year olds was higher, at 52.4 (Health Survey for England);
- Green, McGinnity, Melzer, Ford and Goodman (2005): Mental health of children and young people in Great Britain, 2004 ;
- Calderdale Council: Calderdale therapeutic and counselling services for children and young people [PDF 893KB] ;
- Calderdale Council (2015): Transformation Plan for Children and Young People's Emotional Health and Wellbeing - Calderdale ;
- Public Health England (PHE) (2014):
Local action on health inequalities: evidence papers
A summary of evidence about the effect of resilience on health, the unequal distribution of resilience and its contribution to levels of health inequalities. The review outlines the potential actions that can be taken in schools in order to build resilience in children aged 5 to 18 years, in primary and secondary school settings, family homes and communities.
You can find out more in the longer version of this chapter: Children and young people's emotional health and wellbeing - long version [PDF 373KB] .
More information on children and young people can be found in the Further resources .
Commissioning team, Adult and Children's Services, Calderdale Council
edited by Emily Powell, Public Health Intelligence Intern, Public Health, Calderdale Council