Abstract
Given that two decades of the 21st century have almost already passed, it seems odd that the case for parity of investment, emphasis, and esteem for the treatment of mental health disorders in children versus physical health problems still needs to be made. But despite some progress, that is where we still are, and that is the case that we continue to need to make. We are fortunate in the level of evidence we now have to make this argument, and these data are compelling. Data from the United Kingdom recently revealed that one in eight children and young people in England suffer from a mental health disorder. This rises steeply with age, and self-harm or suicide attempts occur in 25% of 11 to 16-year-olds (NHS Digital, 2018). Moreover we now live, for the first time in history, within an era where death rates in the very youngest in our society are less than their adolescent contemporaries, and when digging down into causes of deaths in this is older group, we find that suicide is a leading cause of mortality (Viner et al., 2011).
There is therefore a lot to tackle, and this includes intervening at a range of complex levels, not only at the coalface delivery of mental health services, but also tackling social determinants of health, and for specific health care groups with long-standing conditions (Delamater, Guzman, & Aparicio, 2017). In the immediate sense, however, a key issue in the United Kingdom, as for many countries, is timely access to mental health services, with some 75% of children and young people with a mental health problem not accessing treatment (Lamb, 2017), and persistence of a mental health disorder in children and young people remaining as high as 50% at 3 years (Ford, Macdiarmid, Russell, Racey, & Goodman, 2017). This is despite recent data suggesting that children, young people, and their parents are more than ever likely to recognize and seek help and support for a mental health disorder (NHS Digital, 2018).
In recognition of these issues, the UK government has recently published a bold and ambitious long-term plan to tackle mental health, promising to increase, as a share of total spending, the financial provision to children and young people (NHS England, 2019). A significant focus for this plan is to embed mental health professionals within schools, a joint enterprise by the departments of health and education (Department of Health & Social Care and Department for Education, 2018). At the time of writing, trail-blazer pilot schemes are running, pleasingly with a determination to collect data to measure outcome, and experience. So why schools? In many ways, it makes good sense to place a significant emphasis within schools on identifying, and potentially treating, new-onset emotional mental health disorders in children in young people. For a start, (most) children and young people spend a considerable amount of time in school, and their educators are often in a helpful position to observe difficulties. There are also, usually, considerate and caring relationships between educators, pupils, and their families (Hewlove-Delgado, Moore, Ukoumunne, Stein, & Ford, 2015). Furthermore, identifying children in school is a potentially helpful way of identifying children early on in the course of their illness, promoting earlier and more successful interventions. We also know that mental health and education play a symbiotic relationship with each other: in terms of not only the impact of mental health disorders on educational attainment and ability, but also the potential effects of challenges and stressors that may emerge as a consequence of education itself (Elias, 1989).
Getting this right is important and beset with a number of potential stumbling blocks. To begin with, those responsible for detecting and managing mental health disorders must be appropriately trained and be able to work effectively alongside teachers and other school staff. Anecdotal reports from teachers’ representative bodies suggest anxiety about the skills, support, and understanding by teachers associated with the new proposals. In this edition of Clinical Child and Psychology and Psychiatry, Cortina et al. (2019) provide the interesting results of a service evaluation of a workshop aimed at improving co-working between mental health agencies and education. Using the CASCADE framework, a structured approach to key issues in inter-agency working such as clarity of roles and agreement on priorities, a large number of schools and local mental health teams, across a number of regions in the United Kingdom, met over 2 days for workshops to improve co-working. The results are reassuring for the improvements in this arena. After workshop, measures of the perceptions of efficacy of interagency work increased compared to before, and in a large number of cases, there was ongoing improved relationships and ongoing collaboration. Despite this, there was evidence of ongoing disagreements in a number of domains of co-working, demonstrating the need for repeated efforts to improve relationships and understanding. This article provides important insights into the challenges that are likely to exist between mental health professionals within schools and outside agencies; however, such evaluations need replication. In particular, replication should be in more socioeconomically diverse settings, for as Cortina et al. acknowledge in their paper, the areas of their study were relatively well resourced and perhaps, to some extent, already joined up.
Another area of concern for the government’s plan is potential impact upon the capacity of services, such as community child and adolescent mental health services (CAMHS) that schools will refer on to. It seems likely that mental health professionals in schools will identify more serious disorders, which may lead to an increased flow of patients to local CAMHS, services which are already struggling with high levels of demand. Conversely, it could be argued that if school mental health professionals are able to successfully manage more moderate levels of disorder, this might have the potential to take the pressure off of CAMHS, and free up these services for patients with more severe illness. This calls for working together. There is also the more fundamental problem of placing a significant emphasis on school-based screening and interventions, in that this is unlikely to help children who are not in school. This group represents a broad mix of children and young people, many with severe mental health problems, and who are potentially the most vulnerable in our society. In this edition of Clinical Child and Psychology and Psychiatry, Melvin et al. (2019) study a group of children who are not in school, and what is striking is the high level of anxiety and low mood, but also that they are amenable to treatment. Also in this edition, Kljakovic and Kelly (2019) report important information on young people with school refusal receiving alternative education provision in a particularly deprived area in London. They found that a large number of these young people were already known to CAMHS, but importantly, there appeared to be a large number of reasons other than mental health, associated with their school non-attendance. Young people from this group reported themselves that engaging with clinicians was challenging, and professionals working with them perceived that gradual, graded approaches were most successful in reintegrating to schools. This implies that professional inputs both ends of school, that is, outside of and within, may be key, and potentially speaks of a role for mental health workers within schools to support children back in. This will only happen if they are allowed to look outwards, as well as in.
Time will tell whether the long-term plan, and the focus on school interventions as part of it, will deliver success. Many of those working in health care are relieved that there is a long game in mind, rather than more short-term policies of the past. Of course, politics and governments are rarely stable in the long term, and the long-term plan is potentially vulnerable to political change. There will need to be some flexibility in any case as effects are measured and problems found. What must not change, and is in our control, is the continued assertion of the narrative from health professionals and policy makers alike for the importance of child and adolescent mental health. That above all, must keep going.