Emotional & Mental Health Needs Assessment
For Children and Young People in Hampshire
Final
1
Contents
Executive Summary
Recommendations
Glossary
Section 1: Introduction
1.1 The importance of emotional wellbeing and mental health in children and young people
1.2 The interaction between Physical Health and Mental Health
1.3 Costs of poor mental health in children
Section 2: Health Needs Assessment
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
Aim
Objectives
Method
Limitations of the needs assessment
Scope of the needs assessment
Common functional disorders in children
National context
Local context
Section 3: Evidence of what interventions work
3.1
3.2
3.3
3.4
Scale of the issue
Factors influencing and influenced by mental health
Vulnerable Young People
Rates and profile of mental health problems among children in Hampshire
Section 4: Evidence of what interventions work
4.1
4.2
4.3
4.4
Early Intervention & Diagnosis
Effective interventions: Maternal Mental Health & the Early Years
Effective interventions: Parenting
Effective interventions: School based programmes
Section 5: Benchmarking
5.1 Programme Budgeting Analysis
5.2 Spend Quadrant Outcomes Analysis
Section 6: Projected need
Section 7: Services in relation to need
7.1 Introduction
7.2 Estimated need for services at each tier
Section 8: Stakeholder Views
8.1 Findings of local consultation
8.2 ‘What do I think?’ Survey
Section 9: Recommendations
Appendix 1: Further examples of local CAMHS tier 1 and 2 services
Appendix 2: Stakeholder Engagement Summary
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Executive Summary
The aim of this needs assessment is to identify and quantify the emotional wellbeing and
mental health needs of the children and young people living in Hampshire to inform the
planning and procurement of appropriate, high quality services and interventions to improve
outcomes.
Children and young people in Hampshire have told us that they want people to:

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Communicate with them well.
Be inviting.
Have a sense of humour.
Be trustworthy and available.
They want to be involved in decisions that involve them and be treated as individuals.
Overall they wanted to make sure that whatever we do we ‘make it worthwhile’.
This needs assessment considers the risk and protective factors for mental health in
children. Where possible we have looked at needs in children aged between 0 and 25 years.
This population has been chosen as it is recognised that emotional development continues
into the early 20’s. Need was identified through a formal public health model, by
triangulating corporate, epidemiological and service user intelligence using a variety of local
and national data sources including ChiMat, ONS and Children and Adolescent Mental
Health Services (CAMHS) activity data.
Data availability is a key limitation of this needs assessment. National prevalence data from
a comprehensive survey that is over 10 years old has had to be used to estimate current
local prevalence as this is the most up to date data available. It is unlikely that this provides
an accurate picture of children’s mental health today locally or nationally. However it is the
best information that we have and does give some indication of the problem.
Good mental health is important in a child’s capacity for relationships and their educational
attainment. It enables social inclusion and the ability to recognise and take life opportunities.
Nationally it is estimated that 10% of all children aged between 5 and 16 years will have a
clinically diagnosable mental health problem at any one time; with half of all lifetime cases of
mental ill health starting before the age of 14 and three quarters by the age of 24.
The 2004 survey found that mental health disorders are more common in boys (11.4%)
compared to girls (7.8%) and rates increase with age. Among 5-10 year olds 5% of girls and
10% of boys had a mental health disorder while among 11-16 year olds the rates were 10%
for girls and 13% for boys. The most common type of mental health problems in children and
3
young people were conduct and emotional disorders, both increase with age. There were
higher rates of conduct disorders in boys and emotional disorders in girls.
It is estimated that 17, 845 children aged between 5-16 years and 12, 365 aged between 2-5
years have a mental health disorder in Hampshire, equivalent to about 13% of all children
aged 2-16.
The needs assessment identified five key local challenges:

Accurate local information. We do not have accurate local information of the true
scale of mental health problems in children and young people. We have to rely on
estimates derived by applying the findings of a survey conducted 10 years ago to our
local population. While this is the best evidence that we have it is far from ideal to
inform the planning of services. Childhood and the way we live our lives has changed
in the last ten years and will have impacted on children’s mental health.

Mental health needs in children are changing and probably increasing.
Indications are that mental health needs in children are increasing and will continue
to do so. In the absence of up to date epidemiological data it is not clear whether this
is because we are getting better at recognising the need or whether the profile of
needs is changing. This is due to a number of factors:
o Increase in the number of children living in Hampshire. By 2020 we predict
that there will be 9,640 more children living in Hampshire. The recent rise in
births, continuous housing development and inward migration are all
contributing to the increase. This is likely to continue and we should consider
these projections as ‘lower end of the range’ estimates.
o Underdiagnosis. Mental health conditions in children in Hampshire, in
common with the rest of England are likely to be underdiagnosed. The
increased national and local focus on children’s mental health and the drive
for parity with physical health is likely to lead to improved awareness and
diagnosis of mental health problems in children and a reduction in
underdiagnosis. At the same time there will be increased opportunities for
prevention and early intervention which could reduce some of the need for
specialist mental health interventions.
o Increasing numbers of vulnerable children. Trend data suggest that we will
continue to see an increase in the number of vulnerable children in
Hampshire who we know are at significantly increased risk of mental health
disorders, for example looked after children and children with learning
disabilities.
o Lifestyle behaviours. The long term impact of lifestyle behaviours which
increase the risk of poor mental health such as obesity, physical inactivity and
substance misuse is more difficult to predict. While we have had some
success in influencing risky behaviours in children it is unlikely that we will
see a dramatic reduction over the next few years and these behaviours will
continue to affect the mental health of children.
4
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Mental health problems in children are poorly understood by non specialists.
Evidence suggest that awareness of mental health problems in children among
adults is poorly understood. Parents and carers have told us they want more
information about their child’s mental health and professionals have asked for more
information about the best way to support those children with mental health needs
who do not require a specialist mental health service to help ensure that their health
does not get worse.

Self Harm. Rates of hospital admission for self harm among 10-24 year olds in
Hampshire are significantly above the England average. Further work is needed to
understand if this indicates a higher rate of self harming among young people in our
community or reflects service provision and access to services so that we can take
appropriate action to address this.

Specialist and non specialist services. We need to ensure that our specialist
services are high quality and can respond in timely way to the needs of children who
require specialist support. It is important that they can meet the needs of children
from vulnerable groups. We need to review the services that are available for
children who need support but do not need specialist intervention to ensure that they
are appropriate for the needs of our population.
Recommendations
Action can be taken to improve mental health in children at a societal level, community level
and at an individual and family level.
Interventions should be evidence based and cost effective.
Action is needed at all levels to improve the mental health of children.
The recommendations from the 2013 JSNA remain highly relevant and all are supported by
the findings in this needs assessment. There should be an increased focus on implementing
them:
 Promoting maternal mental health
Ensure that the health visiting contract continues to include the responsibility to
identify mothers at risk or in early stages of postnatal depression, and then offer
appropriate support and treatment.

Promoting positive parenting
Enable access to evidence based parenting programmes for those at highest
risk.

Ensuring access to mental health services
Enable access to effective services to diagnose and treat conduct disorders in
childhood, especially amongst first time entrants to the youth justice system.
5
Ensure that child and adolescent mental health services meet the breadth of
need of our young people and are readily accessible to them and are nonstigmatising.

Looked after children
Ensure there is adequate support for young people leaving care, particularly
transition to adult services.
In addition the findings of this needs assessment lead to the following recommendations:

Awareness raising
Raise awareness of the importance of good mental health in children amongst all
those who work with children to improve early recognition and intervention as
appropriate.
Evidence-based mental health training for non-mental health professionals. This
could include training for midwives, health visitors, school teachers and staff,
those working in the voluntary sector, police and probation staff in acute and
community settings.
High quality information about child development, emotional wellbeing and
mental health and where to get help should be readily available to parents,
carers and young people.

Promoting mental health
Organisations should work together to promote good mental health in children by
building protective factors and reducing exposure to the risks for poor mental
health wherever they can.
Encourage schools to adopt a whole school approach to promoting resilience
and good mental and physical health, including tackling bullying.
Ensure that programmes aimed at promoting resilience, emotional wellbeing and
mental health are both girls and boys.

Universal services
Investment is needed in universal and targeted services (Tier 1 and 2) to
address the unmet needs of children with mental health conditions at an early
stage to help to prevent progression to more serious illness and to reduce the
future social, health and economic costs associated with poor mental health.

Vulnerable children
Action should be taken to ensure that those children and young people who are
at a higher risk of mental health problems are identified so that they get the right
support at the right time – for example looked after children, children with
learning disabilities and children in contact with the Criminal Justice System.

Specialist mental health services
6
Ensure all children, young people and families have timely access to timely,
evidence- based high quality specialist mental health support when it is needed
Ensure that our Specialist Child and Adolescent Mental Health Service can meet
the needs of the increasing numbers of vulnerable children in a timely manner.

Parenting
Undertake a review of parenting to quantify the reported gaps so that action can
be taken to address unmet need.

Prevention and early intervention services ( Tier 1 and 2)
Commissioners should review the capacity of and strengthen prevention and
early intervention (Tier one and two) services to ensure they are adequate to
meet the needs of children and young people, particularly vulnerable children
and those children at increased risk of developing mental health problems.

Self Harm
Investigate the high rate of admissions for self harm.
Review strategies for the prevention of self harm.
Review and improve the pathway of care for young people who self harm.

Wider determinants
Encourage organisations to consider the impact on children’s mental health of
their strategies, policies and initiatives.

Information
Continue to build on and support the Hampshire pupil’s attitude survey with a
view to obtaining a more representative view of attitude and emotional health
and wellbeing across the County.
Advocate for better information about children’s mental health needs so that we
can quantify the issue.
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Glossary
Mental health: The World Health Organisation (WHO) defines mental health as: ‘a state of
wellbeing in which the individual realises his or her own abilities, 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’
Emotional wellbeing: A positive state of mind and body, feelings of being safe and able to
cope, as well as a sense of connection with people, communities and the wider environment.
Organic mental disorder: is also known as organic brain syndrome or chronic organic brain
syndrome. It is a form of decreased mental function due to a medical or physical disease,
rather than a psychiatric illness.
Functional disorders: Such disorders have a non-specific cause and are considered to be
a disorder of the mind rather than the brain.
Health Needs Assessment: A health needs assessment (HNA) reviews the health issues
facing a population and helps commissioners to agree priorities and to identify where
valuable resources should be allocated.
Prevalence: This gives an indication of the burden of the disease. It is a measure of the
proportion of individuals in a population having a disease or characteristic at a given time.
Incidence: This refers to the number of new cases of a disease in a defined time period.
Terminology
To assist the reader throughout this needs assessment we have generally used the following
terms:
‘mental health’ to mean emotional wellbeing and mental health
‘children ’ to mean children and young people
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Section 1: Introduction
1.1 The importance of emotional wellbeing and mental health in children and young
people
‘Health is the basis for a good quality of life and mental health is of overriding importance in
this’ (Article 24 of the United Nations convention on the Rights of the Child).
Children and young people with good mental health do better. They are happier in their
families; they learn better and do better at school; they are able to enjoy friendships and new
experiences. They are more likely to grow up to enjoy healthy and fulfilling lives and to make
a positive contribution to society and to have good mental health as an adult.
Thus, promoting good mental health has both individual and community benefits, not least of
which is the impact that mental health has on physical health, and vice-versa.
Many things affect children’s health and so it is unsurprising that there are many definitions.
Children in Hampshire have told us that good emotional wellnbeing and mental health
means ‘feeling safe and secure’, ‘being satisfied with life’ and ‘feeling worthwhile’.
The World Health Organisation (WHO) defines mental health as: ‘a state of wellbeing in
which the individual realises his or her own abilities, 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’1.
Emotional wellbeing has been defined as a positive state of mind and body, feeling safe and
able to cope, with a sense of connection with people, communities and the wider
environment2.
These definitions are useful as they highlight that emotional wellbeing and mental health are
not about feeling happy all the time.
Although most children grow up mentally healthy surveys suggest that more children and
young people have problems with their mental health today than 30 years ago3. This is
probably because of changes in the way we live now and how these affect the experience of
growing up. Mental health problems in children account for a significant proportion of the
1
WHO | Mental health: a state of well-being
As set out in two diagnostic manuals: World Health Organization. 2007. The ICD-10 Classification of
Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines. Geneva: WHO
and American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR). Arlington: APA.
3 Young Minds
2
9
burden of ill health in this age group4. It is estimated that at any one time one in ten children
aged between 5 and 16 years in England has a clinically diagnosable mental health problem
and one in seven has less severe mental health problems5.
Early positive intervention makes a real difference. We know that giving children and their
families the right type of support in theearly years can help to avoid many of the costly and
damaging social problems in society6.
Emotional and mental ill health problems that develop in childhood can become an enduring
life-long burden on the individual, community and society; significantly interfering with their
ability to be economically active and affecting their cognitive, emotional and social abilities
as well as significantly shortening their life span. Rates of disorder rise steeply from middle
to late adolescence with more than a half of all adults with mental health problems being
diagnosed in childhood and three quarters by the age of 24. Between a quarter and half of
adult mental illness may be preventable with appropriate interventions in childhood and
adolescence.
Good mental well-being in children is associated with:
 Better educational attainment and future prospects
 Improved learning
 Reduced risk taking behaviours including: smoking and alcohol and substance
misuse
 Reduced health inequalities.
1.2
The interaction between Physical Health and Mental Health
Government policy is clear: that mental health is to be given equal status, or parity of
esteem, to physical health. This includes parity not just in health and social care services,
support and treatment, but in terms of public health and health improvement7.
In Hampshire the vast majority of children are healthy. Mental health disorders amongst
children attending primary care are higher than in the general community, with around 1 in 3
having a diagnosable mental health problem. We know that children who go on to die from
suicide have a higher rate of consultation with a GP in the month and week preceding death
than their peers. Surveys show that three-quarters of children see their GP at least once a
year for various issues, Although this provides a valuable opportunity for screening for
mental health problems8 research suggests that more evidence is required to explore better
4https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/252660/33571_29013
04_CMO_Chapter_10.pdf
5https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/252660/33571_29013
04_CMO_Chapter_10.pdf
6 'Fair Society Healthy Lives' (The Marmot Review) IHEhttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/284086/earlyintervention-next-steps2.pdf
7
PHE14-36 PHE approach to improving the publics mental health v00.08 (20141119).docx 19/11/2014 18:24
8
Freer M, Shiers D, Churchill D, Friel J (2010) Meeting the mental health needs of young people: a
GP’s perspective. In Goldie I (ed) Public Mental Health Today. A handbook (pp. 241-258). Brighton,
Pavilion Publishing/Mental Health Foundation.
10
ways of improving health professionals’ identification of suicide risk and of improving
collaborative working between primary and secondary healthcare services9.
1.3 Costs of poor mental health in children
The Centre for Mental Health estimates that in 2009/10 the economic and social costs of
mental illness at all ages in England were £105 billion. The costs fall mainly upon those who
experience mental ill health and their families but there is also a high cost for taxpayers and
business. Mental health problems carried a bigger cost to society than crime, and with falling
crime rates the difference is likely to increase10.
The Chief Medical Officer in her report: Our Children Deserve Better: Prevention Pays
(2012) estimated that among children aged 5-15 years in the UK the short term costs of
emotional, conduct and hyperkinetic disorders each year are £1.58 billion and £2.35 billion
annually in the long term.
9
Pearson,A.,Saini, P., DaCruz, D.,Miles,C.,While,D.,Swinson,N.,Williams,A.,Shaw,J.,Appleby,L and
Kapur,N (2009) Primary care contact prior to suicide in individuals with mental illness British Journal
of General Practice,
10 http://www.centreformentalhealth.org.uk/pdfs/economic_and_social_costs_2010.pdf
11
Section 2: Health needs assessment
Health needs assessment is a systematic method of identifying health and social care
needs. It is used to make recommendations as to how those needs can be met to improve
the health of the population using resources most effectively. . Within this context ‘need’ can
be defined as the ability to gain or benefit from health care or wider social and environmental
changes11.
2.1 The Aim
The aim of this needs assessment is to identify and quantify emotional wellbeing and mental
health needs of the children and young people living in Hampshire to inform the planning
and procurement of appropriate services and interventions.
2.2 Objectives







To estimate the current and future population of children with mental health issues
in Hampshire and understand their demographic profile.
To describe the health of children with mental health problems, including risk factors
and protective factors for developing poor mental health.
To review local mental health services and identify the extent to which current service
provision is effective in meeting the needs of children and their families.
To compare local service expenditure with appropriate comparators.
To identify evidence of interventions which work with respect to promoting, assessing
and treating emotional mental health in children.
To identify recommendations for future service provision.
To inform the production of the Joint Hampshire Strategy for Emotional Health and
Wellbeing (Children and Young People) commissioned by the Hampshire Children’s
Trust.
2.3 Method
This needs assessment uses formal public health models and triangulates needs/assets
identified through corporate, epidemiological and service user intelligence. It uses a variety
of local and national data sources including ChiMat, ONS and CAMHS Activity Data.
11
Wright J Williams, Wilkinson JR (1998). Health needs assessment. Development and importance
of health needs assessment BMJ. Apr 25, 1998; 316(7140): 1310–1313. PMCID: PMC1113037
12
2.4 Limitations of the needs assessment







There is limited data on the prevalence of mental health disorders in children e.
National prevalence data is dated, relying on a comprehensive survey that was
conducted in 2004, over 10 years ago. This is unlikely to accurately reflect current
national prevalence.
While this is the best evidence that we have it is far from ideal to inform service
planning.. Childhood and the way we live our lives has changed considerably in the
last ten years particularly with the dramatic broadening of the scope and increase in
exposure of children to media in all its forms.
There is no local prevalence data. Local estimates can only be derived by applying
this national prevalence data to our local population. This is unlikely to show an
accurate picture of current local prevalence.
The Hampshire What do I think? survey presents the views of local pupils but is not
necessarily representative of the whole school population as not all children take
part.
Programme budgeting data cannot be used to analyse changes in investment in
specific service areas between years because significant changes to the data
calculation methodology were introduced in 2010/11.
There is a mismatch between the programme budgeting year to which the
expenditure data relate and the clinical data.
2.5 Scope of the needs assessment
This needs assessment considers the risk and protective factors for mental health in children
and common mental health disorders. Autism is outside the scope of this needs assessment
as there is a separate needs assessment and strategy for children with autism.
2.6 Common Mental Health Disorders in children
Conduct disorders - characterised by repetitive and persistent patterns of antisocial,
aggressive or defiant behaviour that amounts to significant violations of age appropriate
social expectations. Conduct disorders, and associated antisocial behaviour, are the most
common mental and behavioural problems in children. They are the most common reason
for referrals to child and adolescent mental health services12.
Emotional disorders – a generalised term to encompass psychological disorders that affect
the emotions, for example anxiety and depression.
Anxiety - Anxiety problems affect a child’s ability to develop, learn and to maintain and
sustain friendships. Symptoms of anxiety include feeling fearful, breathlessness, being
tearful, having difficulty sleeping, irritability a feeling sick13.
12
NICE clinical guideline 158. guidance.nice.org.uk/cg158.
13
Depression – Feelings of lowness or sadness which dominate and interfere with daily life
can lead to illness. Depression also affects a child’s ability to develop, learn and to maintain
and sustain friendships; but does not impact on their environment. Depression affects 2% of
children under 12 years and 5% of teenagers13.
Attention Deficit Hyperactivity Disorder and Hyperkinetic disorders – behavioural
disorders which often becomes obvious in early childhood. The behaviours are due
to underlying problems of poor attention, hyperactivity and impulsivity13.
Eating disorders – The most common types are anorexia nervosa and bulimia nervosa.
Eating Disorders can emerge when worries about weight begin to dominate a person’s life,
where the individual persistently worries about being overweight and eats very little. In the
case of bulimia eating small amounts is combined with binging, vomiting or the taking of
laxatives to control weight. Both disorders are more common in girls14.
Dual diagnosis (mental health and substance misuse) – Substance misuse can result in
physical or emotional harm and can lead to mental health problems13.
Sexualized behaviour – Harmful sexual behaviour involves one or more children engaging
in sexual discussions or acts that are inappropriate for their age or stage of development.
These can range from using sexually explicit words and phrases to full penetrative sex with
other children or adults15.
Self-Harm - Self-harm describes a wide range of things that people do to themselves in a
deliberate and usually hidden way. In the vast majority of cases self-harm remains a
secretive behaviour that can go on for a long time without being discovered. Common
methods of harm include: cutting, burning, scalding, hitting or scratching and swallowing
toxic substances or objects. Self- harm is often used as a coping mechanism, a way of
inflicting punishment on oneself, self-validation or a way to influence others14.
Obsessive-compulsive disorder (OCD) – This is the name given to a condition in which a
person has obsessions and/or compulsions, but usually both. An obsession is a thought,
image or impulse that keeps coming into a person’s mind and is difficult to get rid of. A
compulsion is a feeling that a person has that compels them to repeat physical actions or
mental acts, usually in response to an obsessive thought. For example, if a person is
worried about dirt they might clean something repeatedly16.
2.7 National Context
13
http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/adhdhyperkineticdisorder.a
spx
14
Department of Health (2014) Mental health & behaviour in schools
Rich,P (2011) Understanding, assessing and rehabilitating juvenile sexual offenders. 2nd ed. New
Jersey: Wiley
16 NICE clinical guidelines 31 (2005) http://www.nice.org.uk/nicemedia/pdf/cg031publicinfo.pdf
15
14
There is increasing national recognition of the importance of mental health in children and a
significant body of national policy, reviews and guidance.
These include:
Every Child Matters (2003) - Outlines how to ensure children are healthy, safe, enjoying
and achieving, making a positive contribution and have economic wellbeing.
National CAMHS Review (2008) - Makes recommendations for improved access to
specialist mental health services for children and young people, particularly for vulnerable
groups and also advocates better advice and support for parents.
Fair Society, Healthy Lives; The Marmot Review (2010) - Acknowledges the links
between health inequalities and mental wellbeing and physical health and the importance of
addressing these, particularly for the early years of children’s development.
Healthy People, Healthy Lives: Our Strategy for Public Health in England (2010) –
Emphasises health and wellbeing throughout life. States that central government will
support interventions that promote mental health resilience and effective early treatment,
including talking therapies, for children and adolescents with mental health problems, thus
reducing the likelihood of problems extending into adulthood.
Confident Communities, Brighter Futures: A framework for developing Well-being
(2010) sets out the argument and evidence base for prioritising well-being, and provides a systematic
approach to improving mental well-being with selected evidence-based approaches and interventions
that have been shown to be effective across the life course, and across key public health domains.
Refers to the benefits of green space to mental health, underlining that “access to nature can
significantly contribute to our mental capital and wellbeing.”
The Munro Review of Child Protection: Final Report, A child-centred system (2011) –
Recommends that the Government places a duty on local authorities and their statutory
partners to secure the sufficient provision of local early help services for children, young and
people and families. This should lead to the identification of the early help that is needed by
a particular child and their family and to the provision of an offer of help where their needs do
not meet the criteria for receiving children’s social care services. The aim is to support
families to break out of a cycle of poor outcomes, protect children from harm and maximize
their opportunities to experience supportive relationships, to enable them to achieve during
their time at school. Emphasises the importance of working together to ensure that this has
maximum impact within educational settings, families and communities.
No Health Without Mental Health; a cross-government mental health outcomes
strategy for people of all ages (2011) – This strategy sets out the governments ambition to
mainstream mental health and establish parity of esteem between services for people of all
ages with mental and physical health problems and to improve outcomes for everyone with
mental health problems through high quality services that are equally accessible to all.
Early Interventions Next Steps (2011) - describes how intervention in children's earliest
years can eliminate or reduce costly and damaging social problems.
15
Children and Young People’s Health Outcomes Framework report (2012) – highlights
that those who work with children outside the healthcare system, such as teachers and
youth workers, have an important contribution to make to improving health outcomes, but
that their training in mental health is too often minimal or non-existent. The report also
recognises the impact that poor maternal mental health has on both the physical and mental
health of the child.The forum makes a number of recommendations for stakeholders
including the adoption of a life course approach by stakeholders and collaborative working
between local authorities, CCG’s and child and maternity services.
CMO’s Annual Report 2012: Our Children Deserve Better: Prevention Pays (2013) recommends that a regular survey on mental health among children and young people,
including comparisons with other developed countries, should be commissioned and
published annually, to improve the evidence base for meeting young people’s mental health
needs.
NICE local government public health briefing: Social and emotional wellbeing for
children and young people (2013) - provides those involved in commissioning and
delivering services for children and young people with the information to adopt an approach
that increases resilience and wellbeing.
How healthy behaviour supports children’s wellbeing (2013) – Public Health England
briefing looking at health behaviours, their positive and negative effects and the implications
for practice and parents.
The Mandate: a mandate from the government to the NHS Commissioning Board:
April 2013 to March 2015 -emphasises the parity between mental health and physical
health. This means everyone who needs mental health services having timely access to the
best available treatment.
The Health Visitor Implementation Plan 2011-15 – ‘A Call to Action’ published in
February 2011, to support implementation of the Healthy Child Programme. The plan sets
out how this extra capacity will contribute to improved public health outcomes and better
personalised care for all families with children under 5 by expanding and strengthening
health visiting services through the provision of an additional 4,200 health visitors by April
2015.
Closing the Gap: Priorities for essential change in mental health (2014) – this DH report
sets out how the coalition government is seeking to close the gap between the long and
short term action plans for mental health. Maternal mental health, the challenges of transition
and supporting schools to deliver school based mental & emotional health programmes are
highlighted. .
Mental Health Behaviour in schools, Departmental advice for school staff (2014) Prepared by the Department of Education, this document provides advice and practical tools
to help schools promote mental health and address problems early and build pupil resilience.
2.8 Local Context
16
Hampshire Joint Strategic Needs Assessment (JSNA) Children and Young People
Chapter - Joint Strategic Needs Assessment (JSNA) pulls together a wide range of
information about the current and future health and wellbeing of the local population along
with the associated inequalities and their health needs of the people of Hampshire. The
JSNA highlights the key issues for the county and has informed the four goals of Hampshire
Health and Wellbeing Strategy17.
Hampshire Health and Wellbeing Strategy - Hampshire’s Joint Health and Wellbeing
Strategy has been developed by Hampshire’s Health and Wellbeing Board to improve health
across the county. Used by all organisations that make up the Board the strategy guides
working together, the services commissioned and provided and how they are delivered. It
has four key themes:
 Starting well - So every child can thrive.
 Living well - Empowering people to live healthier lives.
 Ageing well - Supporting people to remain independent, have choice, control and
timely access to high quality services.
 Healthier Communities - Helping communities to be strong and support those who
may need extra help. Clearly a strategy.
Hampshire Adult Mental Health Needs Assessment 2013 - The aim of the mental health
needs assessment was to provide commissioners and other stakeholders with information to
help plan, negotiate and change services if necessary. The parameters were set to
determine the prevalence of common mental health disorders affecting 18-64 year olds
within Hampshire, identify the existing commissioned services and to set out the evidence
for effective treatment.
Hampshire Children’s Trust - Children and Young People’s Strategy 2012-2015 - The
Children and Young People's Plan (CYPP) is the overarching strategy for Hampshire's
Children's Trust, setting the direction and priorities for improving outcomes for children,
young people and families. .
17
www.hants.gov.uk/jsna.
17
Section 3: Level of need in the population
3.1 The scale of the issue
In terms of geography Hampshire County Council is the eighth largest of the 34 shire
counties in England and has the the third largest population. Hampshire has 11 local
authorities; Winchester, Test Valley, Rushmoor, Havant, Fareham, East Hampshire, New
Forest, Hart, Basingstoke & Deane, Gosport and Eastleigh. Hampshire has a significant
number of Ministry of Defence locations belonging to all three forces – British Army, Royal
Navy and Royal Air Force8.
There are approximately 396,910 children aged 0-25 years in Hampshire, which is around
30% of the total population. Hampshire’s population is increasing and currently is estimated
to be 1,322,118. Birth projections (2010 to 2033) for Hampshire show an on-going increase
in the birth rate following the general trend for England and the South East, possibly
plateauing by 20168.
Although the total number of children will continue to increase, the proportion of children in
the population is forecast to decline marginally, with those under 18 accounting for 21% of
the total population by 2016 compared to 23% currently8.
Bestestimates suggest that one in ten children aged between 5 and 16 years has a clinically
diagnosable mental health problem.18 In Hampshire this equates to 17, 845 five to sixteen
year olds. However, the true scale of mental health problems in young people is unknown.
There are no up to date national or local surveys of mental health issues in children and the
subtle ways that mental health problems present and the differences in definitions and
thresholds for defining emotional or mental health problems all lead to variations in reported
prevalence19 20.
3.1.2 Mental Health Awareness
Adults in general have been shown to have low awareness of the importance of children’s
mental health. A survey of 2,105 adults in the UK revealed that 38% of them did not know
which signs and symptoms to look out for to assess children's mental health, and the
majority of those who did know were concerned to raise the issue in case they were
mistaken. Around 40% of men surveyed believed that many children diagnosed with a
mental illness were just showing bad behaviour. These attitudes are likely to exist among
Hampshire adults21.
3.2 Factors influencing and influenced by mental health
18
CMO report 2012
Health Foundation (1999) Bright Futures: Promoting children and young people’s mental
health.
20 NCH (2007) Literature Review The Emotional Harm & Wellbeing of Children
21 The Lancet, Mental health and wellbeing in children and adolescents Volume 383, Issue 9924,
Page 1183, 5 April 2014
19Mental
18
The influences on a child’s mental health are many and complex. The risk of developing a
mental health problem is strongly increased by social disadvantage and childhood adversity.
The following section reviews the key factors that influence mental health in children and
where possible estimates their prevalence in Hampshire’s children. It is acknowledged that
not every factor that impacts on mental health is considered in this needs assessment as the
list is so extensive.
The effect of risk factors is cumulative. A child with a single risk factor present in their life is
thought to have a 1 - 2% chance of developing a mental health problem, whereas for a child
with three risk factors the chance is 8%.With four or more risk factors the chance is 20%22.
However, the presence of risk factors can be mitigated by protective factors that build
resilience. Early intervention to halt the accumulation of risk is effective and vital. 23 24.
Children who are resilient – they can ‘bounce back’ and recover quickly from difficulties - are
able to adapt and thrive even if they experience significant risks or trauma in their lives and
they are more likely to have good mental and physical health.
Some groups of children are at particularly increased risk of developing mental health
problems, for example looked after children, children with learning disabilities, lesbian, gay,
bisexual or transgender (LGBT) young people, young offenders, young carers and refugees
or asylum seekers, children from gypsy and traveller communities and children from service
families.
The main risk and protective factors for mental health in children are set out in table 1 below.
Table 1: Risk and Protective factors for children and young people’s mental health
Source: Department of Health 2014 Mental Health & Behaviour in Schools.
In the child
•
•
•
•
•
•
•
•
Risk factors
Genetic influences
Low IQ and learning
disabilities
Specific development
delay or neuro-diversity
Communication difficulties
Difficult temperament
Physical illness
Academic failure
Low self-esteem
Protective factors
• Secure attachment experience
• Outgoing temperament as an
infant
• Good communication skills,
sociability
• Being a planner and having a
belief in control
• Humour
• Problem solving skills and a
positive attitude
• Experiences of success and
22
https://www.actionforchildren.org.uk/media/145524/emotional_harm_and_wellbeing_of_children.pdf
23 Rutter, M., Giller, H. and Hagell, A. (1998) Antisocial behaviour by young
people Cambridge: Cambridge University Press.
24 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/284086/earlyintervention-next-steps2.pdf
19
•
•
•
In the family
•
•
•
•
•
•
•
•
•
In school
•
•
•
•
•
•
Community
•
•
•
Overt parental conflict
including Domestic
Violence
Family breakdown
(including where children
are taken into care or
adopted)
Inconsistent or unclear
discipline
Hostile or rejecting
relationships
Failure to adapt to a
child’s changing needs
Physical, sexual or
emotional abuse
Parental psychiatric illness
Parental criminality,
alcoholism or personality
disorder
Death and loss – including
loss of friendship
•
Bullying
Discrimination
Breakdown in or lack of
positive friendships
Deviant peer influences
Peer pressure
Poor pupil to teacher
relationships
•
Socio-economic
disadvantage
Homelessness
Disaster, accidents, war or
other overwhelming
events
•
•
•
•
•
•
•
•
•
•
•
•
•
achievement
Faith or spirituality
Capacity to reflect
Being female (in younger
children
At least one good parent-child
relationship (or one supportive
adult)
Affection
Clear, consistent discipline
Support for education
Supportive long term relationship
or the absence of severe discord
Clear policies on behaviour and
bullying
‘Open-door’ policy for children to
raise problems
A whole-school approach to
promoting good mental health
Positive classroom management
A sense of belonging
Positive peer influences
Wider supportive network
Good housing
High standard of living
High morale school with positive
policies for behaviour, attitudes
and anti-bullying
20
•
•
Discrimination
Other significant life
events
•
•
Opportunities for valued social
roles
Range of sport/leisure activities
3.2.1 Deprivation & Inequalities
Socio economic disadvantage is a major risk factor for poor mental health in children.
Poverty has a profound impact on the growing and developing child, with lifelong
implications. A childhood spent in poverty reduces access to positive experiences and
opportunities and this is exacerbated by the effects of a suboptimal living environment and
often some form of malnutrition. The effects can be life-long, hard to escape and affect every
aspect of the child’s future, from expectation to achievement and associated health
outcomes25.
The social gradient in mental health problems is particularly pronounced in childhood. There
is a three-fold variation in prevalence between the highest and lowest socio-economic
groups.
Table 2: Deprivation in Hampshire
Source: Hampshire Health Profiles 2014
The table above shows Hampshire to be significantly better than England and the region in
terms of county wide deprivation and children living in poverty. However, there are still just
under 50,000 children experiencing socio economic deprivation.
The Department for Communities and Local Government has created an Index of Multiple
Deprivation (IMD) which identifies the most deprived areas across the country by allocating a
score. This score is built from different domains namely income; employment; health;
education; housing; crime; and environment.
The map in figure 1 shows that Hampshire as a whole has low levels of deprivation and can
be described as a prosperous area. Most areas are above the middle quintile in terms of the
index of multiple deprivation compared to England. Large swathes of the central rural belt
and north Hampshire are amongst the least deprived areas in England. Deprivation in
Hampshire is most concentrated in a small number of neighbourhoods including Leigh Park
and Wecock in Havant and Rowner and Town in Gosport. Alongside these populations are
pockets of very localised deprivation affecting people in varying ways across the county; for
example in Aldershot, Andover, Basingstoke, and Blackfield and Holbury in New
25
'Fair Society Healthy Lives' (The Marmot Review) - IHE
21
Forest.There are pockets of deprivation (shown in red on the map) in the Efford Way area of
Pennington in the New Forest, in Eastleigh, in Romsey and in locations within Basingstoke
(e.g. Popley) (Director of Public Health report 2013-2014).
There is a strong link between children’s mental ill health and family income with a higher
prevalence amongst children from families with low incomes. Children living in poor
households are three times as likely to have mental health problems as children in well-off
households26 . The most recent data from 2011 shows that there were 29,000 children and
young people aged 0-15 living in poverty in Hampshire: 11.8% compared to 21.7% across
England. Havant and Gosport have the highest proportion of children living in poverty
(Director of Public Health report 2013-2014).
Figure 1: 2010 Index of Multiple Deprivation (quintile distribution relative to England)
Although Hampshire compares favourably to England this still means that almost 1 in 12 ? 8
if 12% of our children are growing up in poverty and these County wide data mask the reality
of poverty in some areas. For example 1 in 5 children in Havant and 1 in 5-6 children in
Gosport are living in poverty (JSNA, 2013).
The 2012 CMO report highlights the associations between the prevalence of mental health
disorders in children and young people and a range of measures of social and family
structure found in the 2004 national survey of mental health in children 26.
26http://www.mentalhealth.org.uk/content/assets/PDF/publications/fundamental_facts_2007.pdf?view=
Standard
22
Table 3: Associations between childhood mental illness and a range of measures of
social disadvantage (Green et al 2005).
3.2.2 Ethnicity
There is limited research into mental health problems in children from Black and Ethnic
Minority groups. The most complete study by Green and colleagues has a number of
limitations; firstly it is over ten years old, secondly it uses small sample sizes and had
difficulty in ascertaining information from non-English speaking parents. This means that
although the study found differences in the rates of mental health problems across different
ethnic groups the results are difficult to interpret27. Rates of mental disorder were highest in
those categorised as white (10%) with rates of 9% in the black group, 8% in
Pakistani/Bangladeshi children and 3% in children categorised as Indian.
The 2011 Census shows that Hampshire has a predominantly white population (Census
2011) with 95.0% of the population estimated to be of a white ethnic group. Rushmoor has
the highest proportion of its population from non – white ethnic groups (15.3% - an increase
from 4.4% in 2001). This is mostly due to a growing Nepalese population. The proportion of
black African Caribbean people in Hampshire is 0.7% (8,298) of the population compared to
3.4% in England.
Variation across the county’s other districts is relatively small, from a non-white population of
7.1% in Basingstoke and Deane (up from 3.4% in 2001); to a low of 2.9% (up from 1.5% in
2001) in Havant28.
The 2011 Census also reported that 9.6% of Hampshire children (aged 0-19 years) are from
a non-White British ethnic group, 3.2% are categorised as being of Mixed/multiple ethnicity,
3.1% as Asian and 2.1% White Other.
27
Green, H., McGinnity, A., Meltzer, H., Ford, T. and Goodman, R. (2004) Mental health of children
and young people in Great Britain, 2004. Office for National Statistics. London, HMSO.
28 JSNA 2013
23
With an increasingly diverse population it is important to better understand the mental health
needs across different ethnic groups through research into the prevalence of mental health
conditions, access and use of services and whether some communities are more resilient 29.
Locally we do not have a good understanding of the mental health needs of the children in
the Nepali community.
3.2.3 Maternal health in pregnancy
Maternal smoking, use of alcohol and poor diet are associated with lower birth weight and
poor mental health in children. Anxiety, depression and maternal stress during pregnancy
have been linked to impaired emotional, cognitive and language development in infants.
3.2.4 Parental mental Health
Good maternal and paternal mental health is key to fostering good mental health in children.
Parental mental illness at any stage of childhood is known to be associated with a higher
rate of mental health problems in children30 31. There are approximately 50,000 young
people living with a parent with a severe mental health disorder in the UK. This effect has
been attributed to one or more factors – genetic predisposition, the impact of parenting style
and ability, and learnt behaviour32. Further work needs to be undertaken to quantify this risk
locally.
It is estimated that around 10-15% of new mothers suffer some perinatal mental health
difficulties33 with 22% of mothers affected one year after the birth34. This can lead to
cognitive and emotional disturbance in the baby alongside the effects on the mother.
Children of depressed mothers are more likely to access Child and Adolescent Mental
Health Services (CAMHS) and suffer mental health problems as adolescents and adults.
Maternal depression is associated with increased rates of birth complications, stillbirths and
low birth-weight babies. It is also associated with a five-fold increased risk of later mental
health problems for the child and can affect the child’s cognitive and emotional development.
Social isolation is a known risk factor for postnatal depression and reducing this could have
a range of clinical and psycho-social benefits.
29
CMO report 2012
Manning C, Gregoire A: Effects of parental parental illness on children. Psychiatry 2009,8: 7-9
31 Royal College of Psychiatrists: Parental mental illness : The problems of children .Information for
parents, carers and anyone who works with young people. London Royal College of
Psychiatrists,2012.
32 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.
33 NICE (2006) Routine postnatal care of women and their babies.
34 Children & Young Peoples Health Outcomes Forum. Report of the Children & Young People’s
Health Outcomes Forum Mental Health sub Group
30
24
It is therefore important that at each postnatal contact women have their emotional mental
wellbeing assessed by healthcare professionals and that professionals are aware of the
signs and symptoms of maternal mental health problems35.
There are about 15,300 births each year in Hampshire and this equates to between 1,530
and 3,000 women each year with perinatal mental health difficulties and as many as 3,360
affected a year after birth.
It is important that we continue to commission an effective ? postnatal service delivered by
midwives and health visitors which can identify and support mothers with post natal
depression as early as possible and that relevant health professionals are aware of the signs
and symptoms of maternal mental health problems and how to manage them 36.
3.2.5 Parenting
Good parenting is a protective factor and helps children to develop good social and
emotional skills and resilience. It is also the single greatest influence on children’s health
outcomes including accident rates, teenage pregnancy, substance misuse, truancy, school
exclusion and underachievement, child abuse, employability, juvenile crime, as well as
mental illness.
In the pre-school years children develop social-emotional skills, such as self-awareness,
self–regulation and empathy as they learn to express their emotions and interact with others.
These skills continue to develop throughout the primary school years and a positive
relationship with at least one parent or primary carer is important in the development of
resilience and well-being.
Given the significance of parents or primary carers in a child’s life, supporting and enabling
parents to carry out their role is an important area for intervention to promote good mental
health in children37.
3.2.6 Adverse childhood events
Findings from the ACE study in America, which includes 17,000 volunteers, has shown that
exposure to harsh or traumatic events in childhood (known as Adverse Childhood Events)
such as child abuse or neglect can lead to health, social and economic problems in
adulthood. The more categories of trauma experienced the greater the likelihood of a wide
range of adverse short- and long-term outcomes including alcohol abuse, depression,
intimate partner violence, chronic obstructive pulmonary disease (COPD) illicit drug use,
unintended pregnancy and suicide attempts38.
35
Postnatal care | List-of-quality-statements | Guidance and guidelines | NICE
37
NCH (2007) Literature Review The Emotional Harm & Wellbeing of Children
http://acestudy.org/home
38
25
The WHO reports that a significant portion of the global burden of disease is caused by child
abuse. Early neglect and trauma are associated with problems in later life including anxiety,
impulsivity and hyperactivity, as well as poor problem solving and empathy. Good parenting
helps children to develop good social and emotional skill and has been shown ? to be
protective .
In addition to the physical injuries, the maltreatment of children is associated with a number
of other consequences that are associated with poor mental health in childhood and
adulthood including: cognitive impairment and developmental delays; delinquent, violent
and other risk-taking behaviours; eating and sleep disorders; poor school performance; poor
relationships; reproductive health problems; post-traumatic stress disorder; depression and
anxiety and suicidal behaviour and self-harm39.
3.2.7 Natural environment
There is evidence that access to green open spaces has a positive effect on mental
wellbeing and cognitive function in children40 41. Being outdoors is the most powerful
correlate of physical activity, particularly in pre-school children and natural environments in
urban settings can increase the likelihood of physical activity and play.
Children who play in green spaces also develop better motor skills than those who don’t.
Encouraging more children with Attention Deficit Hyperactivity Disorder to take up active
play and sport in safe, green spaces could be a natural and effective alternative to
medication, while simultaneously improving overall health and wellbeing45.
3.2.8 Physical activity
Physical activity is associated with improved concentration levels, more positive social
behaviour, such as being kind to class mates and attempting to resolve disputes, and with
children feeling liked by peers and that they have enough friends. Physical activity is also
associated with lower levels of anxiety and depression, with children being happier with their
appearance and reporting higher levels of self-esteem, happiness and satisfaction with their
lives 42.
There are limited data at district area level to estimate how many children and young people
are “active”. The 2012 Health Survey for England (HSE)i gathered data on physical activity
levels of children aged 2 to 15 outside of school time and is the most recent source of
information on physical activity among children. A higher proportion of boys than girls aged
5-15 (21% and 16% respectively) were classified as meeting current guidelines for children
and young people of at least one hour of moderately intensive physical activity per day.
Among both sexes, the proportion meeting guidelines was lower in older children. The
proportion of boys meeting guidelines decreased from 24% in those aged 5-7 to 14% aged
13-15. Among girls the decrease was from 23% to 8% respectively. Extrapolating national
39http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/childabusefacts.p
df
40
Burls A. Journal of Public Health vol 6 issue 3
http://www.fph.org.uk/uploads/r_great_outdoors.pdf
42 How Healthy behaviour supports children's wellbeing - Public Health England
41
26
proportions from the HSE (2012) would mean that no more than 16,460 boys and 11,800
girls in Hampshire aged between 5-15 years do the recommended levels of physical
activity43.
3.2.9 Screen time
Increased screen time and exposure to media (such as bedroom TVs) is consistently
associated with reduced feelings of social acceptance, increased feelings of loneliness,
conduct problems and aggression and lower levels of self reported happiness. Long-term
research suggests TV viewing at younger ages (one to three years old) predicts later
attention and hyperactivity difficulties (among seven-year olds) taking into account baseline
levels of difficulty.
Playing computer games has been found to be significantly linked to poor emotional
wellbeing46.
3.2.10 Educational attainment
Educational attainment is one of the most important determinants of future health outcomes
and is a protective factor for mental health in children and adults.
Conversely having a mental health disorder as a child can have a considerable negative
impact on educational achievement, especially for those with conduct and emotional
disorders. Some of this difference may be accounted for by the co-existence of learning
disabilities and the high correlation between having a mental disorder and missing school
which occurs in approximately 25-30% of depressed and anxious children and 20% of
children with conduct disorders (Green et al, 2005).
Achieving five A* to C GCSEs is used as a measure of educational attainment in 16 year
olds. In Hampshire GCSE achievement was significantly worse than the England average in
2010/11 and 2012/13. Although educational attainment in Hampshire is improving it is doing
so at a slower rate compared to England as a whole and is lower than would be expected for
our population. Only 60% of young people gain five or more GCSEs at A* to C grade
including Maths and English44. There is variation between the districts with lower levels of
attainment in the more socio economically deprived districts. The lowest levels are in
Rushmoor (42.5%) Havant (49.5%) and Gosport (50.5%).
There is an educational attainment gap between vulnerable groups of children such as
looked after children, those eligible for free school meals (a proxy measure for children living
in low income families) children with special educational needs and young carers and the
general population.
This gap is particularly marked for looked after children in Hampshire where only 9% achieve
5 GCSE A* - C grades compared to just under 16% in England as a whole. This compounds
the already increased risk to the mental health of this group of very vulnerable children. For
43
44
Director of Public Health Annual Report 2103-14
CHI- MAT Health profile - Hampshire 2014
27
Hampshire children eligible for free school meals 26% achieved five A*-C grade GCSEs (or
equivalent) including English and maths in 2011/12. The attainment gap for children with
special educational needs in Hampshire was 50%.
There is variation in educational attainment between ethnic minority groups45. In Hampshire
attainment for children from gypsy, Roma and traveller groups is particularly poor with less
than 10% achieving 5 A*-C GCSEs.
3.2.11 Post 16 years education, employment and training
Being in education, employment and training between the ages of 16-18 increases a young
person’s resilience and is essential to their future employability and wellbeing46. Those who
are not engaged with learning or with their peers and teachers are more likely to use drugs
and engage in socially disruptive behaviours, report anxiety/depressive symptoms, have
poor adult relationships and fail to complete secondary school47.
In the UK rates of participation in education and training have historically been low compared
to other countries in the OECD (Organisation for Economic Cooperation and
Development)40.
In Hampshire about 86% of 17 year olds are in education or work based learning. The
proportion of 16-18 year olds who are not in education, training or employment was 4.8 % in
2012, below the national average (5.8 %). However, his proportion is much higher for care
leavers over half of whom were not in employment, education or training in 2011/12.
3.2.12 Bullying
Bullying is defined as, “Behaviour by an individual or group, usually repeated over time, that
intentionally hurts another individual or group either physically or emotionally” Department of
Children, Schools and Families.
Bullying can have a significant impact and long term effects on children’s lives by impairing
their resilience and mental wellbeing. Whereas a positive and supportive whole school
environment, without bullying or conflict is known to be beneficial and contributes to good
wellbeing.
The Hampshire What do I Think? pupil attitude survey provides an indication of the level of
bullying in Hampshire schools. There are peaks in year 2 and again in year 7 when children
transition from primary to secondary school.
The 2013 survey found that in those who responded about a quarter of year 9’s had
experienced bullying and 23% of year 7’s.
45
A detailed assessment is presented in the 2013 JSNA
Chi Mat 2012 Accessed May 2014
47 Bond L et al 2007. Social and School Connectedness in Early Secondary School as Predictors of
Late Teenage Substance Use, Mental Health, and Academic Outcomes. Journal of Adolescent Health
46
28
The most common form of bullying was verbal abuse. Bullying was most often related to
appearance. As pupils got older, cyber-bullying and subtle indirect forms of bullying were
more frequently experienced.
Figure 2 : Percentages of children bullied at school in years 2, 6, 7 and 9 2008-2012
Source: HCC What do I think? Pupil Attitude Survey
3.2.13 Housing and homelessness
Good-quality, affordable, safe housing is essential to our wellbeing. Poor housing or
homelessness is associated with an increased risk of depression and anxiety, as well as
increased risks of physical illness and can make it more difficult to manage an episode of
mental distress.
Children living in rented accommodation, either social or private sector, are more likely to
suffer from a mental health problem than those living in owner-occupier households48 . In
Hampshire the majority of households are privately owned either outright or with a mortgage.
10.6% of households live in private rented accommodation which is lower than the national
(15.4%) and regional (14.7%) rates. Gosport and Rushmoor have the highest proportion of
households living in private rented accommodation at 12.7% and the lowest is in Fareham
(8.4%) .
The Mental Health Foundation and Barnardos49 found that rates of serious mental illness are
eight times higher amongst young people living in bed and breakfast and hostel
accommodation and eleven times higher for those who sleep rough, compared to the
general population. Homeless adolescents and young rough sleepers are more likely to
present with depression and attempted suicide, alcohol and drug misuse, and are vulnerable
to sexually transmitted diseases, including acquired immune deficiency syndrome (AIDS)50.
48
Mental Health Foundation 2007 Fundamental Facts . The latest facts and figures on mental health
Mental Health Foundation 2002 The Mental Health Needs of Homeless Young People; Bright
Futures, Working with Vulnerable young people.
50 CHI-MAT CAMHS needs assessment – accessed 15th August 2014
49
29
One study estimated that the number of young people aged 16 to 24 sleeping rough in
England in 2008/9 was 3,200, giving a rate of 51.3 per 100,000. A study of 16 to 25 year
olds who were sleeping rough in London found that 67% had mental health problems47
Applying these rates to the Hampshire population suggests that there may be 50 young
people with mental health problems who are sleeping rough in Hampshire. .
A survey of 142 homeless people in Hampshire found their described needs included mental
ill health and substance misuse51.
3.2.14 Fuel poverty
Cold homes place young people at risk of developing mental health problems. Although the
proportion of homes in Hampshire affected by fuel poverty is below the national average the
impacts on the mental health of those children living in cold homes, particularly in
adolescence, can be significant. There are a range of associated emotional and mental
health and wellbeing issues, including 4 times the risk of multiple mental health problems
compared to those children who have always lived in a warm home. This has been
associated with the influence of fuel poverty on risk taking, for example early alcohol and
tobacco use and truancy among adolescents as a consequence of seeking privacy outside
the home.52
Cold homes may also adversely impact on educational attainment
in the private rented sector.
53
. Fuel poverty is highest
3.2.15 Crime
Crime in a neighbourhood may lead to fear, stress, feelings of being unsafe, and poor
mental health. In a study undertaken in Greenwich in London, Guite et al34 conducted a
postal survey based on a theoretical model of domains that could link the physical and urban
environment with mental well-being. Mental health was measured using the SF36 subscales
for mental health (MH) and vitality (V). It was found that better mental well-being was
associated with a number of factors including feeling safet, a lack of overcrowding in the
home, reduced noise, and access to green spaces and community facilities. Participants
who felt unsafe to go out in the day were more likely to lower mental health scores on the
measures used.54. Violent crime in Hampshire (8.8%) is however lower than the England
average of 10.6%55.
3.2.16 Domestic abuse
The effects on children of violence in the home can be very damaging and contribute to the
development of antisocial behaviour, low self-esteem, an increased risk of suicide and
51
JSNA 2013
Hampshire Excess Winter Deaths and Fuel poverty strategy 2014-2018
53 Chief Medical Officer Annual Report (2012) Our Children Deserve Better, Prevention Pays
54Guite HF, Clark C, Ackrill G. (2006) .The impact of the physical and urban environment on mental
well-being Public Health Dec;120(12):1117-26. Epub 2006 Nov 9
55 PHE (2014) Hampshire Health Profiles
52
30
alcohol abuse56 57. These effects are likely to persist throughout adult life. Domestic abuse
is under reported and almost a third starts or escalates during pregnancy.
Women who have been abused in childhood are four times more likely to develop major
depression in adulthood and those who experience childhood sexual abuse are almost three
and a half times as likely to be treated for psychiatric disorders in adulthood as the general
population. They are five times as likely to have a diagnosis of personality disorder58.
There is currently no routine data collection in Hampshire regarding the number of children
who are affected by domestic abuse.
NICE recommends that professionals are trained to identify and where necessary refer
children affected by domestic abuse so that their emotional and psychological needs can be
addressed as well as their physical ones. Health and social care professionals should be
trained to ask about domestic violence and abuse in a way that makes it easier for people to
disclose it. This includes midwives during pregnancy and health visitors59.
3.2.17 Sexuality
Mental ill health is more prevalent among lesbian bisexual, gay and transgender people
(LBGT) people.60 These associations being particularly evident for measures of suicidal
behaviour and multiple disorder 61.
More than half (65 per cent) of lesbian, gay and bisexual young people experience
homophobic bullying at school: 66% of boys and 46% of girls. This may be because boys
are more likely to report their experience. Gay and lesbian pupils are more likely to be bullied
than their bisexual counterparts. While there are no significant differences in rates of bullying
due to ethnicity among gay and bisexual boys, homophobic bullying of black and minority
ethnic lesbians and bisexual girls is lower, but still experienced by a third at 33 per cent52 .
Stonewall reports that this bullying leads these young people to skip school and is
associated with poor self-esteem and lower educational attainment and aspirations. Where
homophobic bullying is prevented and tackled effectively, lesbian, gay and bisexual young
people are more than twice as likely to feel part of their school community, to enjoy going to
school, feel respected and to be themselves62.
Dube SR et al ‘Childhood abuse, household dysfunction and the irsk of attempted suicide
throughout the lifespan’ JAMA 2001;vol 286, No 24 3089-3096
57Dixon M, Reed H, Rogers B, Stone L ‘ Crime share: The unequal impact of crime’ Institute for Public
Policy 2006.
58 Mental Health Foundation – The fundamental Facts 2007
59 Domestic violence and abuse: how health services, social care and the organisations they work
with can respond effectively | 1-Recommendations | Guidance and guidelines | NICE
60 DoH and PHE (2014) The LBGT Public Health Outcomes Framework Companion Document.
61 Ferguson D, Horwood LJ, Beautrais Al. Is sexual orientation related to mental health problems and
suicidality in young people? Arch Gen Psychiatry. 1999 Oct;56(10):876-80
62 The School Report 2007 :The experiences of young gay people in Britain's schools (2007)
Stonewall
56
31
Half of lesbians and bisexual girls have symptoms consistent with depression compared to
three in ten (29%) gay and bisexual boys. Gay pupils who don’t feel they have an adult to
talk to are much more likely to have symptoms of depression than gay pupils who do have
an adult to talk to (54% compared to 37%). Similarly, just under half (46%) of those who
experience bullying report having low self-esteem compared to 35% in gay young people
who aren’t bullied63.
3.2.18 Substance misuse64
Young people with mental illness are more likely to misuse substances. There is no routine
comprehensive data collection of the number of children in Hampshire who are drinking
alcohol or misusing drugs. The 2013 What do I Think ? pupil attitude survey65 of children in
year 9 found that Cannabis was the most common drug taken in this age group. Cannabis
use has been shown to increase the risk of developing schizophrenia.
Hospital admissions for substance misuse in 15-24 year olds give some indication of local
need.
Figure 3: Hospital admissions for substance misuse in young people aged 15-24
years
Admission rates are highest in Havant and Gosport and Rushmoor which we may expect as
these are areas of relatively high deprivation where substance misuse is likely to be higher.
3.2.19 Alcohol
Problem or harmful drinking has implications for physical and mental health. Alcohol
increases the likelihood of risky sexual behaviour which can include unwanted and
unprotected sexual activity. Alcohol can have a serious impact on brain development. In
particular, the areas responsible for planning, judging, and decision-making can be affected
63
Centre for Family Research 2012
See the Substance misuse chapter in the 2013 JSNA for more information
65 A annual Countywide school based survey
64
32
by alcohol with implications for emotional wellbeing66. There is a considerable overlap
between alcohol and mental illness67. A third of suicides in young people are linked to
alcohol intoxication68.
Alcohol specific admissions in under 18s provide some indication of need, although of
course most children who are drinking alcohol will not be admitted to hospital and so it is a
crude measure. In line with the England rate there has been a 9% year on year growth in the
rate of alcohol related admissions in under 18s in Hampshire since 2002/369.
Figure 4: Alcohol specific admissions in under 18s in Hampshire
Rates vary between local authorities with the highest rates in New Forest and Rushmoor
although these are not significantly different from the rates in Basingstoke and Deane,
Eastleigh, Gosport and Waverley.
3.3 Vulnerable young people
Some groups of children are more likely than others to experience mental health problems
as a result of the circumstances that make them vulnerable. These include:
 Looked after children
 Children with special educational needs
 Young carers
 Children with Autism spectrum disorder
 Teenage parents
 Asylum seekers and refugees
 Homeless children and those living in temporary accommodation
 Children with learning disabilities
66
http://www.drinkaware.co.uk/check-the-facts/alcohol-and-your-child/teenagers-drugs-alcohol
North East Public Health Observatory 2008
68 Cornah D. Cheers? Understadning the relationship between alcohol and mental health.
http://www.mentalhealth.org.uk/content/assets/PDF/publications/cheers_report.pdf?view=Standard
69 Hampshire JSNA 2013
67
33

Young offenders
3.3.1 Looked after children
Children on the Child Protection Register and Looked after Children are a particularly
vulnerable population and we know that a high proportion experience poor health,
educational and social outcomes after leaving care. They have higher rates of adverse
childhood experiences, including physical, sexual and emotional abuse or neglect, compared
to children in the general population and are significantly more likely to experience mental
health problems 70. Looked after children have a four to five time’s higher risk of self- harm,
and a six to eight times increased risk of conduct disorders than the general population with
around 60% (and 72% of those in residential care) having some level of emotional and
mental health problem. Among looked after children aged 5-17 Meltzer found that 37% had
clinically significant conduct disorders, 12% had emotional disorders, such as anxiety or
depression, and 7% had a hyperkinetic disorder71.
Looked after Children and care leavers are between four and five times more likely to
attempt suicide in adulthood72.
There is a rising trend in the numbers of reported looked after children in Hampshire from
1,015 in 2008 to 1,130 in 2013, mirroring the pattern across England. We estimate that 500
of these children will have a mental health disorder, the majority of which will be conduct
disorders. This represents an additional need for mental health services.
3.3.2 Young People with Special Educational Needs
The term Special Educational Needs is used to describe the needs of children who have
learning difficulties and/or disabilities that make learning or access to education more difficult
than for children of the same age.
Children with a mental illness are three times more likely to have special needs. Those
with learning disabilities are over six times more likely to have a diagnosable psychiatric
disorder than their peers meaning that approximately one in three children with a learning
disability in Britain have a diagnosable psychiatric disorder73.
According to the March 2013 Hampshire School Census, 2.6% (4,364) of Hampshire school
pupils were recorded as having special educational need (SEN) statements. The most
frequent type of SEN in Hampshire is for moderate learning difficultly (28.1%) followed by
behavioural, emotional and social difficulties (24.3%).
70
Ford, T. et al, Psychiatric disorder among British children looked after by local authorities:
comparison with children living in private households. The British Journal of Psychiatry (2007) 190:
319-325 2007
71 Meltzer H, Gatward R, Corbin T, Goodman R, Ford T ‘The mental health of young people looked
after by local authorities in England. Office of National Statistics.
72 Children & Young People’s Health Outcomes Forum, 2012
73 Young Minds 2013
34
Emerson et al74 calculated the prevalence of a learning disability in children for different age
groups as follows: 5 to 9 years: 0.97%; 10 to 14 years: 2.26%; and 15 to 19 years: 2.67%..
The Foundation for people with learning disabilities estimates that 40% of those with a
learning disability have a mental health problem.75. Table 4 sets out the estimated number
of children in Hampshire with a learning disability who have a mental health problem using
these prevalence rates. .
Table 4: Estimated total number of children with learning disabilities in Hampshire
with a Mental Health Problem 2012
Source: Office for National Statistics mid-year population estimates for 2012.
Age
5-9 years
Number with Learning 735
Disability
Number with a Learning 295
Disability & Mental Health
Problem
10-14 years
1740
15-19 years
2135
700
855
The number of children with learning disability increases with age; this may be due to the
easier identification of learning disability as the child grows older. However the proportion of
children with a mental health problem is constant in each age band at 40%.
By applying the prevalence estimates from Emerson et al47 to the Hampshire County
Environment Department 2012 population forecasts, it is anticipated that by 2019 there will
be an increase in the numbers of young people with a learning disability aged between 5
and 14 years: ,
 6.5% in boys and 7.7% in girls in the 5-9 age group
 3.5% boys and 4.4% girls in the 10-14 age group
with a concomitant increase in mental health problems. .
3.3.3 Autistic Spectrum Disorder76
Autistic Spectrum Disorder (ASD) is defined in the Hampshire Autism Strategy as “a lifelong
developmental ‘hidden’ disability that affects the way a person communicates with, and
relates to, people and the world around them”. People with an ASD are at much higher risk
of developing a mental health problem than the general population. 70% of children with
ASD will have a mental health problem at some point in their life and 40% will have two or
more77.
There are an estimated 2,802 children aged 0-17 years and 3,823 children and young
people aged 0-24 years living with autism in Hampshire. Only a small proportion of these are
known to services. These figures are estimated and actual numbers are likely to be higher.
74
Emerson, E. and Hatton, C. (2004) Estimating current need/demand for supports for adults with
learning disabilities in England. Institute for Health Research, Lancaster University, Lancaster
75 Foundation for people with learning disabilities (2002) Count us in. Foundation for people with
learning. London
76 Please refer to the needs assessment for children with autism for more detailed information
77 Young Minds
35
3.3.4 Young carers
A young carer is a child or young person under 18 who provides regular and ongoing care
and emotional support to a family member who is physically or mentally ill, disabled or
misuses substances. Data, compiled from the 2011 census, showed that there were nearly
a quarter of a million people young carers aged 19 and under in England and Wales. . The
number of young carers aged 0-24 years in Hampshire has doubled since the 2001 census,
from 3,300
in 2001 to 7,604 in 2011. Young carers make up 0.5% of pupils within
Hampshire schools78.
Young Carers become vulnerable and at increased risk of mental health problems when the
level of care giving and responsibility to the person in need of care becomes excessive or
inappropriate for them , impacting negatively on their emotional or physical wellbeing or
educational achievement and life chances. They can experience anxiety, stress, stigma and
resentment on account of their increased responsibilities and neglect. Compounding these
experiences is the fact that professionals often do not acknowledge their role and therefore
fail to identify and support them.
We know that many of these young people will need special support from services such as
school nursing and sometimes specialist mental health services to help them maintain good
mental health79 80.
3.3.5 Young offenders
Young Offenders have at least three times the rate of mental health problems compared to
the general population, although this is probably an underestimate and local data shows that
almost half of young people in contact with the Hampshire Youth Offending Team were
known to mental health services. The most common disorders are similar to those in the
general population - conduct, emotional and attention deficit disorders but there are also
high rates of post-traumatic stress disorder (PTSD), self-harm, emerging personality disorder
and psychosis81.
Frequently these disorders will have been present for some time but been undiagnosed and
untreated. There is evidence to show that interventions to address conduct disorders reduce
offending behaviour.
The severity and complexity of need increases for those in custodial settings and young
people in prison are 18 times more likely to take their own lives than others of the same
age82.
78
JSNA 2013
Department of Health (2014 )School Nurse Programme: Supporting implementation of the new
service offer:
Supporting the health and wellbeing of young carers
80 Department of Health (2014) 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
81 Tunnard J (2008). In Child and adolescent mental health today: a handbook. Pavilion
82 Report of the child health outcomes forum - mental health subgroup
79
36
One third of all children and young people in contact with the youth justice system have been
looked after.
In Hampshire, the level of first-time offending continues to fall from 1,340 in 2011 per
100,000 young people aged 10-17, to 512 per 100,000 in 2012 which is similar to the
England rate (537/100,000).83 Offending rates among Looked After Children in Hampshire
are higher at 800/100,000 and are above the England rate.
3.3.6 Teenage parents
Low levels of emotional and mental health and wellbeing are a risk factor for teenage
pregnancy and may also develop as a consequence of teenage pregnancy. Although early
parenthood can be a positive experience for some young people, it is recognised that
becoming a parent at an early age often has a detrimental effect on the long term outcomes
of teenage mothers, fathers and their children84. Teenage mothers have three times the rate
of post-natal depression of older mothers and a higher risk of poor mental health for three
years after the birth85. The under 18 conceptions rate in Hampshire is better than the
England average, 21% compared to 27.7%86.
3.3.7 Asylum seekers, refugees and immigrants
The children of asylum seekers and refugees and unaccompanied children who are asylum
seekers are a very vulnerable group. They are likely to experience poverty, dependence and
a lack of cohesive social support. They may have experienced the death of a close family
member or friend and witnessed or been subject to extremely traumatic events. Some may
be living with adults who are unfamiliar to them.
They have been shown to be at significant risk of developing mental health problems such
as depression and anxiety and p ost-traumatic stress disorder which is frequently
underdiagnosed in children. We do not have an accurate picture of the numbers of children
of asylum seekers in Hampshire but it is important that this group of highly vulnerable
children are provided with the right kind of support and that services are made accessible to
them.
3.3.8 Children of parents in the armed forces
Evidence suggests that for some families the impact of parental deployment and constant
mobility on the family dynamic can lead to increased levels of stress and
emotional/behavioural difficulties in adolescents and their care –givers. Studies have shown
increased child depression and externalising behaviours (e.g. verbal or physical aggression
83
Chi-mat Child Health Profiles for Hampshire 2011 and 2014 accessed May 2014
Swann, C., Bowe. K., McCormick, G. & Kosmin, M (2003) Teenage pregnancy and parenthood: A
review of reviews. Health Development Agency
85 DfES (2006) Teenage Pregnancy: Accelerating the Strategy to 2010. Every child matters: Change
for children.
Department for Education and Skills, London.
86 Hampshire Health Profiles 2014
84
37
directed towards others) and that these could be predicted by the cumulative length of a
parent’s deployment during the child’s lifetime87.
The reasons for this may lie in the fact that deployments today have become increasingly
more stressful compared to those of twenty years ago as they are more unpredictable and
dangerous. They are also typically longer, more frequent with shorter breaks in between 88.
Hampshire has a greater range of armed Forces personnel than any other county in the UK.
Approximately 22,000 serving personnel are stationed in Hampshire (including Portsmouth).
In 2010 there were 5,189 service children recorded on the Hampshire school roll, in 2011
5,674 and in 2012 5,649. From 2008-2011 the district of Gosport has consistently had the
largest numbers of service children on record, with Basingstoke and Deane the lowest. The
largest increases in school children from service families have been seen in New Forest,
where there was a recorded increase of 65% from 2008 -2010 and 46% from 2010-2012.
3.4 Rates and profile of mental health problems among children in Hampshire
This section presents information from the Child and Maternal Health Intelligence Network
CAMHS Health Needs assessment report for Hampshire.89 Up to date information about the
prevalence of mental health conditions in children and young people is lacking. The Report
of the Children and Young People’s Health Outcomes Forum (Department of Health, 2012)
"recommends a new survey to support measurement of outcomes for children with mental
health problems. In particular, (we recommend) a survey on a three-yearly basis to look at
prevalence of mental health problems in children and young people’’.
3.4.1 The National Picture: Pre-school children (2-5 years)
There is relatively little information regarding prevalence of mental health disorders in preschool 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
(defined through DSM/ICD classifications) was 19.6%90.
3.4.2 Hampshire Estimates: Pre-school children
Applying the above average prevalence rate to Hampshire, suggests that up to 12,365
children aged 2 to 5 years may have a mental health problem.
87
White, C., de Burgh H.T., Fear, N.T., Iversen, A.C (2011) The impact of deployment to Iraq or
Afghanistan on military children: A review of the literature. International Review of Psychiatry, 23:210217.
88 The Mental Health Foundation (2013) A review of the evidence and perspectives of key
stakeholders. The mental health of serving and ex-Service personnel Mental Health Foundation, 2013
89 http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=34 Accessed 15/08/14
90 Egger, H. L. and Angold, A. (2006) Common emotional and behavioral disorders in preschool
children: presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47
(3-4), 313–37
38
3.4.3 The National Picture: School age children (5-16 years)
The most recent British surveys of mental health problems in children and adolescents were
carried out over ten years ago by the Office for National Statistics in 1999 and 200491 92.
The surveys, referred to as the British Child and Adolescent Mental Health Surveys, included
children aged 5-15 years and found that overall 10% of children had a clinically diagnosable
mental disorder – based on the ICD-10 Classification of Mental and Behavioural Disorders
with strict impairment criteria such that the disorder causes distress to the child or has a
considerable impact on the child’s day to day life.
There were no significant differences in prevalence between geographical regions in
England.
The surveys found that:
 mental health disorders are more common in boys (11.4%) compared to girls (7.8%)
and rates increase with age.
 among 5-10 year olds 5% of girls and 10% of boys had a mental health disorder
 among 11-16 year olds the rates were 10% for girls and 13% for boys.
 the most common type of mental health problems in children and young people are
conduct and emotional disorders, both increase with age. There are higher rates of
conduct disorders in boys and emotional disorders in girls.
 the prevalence of emotional disorders was 4% (anxiety 3%, depression 0.9%);
conduct disorders 6 %, hyperkinetic disorder (severe ADHD) 1.5% and autism
spectrum disorder 0.9%.
 the rate of hyperkinetic disorder is strikingly higher in boys than girls (2.6%
compared to 0.3%).
 rarer disorders, including tics, eating disorders and selective mutism affected 0.4%
of children.
 about 2 % of children had more than one type of disorder.
While this is the best evidence that we have and the findings are still widely quoted, as there
are no more comprehensive recent surveys, it is far from ideal to inform the planning of
services.
Childhood has changed dramatically in the last ten years, particularly with the dramatic
broadening of the scope and increase in exposure of children to media in all its forms. Of
course there are many benefits of media such as opportunities to stay connected with
friends through social media, educational uses and e-health. However, increasingly it is
recognised that there are potential negative impacts on children’s mental health including
problem internet use, the sexualisation and exploitation of children and cyberbullying.
91
Office for National Statistics: The mental health of children and adolescents in Great Britain.
Summary report 2000.Howard Meltzer and Rebecca Gatward.
92 Green H, McGinnity A, Meltzer H, Ford T, Goodman R: Mental Health of children and young people
in Great Britain, 200. http://www.esds.ac.uk/doc/5269/mrdoc/pdf/5269technicalreport.pdf
39
Table 5: Prevalence of mental health disorders from the British Child and Adolescent
Mental Health Surveys 1999 and 2004.
Source: Mental Health of children and Young people in Great Britain 2004
3.4.4 Hampshire Estimates: School Age Children (5-16 years)
In the absence of local survey data we have to applied these rates to the Hampshire
population in order to estimate the local prevalence of mental health disorder by age group
and sex. Note that the numbers in the age groups 5-10 years and 11-16 years do not add up
to those in the 5-16 year age group as the rates are different within each age group.
We estimate that at any one time 17,845 of children aged 5-16 years in Hampshire will have
a diagnosable mental health problem.
40
Table 6: Estimated number of children with a mental health disorder by age group and
sex for Hampshire and by CCG
Source: Office for National Statistics mid year population estimates for 2012 (Green, H. et al (2004)
Estimated
number
of
children
aged 5-10
yrs with
mental
health
disorder
(2012)
Estimated
number
of
children
aged 1116 yrs
with
mental
health
disorder
(2012)
Estimated
number
of
children
aged 5-16
yrs with
mental
health
disorder
(2012)
Estimated
number
of boys
aged 5-10
yrs with
mental
health
disorder
(2012)
Estimated
number
of boys
aged 1116 yrs
with
mental
health
disorder
(2012)
Estimated
number
of boys
aged 5-16
yrs with
mental
health
disorder
(2012)
Estimated
number
of girls
aged 5-10
yrs with
mental
health
disorder
(2012)
Estimated
number
of girls
aged 1116 yrs
with
mental
health
disorder
(2012)
Estimated
number
of girls
aged 5-16
yrs with
mental
health
disorder
(2012)
Hampshire
6,945
11,000
17,845
4,740
6,225
10,930
2,230
4,770
7,020
Fareham
& Gosport
1,045
1,665
2,695
710
930
1,630
340
680
1,010
1,235
1,775
3,020
850
1,000
1,850
395
775
1,185
1,185
1,745
2,930
815
980
1,795
380
1,045
1,665
2,695
710
930
1,630
340
2,675
4,225
6,860
1,820
2,395
4,195
865
North East
Hampshire
&
Farnham
North
Hampshire
South
East
Hampshire
West
Hampshire
760
1,155
735
1,075
1,830
2,705
41
Table 7: Estimated number of children with a mental health disorder by type of
disorder by age group and sex
Source: Office for National Statistics mid year population estimates for 2012
3.4.5 Hampshire Estimates: Children aged 16-19
Young people aged 16 and over are included in the Office for National Statistics surveys of
adult psychiatric morbidity. The methodology is different to that used in the survey of 5-16
year olds and so direct comparison is difficult.
The 2007 survey found that in 16-24 year olds 2.2% experienced a depressive episode,
4.7% screened positive for post traumatic stress disorder, 16.4% experienced anxiety, 0.2%
had a psychotic illness and 1.9% had a diagnosable personality disorder93 94.
A study conducted by Singleton et al (2001) has estimated the prevalence rates for neurotic
disorders in young people aged 16 to 19 years living in private households. The tables
below show how many 16 to 19 year olds would be expected to have a neurotic disorder if
these prevalence rates were applied to the population of Hampshire.
93
94
CMO report 2012
http://www.esds.ac.uk/doc/6379/mrdoc/pdf/6379research_report.pdf
42
Table 8: Estimated number of males aged 16 to 19 with neurotic disorders
Source: Office for National Statistics mid year population estimates for 2012 (Singleton, N. et
al (2001).
Mixed
anxiety and
depressive
disorder
(males 16-19
yrs) (2012)
Hampshire
1680
Generalised
anxiety
disorder
(males 16-19
yrs) (2012)
530
Depressive
episode
(males 1619 yrs)
(2012)
300
All
phobias
(males
16-19
yrs)
(2012)
Obsessive
compulsive
disorder
(males 16-19
yrs) (2012)
200
Panic
disorder
(males
16-19
yrs)
(2012)
300
Any
neurotic
disorder
(males 1619 yrs)
(2012)
165
2830
Table 9: Estimated number of females aged 16 to 19 with neurotic disorders
Source: Office for National Statistics mid year population estimates for 2012 (Singleton, N. et
al (2001).
Hampshire
Mixed
anxiety
and
depressiv
e disorder
(females
16-19 yrs)
(2012)
Generalised
anxiety
disorder
(females 1619 yrs) (2012)
Depressive
episode
(females 1619 yrs)
(2012)
3,800
340
830
All
phobias
(females
16-19
yrs)
(2012)
645
Obsessive
compulsive
disorder
(females 1619 yrs)
(2012)
280
Panic
disorder
(females
16-19
yrs)
(2012)
Any
neurotic
disorder
(females
16-19
yrs)
(2012)
185
5,880
In both males and females in this age group mixed anxiety and depressive disorder is the
most common neurotic disorder.
3.4.6 Deliberate Self Harm: National Picture
Self harm among young people is a major public health concern. It refers to intentional selfpoisoning or self injury irrespective of motive or the extent of suicidal intent. 95. There is
evidence to suggest that rates of self-harm in the UK are higher than anywhere else in
Europe96.
Self-harming is most evident in people with a mental health disorder and occurs more in
young people compared to adults. Levels of self harm are consistently higher among young
females than males.
The 2004 CAMHS survey found a rate of 0.8% in 5-10 year olds with no mental health
disorder rising to 6.2% in those with anxiety disorder and to 7.5% in children with conduct,
95
96
Hawton K, Saunder K,O’Connor R Self Harm and suicide in adolescents. Lancet 2012;379;2373-82
http://www.nspcc.org.uk/Inform/research/briefings/youngpeoplewhoselfharmpdf_wdf63294.pdf
43
hyperkinetic and less common disorders. Rates increased dramatically in adolescence.
Studies consistently show that around 10% of adolescents report having self harmed 97 . In
adolescents with no mental health disorder the rate was 1.2%; with rates of 9.4% in those
with anxiety disorder; 18.8% in those with depression and as many as 1 in 5 of those with
conduct disorder. Self harm is also associated with a history of childhood abuse.
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. Selfpoisoning was the most common method, involving paracetamol in 58.2 % of episodes98.
The National Inquiry into suicide and homicide in people with mental illness found that self
harm presentations, especially those involving alcohol, peaked at night. Repetition of selfharm was frequent (53.3 % had a history of prior self-harm and 17.7 % repeated within a
year) 101. Common characteristics of adolescents who self-harm are similar to the
characteristics of those who die from suicide99.
Young South Asian women in the United Kingdom seem to have a raised risk of self-harm.
Intercultural stresses and consequent family conflicts may be relevant factors103.
As many as 30% of adolescents who self-harm report previous episodes, many of which
have not come to medical attention. At least 10% repeat self-harm during the following
year, with repeats being especially likely in the first two or three months103.
The risk of suicide after deliberate self-harm varies between 0.24% and 4.30%. Our
knowledge of risk factors is limited and can be used only as an adjunct to careful clinical
assessment when making decisions about after care. However, the following factors seem
to indicate a suicide risk: being an older teenage boy; violent method of self-harm; multiple
previous episodes of self-harm; apathy, hopelessness, and insomnia; substance misuse;
and previous admission to a psychiatric hospital103.
3.4.7 Deliberate self harm: Hampshire picture
We are unable to present a comprehensive local picture of self harm in Hampshire as we do
not have routinely collected data.
The Child Health profile for 2014 shows that Hampshire had a higher hospital admission rate
(395.5/100,000) as a result of self –harm in 16-24 year olds in 2012/13 compared to England
97
Windfuhr K, While D, Hunt IM, Shaw J, Appleby L, Kapur N Suicide and accidental deaths in
children and adolescents in England and Wales, 2001- 2010 . Arch Dis Child 2013 Dec;98 (12) 94550
98 Hawton, K., Bergen, H., Waters, K., Ness, J., Cooper, J., Steeg, S., and Kapur, N. (2012)
Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study
of self-harm in England. European child & adolescent psychiatry, 21 (7), 369-77.
99 Hawton, K. and James, A. (2005) Suicide and deliberate self harm in young people. BMJ, 330
(7496), 891-894.
44
(346.6/100,000) and all its comparator local authorities, except for West Sussex100 (Figure
5).
The Child Health Profiles for earlier years present hospital admissions for 0-17 year olds and
so are not directly comparable. In 2010/11 and 2011/12 the Hampshire rate in this younger
age group was not significantly different to the England average.
Evidence suggests that presentation to hospital occurs in only about one in eight
adolescents who self harm in the community 102 and so hospital admissions represent the ‘
tip of the iceberg’.
Further work is being undertaken to understand this finding – we do not know if these data
indicate a higher rate of self harming among young people in our community or reflect the
service provision and access to services.
Figure 5: Directly Standardised rates of Hospital Admissions as a result of self-harm
(10-24yrs)
Source: Hospital Episode Statistics (HES), prepared by CHIMAT (http://atlas.chimat.org.uk/)
3.4.8 Suicide
Suicide is a leading cause of death in young people aged 15-19 years.101 It is a complex
issue and one which requires further research to understand better the specific risk factors
associated with it.
100
Chi- mat child health profiles 2014 . ( Accessed 16th August 2014)
Why Children Die 2014
http://www.rcpch.ac.uk/sites/default/files/page/Death%20in%20infants,%20children%20and%20young%20pe
ople%20in%20the%20UK.pdf
101
45
Looking at deaths by suicide in the UK between 1997 and 2003, one study made the
following observations102:



Three times as many young men as young women aged between 15 and 19 died by
suicide.
Only 14% of young people who died by 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.
According to ONS, in 2011 there were 159 deaths of 10 to 19 year olds from intentional selfharm or undetermined intent in England and Wales. This is a rate of 2.35 deaths per
100,000 population aged 10 to 19 years.
A review of suicides in children and adolescents between 2001 and 2010 found a similar
suicide rate among 10-19 year olds of 2.25/100,000. Suicide rates were highest amongst
those aged 15-19 years (4.04/100,000 compared to 0.34 in 10-14 year olds) and in males
(3.14 compared to 1.3 for females)103. There was a significant reduction in the rates among
males aged 15-19 during this ten year period.
Since 1 April 2008 local safeguarding children boards (LSCBs) have been required to
review all child deaths in their area through the Child Death Overview Panel (CDOP). From
January 2011 to July 2013 the Hampshire Board reviewed 9 deaths from suicide in young
people from Hampshire.
Nationally the number of reviews completed by the 92 CDOPs where the death was
categorised as “suicide or deliberate self-inflicted harm” was higher in the year end March
2013 compared to 2012 (30% increase). Monitoring will continue to determine future trends.
The ‘Why children die’ report published in May 2014 states that suicide is a non random
preventable event. The report found evidence from a national case audit of children’s deaths
suggesting that many children who died from suicide had not had any contact with mental
health services, and there were reportedly problems with services failing to follow up patients
who had been referred but not turned up for appointments.104
102
Windfuhr, K., While, D., Hunt, I., Turnbull, P. , Lowe, R., Burns, J., Swinson, N., Shaw, J.,
Appleby, L., Kapur, N. and the National Confidential Inquiry into Suicide and Homicide by People with
Mental Illness (2008) Suicide in juveniles and adolescents in the United Kingdom. Journal of Child
Psychology and Psychiatry, 49 (11),1157–67.
103 Windfuhr K, While D, Hunt IM, Shaw J, Appleby L, Kapur N Suicide and accidental deaths in
children and adolescents in England and Wales, 2001- 2010 . Arch Dis Child 2013 Dec;98 (12) 94550
104
/page/Death%20in%20infants,%20children%20and%20young%20people%20in%20the%20UK.pdf
46
Section 4: Evidence of what interventions work
4.1 Early intervention & diagnosis
It is important that professionals who work with children are alert to emerging difficulties and
are able to respond early and in addition are listening closely to concerns raised by parents
and those raised by the child105.
Intervening early can reduce both the risk of the development of a disorder and the risk of
persistence into adult life leading to improved outcomes and generate potential savings for
services and society. In conduct disorders the potential savings from each case prevented
through early intervention have been estimated at £150,000 for severe conduct disorders
and £75,000 for moderate conduct disorders 106.
Despite theclear need for early intervention, evidence suggests that 60-70% of young people
are not offered evidenced based interventions at the earliest opportunity107. In Hampshire
this would mean that approximately 10,707 to 12,492 young people are not accessing
interventions that will enable them to have more functional and fulfilling adult lives.
4.2 Maternal mental health & the early years
Good maternal health is a protective factor and a supportive caring family are the foundation
of good child wellbeing 14. During pregnancy and in the year after birth women can be
affected by a range of mental health problems, including anxiety, depression and postnatal
psychotic disorders. These are collectively called perinatal mental illnesses. Perinatal mental
illnesses affect at least 10% of women and, if untreated, can have a devastating impact on
them and their families. If a mother is affected by perinatal mental illness this increases the
likelihood of her children experiencing behavioural, social or learning difficulties.. 108. It is
therefore important that mothers receive the support they need to care for their children and
that a strong bond develops between a baby and its parents during the first year of life.
The Chief Medical Officer report Our Children Deserve Better, 2012 includes a number of
intervention programmes as identified by the Evidence2Success project for the NICE Public
Health Intervention Advisory Committee on the social and emotional wellbeing of vulnerable
children aged 0–5 years.
Recommended cost effective interventions fell into the following categories:
 pre-school curriculums to enhance children’s readiness for school, in particular skills
in language and literacy.
 parenting group programmes to improve children’s behaviour.
 parent and child therapy programmes to improve children’s relationships with their
parents/carers.
105https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/326551/Mental_Healt
h_and_Behaviour_-_Information_and_Tools_for_Schools_final_website__2__25-06-14.pdf
106 Friedli L, Parsonage M (2007) Mental health promotion: building an economic case. Belfast:
Northern Ireland Association for Mental Health
107 http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/positionstatements.aspx
108 National Maternal Infant Survey, 1988
47
 home-visiting programmes to improve children’s relationships with their
parents/carers intensive child and family support programmes to improve behaviour
and children’s relationships with their parents/carers.
Several additional programmes were cited without adequate cost-effectiveness studies but
with strong evidence of efficacy. These included:
o the detection and treatment of postnatal depression.
o improving relationship quality in the first year of life (e.g. video feedback
interactive programmes).
o Specific child maltreatment prevention programmes based on family therapy
and social learning principles which achieve increased maternal educational
attainment and parent involvement in school as well as decreased family
problems.
4.3 : Parenting
Parenting education is a key intervention for the promotion of mental health in children. The
parent or caregiver/child relationship is vital to a child’s development and future
psychological wellbeing109.
The Healthy Child Programme led by the health visiting service is an evidence based
programme that includes information and guidance to support parenting as part of its
universal component110.
There are many evidence based targeted parenting programmes such as Triple P, Incredible
Years 111 and Family Links . Effective programmes have a strong theory base and a clear
model of change, are delivered by appropriately trained staff and focus on specific parenting
skills and practical take home tips112.
In an Australian trial the Triple P Programme was reported to demonstrate a 22% reduction
in mental health problems in children and a 22% reduction in emotional distress in parents in
less than three years113.
The Family Nurse Partnership is a voluntary home visiting programme for first time young
mothers and fathers , aged 19 or under. It is underpinned by an internationally recognised
robust evidence base, which shows it can improve health, social and educational outcomes
in the short, medium and long term, while also providing cost benefits. A specially trained
109
Caestecker L, Killoran-Ross M (2010) Early years and public health: a case study from the
Glasgow experience.
In Goldie I (ed) Public Mental Health Today. A handbook (pp.121-134). Brighton, Pavilion
Publishing/Mental Health Foundation.
110
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Progr
amme.pdf
111 https://www.education.gov.uk/commissioning-toolkit/Programme/CommissionersSearch
112 Moran D The effectiveness of parenting support 2004
113 Saunders,M.,Ralph,A.,Thompson,R.,Sofrnoff,K,Gardiner,P Bidwell & Dwyer S (2005) Every Family:
A Public Health approach to promoting children’s wellbeing. University of Queensland
48
family nurse visits the young mother regularly, from early in pregnancy until the child is two.
A key component of the programme is parenting support. 114
Systematic reviews of interventions to prevent conduct disorder, anxiety and depression
before adulthood have shown that programmes targeting at-risk children that involve
families, using parent training or child social skills training are the most effective, with a
reduced rate of relapse115.
4.4. : School based programmes
Schools have an important role to play in enabling our young people to grow into functional
adults; part of this is through promoting mental health and wellbeing. Schools provide an
environment that fosters social and emotional wellbeing and equips young people with the
knowledge and skills they need to for life116.
Targeted approaches are required for children who are showing early signs of emotional and
social difficulties. NICE recommends that schools should ensure teachers and practitioners
are trained to identify and assess the early signs of anxiety, emotional distress and
behavioural problems among primary schoolchildren. They should also be able to assess
whether a specialist should be involved and make an appropriate request 117 61.
Effective school based programmes should be implemented consistently, over a long period
of time, with sustained investment and should
 Start early – the most effective programmes are those targeting the youngest
children.
 Adopt a whole school approach where mental health work is integrated across a
whole range of school activity, including the curriculum.
 Include explicit work on the development of mental health skills in students, staff
and sometimes parents61 62.
Summary Evidence Table 1: Effective Emotional Mental health & Wellbeing Interventions
for Children & Young people
For women assessed as having post-natal NICE (2007) Antenatal
depression or any other mental health disorder, and postnatal mental
NICE guidelines for healthcare professionals health: Clinical
Evidence based
include;
management and service
interventions for
· How to predict and detect mental health guidance. Clinical
antenatal &
problems.
guideline 45.
postnatal mental
· When to offer psychological treatments.
health
· How to explain the risks of treatment versus
114
http://fnp.nhs.uk/
DH (2011) No Health Without Mental Health: Delivering better mental health outcomes for people
of all ages. Department of Health.
116 NICE (2009) PH20 Social and emotional wellbeing in secondary education. National Institute for
Health and Clinical Excellence
117 NICE (2008) PH12 Promoting children’s social and emotional wellbeing in primary education.
National Institute for Health and Clinical Excellence
115
49
non-treatment for mental health problems.
· How to manage depression.
· How to organise care, including:
- setting up a specialist multidisciplinary perinatal service in each locality, consisting of
healthcare
professionals,
commissioners,
managers, and service users and carers.
- identifying pathways of care for service users,
with defined roles and competencies for all
professional groups involved.
Evidence based
interventions for
postnatal mental
health
Section on ‘mental health and wellbeing’ which
includes the following:
- At each postnatal contact, women should be
asked about their emotional wellbeing, what
family and social support they have. Women
and their families/partners should be
encouraged to tell their healthcare professional
about any changes in mood, emotional state
and behaviour that are outside of the woman’s
normal pattern.
· All healthcare professionals should be aware
of signs and symptoms of maternal mental
health problems that may be experienced in
the weeks and months after the birth.
· At 10–14 days after birth, women should be
asked about resolution of symptoms of baby
blues (for example, tearfulness, feelings of
anxiety and low mood).
Social
and emotional
wellbeing in
primary
education
Formal guidance on promoting the social and NICE PH12 March 2008
emotional wellbeing in children in primary
education
age.
Guidance
provides
recommendations for universal,
comprehensive and targeted approaches.
Social and
emotional
wellbeing in
secondary
education
Guidance is for those who have a direct or NICE PH20 September
indirect role in, and responsibility for, the social 2009
and emotional wellbeing of young people in
secondary education. This includes teachers,
support staff, governors and professionals with
public health as part of their remit working in
education and other stakeholders.
Evidence based
interventions for
the long term
NICE Guidance for Health & Social Care NICE Guidelines CG133 –
professionals who come into contact with CYP issued November 2011
aged between 8 and 17 years inclusive who
NICE (2006) Routine
postnatal care of women
and their babies, Clinical
guideline 37.
50
management of
self-harm
Evidence based
interventions for
Eating Disorders
in CYP
self- harm.
Evidence base for
CYP with ADHD
At the time of publication (September 2008), NICE Guidelines CG72 methylphenidate, atomoxetine and
Issued: September 2008
dexamfetamine did not have UK marketing
authorisation for the treatment of adults with
ADHD. However, atomoxetine is licensed for
use in adults with ADHD when treatment with
the drug began in childhood. At the time of
publication, methylphenidate and atomoxetine
did not have UK marketing authorisation for
use in children younger than 6 years. Parents
should be advised of the implications of
prescribing unlicensed or 'off-label' drugs.
Informed consent should be obtained and
documented.
Evidence-based
treatments for
CYP with
depression
There are effective treatments for depression NICE Guidelines CG28 in children and young people. Cognitive Issued: September 2005
behavioural therapy for depression has been
shown to be effective in both individual and
group settings.
NICE recommends that most people with NICE Guidelines CG9 anorexia should be managed on an outpatient Issued: January 2004
basis with psychological treatment by a team
skilled in working with this disorder; for children
and young people, family.
NICE draws on the evidence base and practice
learning for CAMHS, with the following
providing a ‘snapshot’ of some of the key
recommendations of the NICE guidance:
it is suggested that the following may help –
advice on complementary and alternative
therapies; information about mentoring/spiritual
guidance and local peer support groups;
guidance on sleep and relaxation;
information about local and national helplines,
information about mental health and about
local voluntary organisations.
Antisocial
behaviour and
conduct disorders
in children and
young people:
Fonagy P, Cottrell D,
Phillips J, Bevington D,
Glaser DE, Allison E:
What works for whom? A
critical review of
treatments for children
and adolescents, 2nd
edn. New York: Guilford
Press; in press.
Several interventions have been developed for NICE Guidelines CS158 –
children with conduct disorder and related Issued March 2013
problems, such as parenting programmes
typically focused on younger children and
multisystem approaches usually focused on
51
recognition,
intervention and
management
older children.
Psychosocial therapies are used for the
treatment for conduct disorders and are both
clinically and cost-effective. Up to the age of 11
years, conduct disorders are best treated
through the modification of parenting practices,
the key factor being to improve positive
parenting.
All effective treatments for conduct disorder
involve the family, multisystemic therapy, brief
strategic family therapy and functional family
therapy appear effective for moderate-tosevere cases.
Three themes are common to all interventions
recommended: a strong focus on working with
parents and families, recognition of the
importance of the wider social system in
enabling effective interventions and a focus on
preventing or reducing the escalation of
existing problems. The guidelines cover a
range of interventions including treatment,
indicated prevention and selective prevention.
Social and
emotional
wellbeing
Recommendations for the social and emotional NICE Guidelines PH 40
wellbeing for children and young people, Issued October 2012
specifically, vulnerable children aged less than
5 years and all children in primary and
secondary education. It is particularly relevant
to health and wellbeing boards.
The guidance recommends that
• A ‘life course perspective’ should be adopted
• There should be a focus on social and
emotional wellbeing as the foundation for the
healthy development in vulnerable children
• Stakeholders should aim to ensure
universal, as well as more targeted, services
provide the target group with additional support
• The guidance should be considered
alongside local child safeguarding policies.
52
Evidence Summary Table 2 : Effective mental health interventions for Young People
Disturbances of conduct: parent training (under Wolpert, M.,Fuggle,P.,Cottrell,
10s); problem solving and social skills training; D.,Fonagy,P.,Phillips,J.,Pilling, S.,
functional or structural family therapy; multi-systemic Stein,S., Target,M. (2006)
therapy (MST); therapeutic fostering (latter two for
Drawing on the Evidence: Advice
severe disturbance).
for mental health professionals
Disturbance of emotion: medication; behavioural working with children and
adolescents.
interventions in school and at home.
CAMHS Publications. London
Anxiety disorders: behavioural and cognitive
behavioural therapy (CBT) including
parents for under 11s; educational support;
medication for obsessive compulsive disorder (OCD)
if CBT alone ineffective.
Attention Deficit Hyperactivity Disorder (ADHD):
medicine; behaviour therapy; parent training; dietary
advice.
Post-traumatic stress disorder: trauma focused
CBT.
Depressive disorders: watchful waiting; CBT;
systemic family therapy; individual psychotherapy;
interpersonal therapy (IPT); booster sessions;
medication.
Psychotic disorders: medication (with CBT and
systemic family therapy possibly helping).
Eating disorders: family therapy; CBT; multi-modal
treatments (though noted to have been insufficiently
researched).
Deliberate self-harm (DSH): brief interventions
(including problem solving) involving the family;
assessment for mental health problems; group
psychotherapy.
Substance misuse: family therapy; multi-systemic
therapy; skills oriented resilience enhancement
programmes in schools and other settings and
motivational interviewing.
Pervasive development disorders: intensive
individual or group behavioural interventions.
Tourette’s syndrome: medication; reassurance for
parents; liaison work with schools.
Physical symptoms with no known cause: CBT;
dietary advice for recurrent abdominal pain.
Coping with painful procedures: CBT; behavioural
53
therapy; hypnosis.
Coping with chronic physical illness and disease:
CBT; behavioural therapy tailored to illness;
psychoanalytic psychotherapy for hard to control
diabetes; systemic family therapy for asthma;
specialist nurse support for children newly diagnosed
with chronic illnesses.
54
Section 5: Benchmarking
5.1 Programme budgeting analysis
Programme budgeting is a tool which can be used to analyse how effectively health needs
are addressed within a finite budget. Programme budgeting looks at how much money has
been spent on major health programmes and the activity and outcomes linked to that
investment.
Programme budgeting data can help to provide a strategic context to how financial
resources are deployed. It is not a definitive statement on actual distribution of spend as
there may be variation in the way that spend is ascribed to a programme and spend on
health services which are general in nature, may include mental health specific activity.
The programme budgeting data for 2012/13 suggest that Hampshire's highest spend area,
excluding programme 23 (Other), was on Mental Health at £186 per head per year.
118
.
The total spend across the main programme categories (23 in total) is charted below and
compares the total mental health spend in Hampshire to the other main programme
categories.
Calculating programme budgeting data is complex and not all healthcare
activity or services can be classified directly to a programme budgeting category or care
setting. When it is not possible to reasonably estimate a programme budgeting category,
expenditure is classified as ‘Other’. The total spend on mental health in Hampshire for
2012/13 was £ 215,345,419. The total spend on CAMHS was £25,296,000 (11.7%).
It should be noted that the use of the word ‘PCT’ within the programme budgeting data will be
replaced with “CCG” by 2015.
118
55
Figure 6: Hampshire programme budgeting expenditure 12/13
Mental health programme spend includes services for the following subcategories: Child and
adolescent mental health (CAMH) disorders, Substance misuse, Organic mental disorders,
Psychotic disorders and Mental health disorders (Other). Mental health spend and ranking
based on this spend is presented in table 10.
Table 10: Hampshire Spending per head of population on Mental Health 12/13
Mental health disorders
Spend per
head
£185.4
National spend
per head
£213
Spend /100,000
population
18.54m
PCT
ranking
33rd ^
2nd
quintile *
MH subcategory
CAMH disorders
£21.8
£13.3
£2.18m
133rd ^
5th
quintile*
^where 1 is lowest
*where 1 is the lowest and 5 the highest spend.
In 12/13 Hampshire’s total mental health spend of £18,537,645 per 100,000 population
placed Hampshire in the 2nd national quintile (where 1 is the lowest and 5 is the highest).
56
The Hampshire Mental Health spend per head is not significantly different to the national
spend (£213), and is at the lower end of spend in the PCT ONS Cluster of PCTs with
comparable demography and mental health need, however, there is wide variation in ONS
Cluster spend across the 1st - 5th quintiles. Hampshire spend was in the 2nd quintile and is
not an outlier compared to the ONS cluster.
Figure 7 below shows Hampshire’s spend on CAMHS is in the 5th quintile, and that it spends
the highest per head of all PCTs in the ONS Cluster with comparable demography and
mental health need.
Figure 7: CAMHS spending 2012/13
Source: Programme Budgeting Benchmarking tool
Table 11: Programme Budgeting total spend trend data for Mental Health for
Hampshire 2006-2013
Programme budget 2006£000
07
Mental health
151.3
disorders
13.6
CAMHS Disorders
(1.0%)
TOTAL Spend ( all 1,408.6
categories)
200708
167.5
2008-09
173.8
200910
187.4
201011
218.6
9.2
(6%)
1,550.4
201112
214.8
201213
215.4
12.8
(8%)
1,635.3
16.2
(9%)
1,848.1
4.7
25.2
25.3
(2.1%) (11.7%) (11.7%)
1,927.5 1,947.1 2,028.8
Table 11 shows that the proportion of the Mental Health budget committed to CAMHS has
increased since 2006/07. The trend data also suggests that mental health has consistently
been the programme with the highest spend in Hampshire since 2006/07.
57
Whilst it provides a useful direction of travel, programme budgeting data cannot be reliably
used to analyse changes in investment in specific service areas between years because
significant changes to the data calculation methodology were introduced in 2010/11.
5.2 Spend outcomes quadrant analysis
The CCG Spend and Outcome tool (SPOT) is a quadrant analysis tool developed by Right
Care ® that demonstrates the relationship between spend and clinical outcomes. The tool
categorises programme budget data into 4 quadrants in terms of spend and outcomes to
allow easy identification of areas that require prioritisation. It graphically illustrates where a
CCG stands, compared to similar CCG populations, on the health outcomes it is achieving
for its health spend and helps identify whether the organisation is getting good value for
money/return on investment (ROI) – as opposed to simple “activity” or “spend” analyses. It
shows that spending more does not necessarily mean better outcomes for people and
spending less doesn’t mean worse outcomes.
When spend for CAMH disorders is analysed against the ‘patients on enhanced Care
Programme Approach (CPA) receiving early follow up (FU)’ as an outcome measure,
Hampshire ‘CCG’ (equivalent to Hampshire PCT and so represents the Hampshire picture)
is in the ‘higher spend /better outcome’ quadrant (see figure 8 below).
58
Figure 8: Spend for Child and Adolescent Mental Health vs enhanced CPA outcome
Programme: Mental Health
Spend: Child and Adolescent Mental Health Disorders
Outcome: Patients on enhanced CPA receiving early FU
Spend and Outcome relative to other CCGs
Higher Spend
Better Outcome
Lower Spend
Better Outcome
Lower Spend
Worse Outcome
All
Higher Spend
Worse Outcome
ONS
SHA
CCG
Z=1
Z=2
However when analysed against the ‘mortality from suicide and injury undetermined’
outcome measure, Hampshire CCG borders between the ‘higher spend /better outcome’ and
‘higher spend /worse outcome’ quadrants (see figure 9 below).
59
Figure 9 : Spend for Child and Adolescent Mental Health vs mortality from suicide
Programme: Mental Health
Spend: Child and Adolescent Mental Health Disorders
Outcome: Mortality from suicide and injury undetermined
Spend and Outcome relative to other CCGs
Higher Spend
Better Outcome
Lower Spend
Better Outcome
Lower Spend
Worse Outcome
All
Higher Spend
Worse Outcome
ONS
SHA
CCG
Z=1
Z=2
60
Section 6: Projected need
By 2020 we predict that there will be 9,640 more children living in Hampshire. The recent
rise in births, continuous housing development and inward migration are all contributing to
the increase and we should consider these projections as ‘lower end of the range’
estimates.
The indications are that we will continue to see an increase in the number of children with
mental health conditions in thedue to the following factors:
 It is unlikely that mental health problems in the child population will become less
common. This means that we can expect an increase in the number of children with
mental health needs simply from the population increase.
 Evidence suggests that mental health conditions in children in England are
underdiagnosed and the Hampshire picture is likely to be similar . The welcome
increased national and local focus on children’s mental health and the drive for parity
with physical health will almost certainly lead to improved identification of mental
health problems in children and a reduction in underdiagnosis. At the same time
there will be increased opportunities for prevention and early intervention which could
reduce some of the need for specialist mental health interventions.
 Trend data suggest that we will continue to see an increase in the number of
vulnerable children in Hampshire who are at significantly increased risk of mental
health disorders, for example looked after children and children with learning
disabilities.
Defining and measuring the landscape of childhood disability is challenging due to the lack
of an agreed definition across health, education and social care domains, with no single
definition being complete. However, there is consensus amongst paediatricians, social
services managers and educationalists that the population of children with disabilities
accessing services is increasing, as is the complexity of their physical disabilities and health
needs – these children will have high mental health needs.
The long term impact of lifestyle behaviours which increase the risk of poor mental health
such as obesity, physical inactivity and substance misuse is more difficult to predict. While
we have had some success in influencing risky behaviours in children it is unlikely that we
will see a dramatic reduction over the next few years and that these behaviours will continue
to affect the mental health of children.
61
Figure 10: Projected number of children aged 5-10 with a mental health disorder by
local authority based on population projections alone
Table 12: Projected number of children aged 11-16 with a mental health disorder by
local authority based on population projections
2012
Male
Population
aged 11-16
Basingstoke
and Deane
East
Hampshire
Eastleigh
Fareham
Gosport
Hart
Havant
New Forest
Rushmoor
Test Valley
Winchester
Hampshire
total
6,169
Estimate
with MH
disorders
778
4,507
4,676
4,034
2,938
3,395
4,223
5,978
3,489
4,551
4,685
48,645
Female
Population
aged 11-16
5,941
Estimate
with MH
disorders
612
568
4,316
589
509
370
428
532
754
440
574
591
6,132
4,407
3,827
2,776
3,126
4,034
5,555
3,403
4,175
4,084
45,644
2019
Male
Population
aged 11-16
6,072
Estimate
with MH
disorders
765
445
4,586
454
395
286
322
416
573
351
430
421
4,705
4,545
3,772
2,879
3,555
4,173
5,586
3,484
4,430
4,908
47,990
Female
Population
aged 11-16
5,769
Estimate
with MH
disorders
595
578
4,443
458
573
476
363
448
526
704
439
558
619
6,050
4,264
3,662
2,668
3,333
3,959
5,261
3,309
4,187
4,340
45,195
440
378
275
344
408
542
341
432
447
4,659
62
Section 7: Services in relation to need
7.1 Introduction
In 2010 the Child and Adolescent Mental Health Service (CAMHS) for Hampshire was retendered. Prior to this three providers delivered the CAMH Service within Hampshire.
CAMHS in Hampshire is currently being provided by the Sussex Partnership NHS
Foundation Trust. They are commissioned to provide services for children up to the age of
18 (19 if the young person has a disability) who have a moderate to severe mental health
difficulty.
Services for children who require admission to an inpatient unit, because of very complex
mental health needs, are commissioned from specialist providers by NHS England.
Since commissioning the Sussex Foundation Partnership NHS FT in 2011 the achievements
of the service include:
 Implementing a Hampshire wide intensive home treatment service. This service
provides intensive community support for children and young people with complex
mental health difficulties, supporting these children and young people within the
community reducing the need for inpatient admissions.
 Re-structuring all Child and Adolescent Mental Health teams across Hampshire to
enable access to a wider range of specialisms and interventions.
 Implementation of the Choice and Partnership Approach (CAPA) across Hampshire.
 Decreasing the number of missed appointments where the child or young person did
not attend their appointment.
 Implementing Hampshire wide referral criteria, which have improved consistency in
accessing the service.
 Successfully bidding for the ‘Increasing Access to Psychological Therapies (IAPT)’
Programme.
 Implementing a consistent approach to performance reporting.
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Figure 12: Hampshire CAMHS Model
64
There is a four-tier pathway of services in Hampshire in line with national policy which places
firm emphasis on prevention and early intervention. ‘Universal services’ which are accessible
to everyone and early interventions for groups of children and families who need additional
support are usually described as tiers 1 and 2. More specialist services, mainly provided by
CAMHSare described as tier 3 and highly ‘specialist services’ which are available for those
children with the most severe and complex needs are at tier 4. As the mental health needs
of children may increase or decrease over time they can move through the tiers to access
services in different tiers at different times.
7.2 Estimated need for services at each tier
The CHI-MAT needs assessment tool 2014 provides estimates of the number of children
and young people who may experience mental health problems appropriate to a response
at Tiers 1, 2, 3 and 4 based on work by Kurtz (1996). The following table shows these
estimates for the population aged 17 and under in Hampshire. However, these estimates
are based on work that is now almost 20 years old and as evidenced in this report the
mental health needs of children and young people have changed considerably in that time
and are thought to be increasing.
Table 13: Estimated number of children / young people who may experience mental
health problems appropriate to a response from CAMHS (0-17)
Source –CHI-MAT CAMHS needs assessment .Accessed 15TH August 2014
Sussex Foundation Trust NHS FT monitoring data for the period of May 2013 to March 2014
were used to compile figures 12 to 16.
Figure 12: Referrals into CAMHS
65
The above figure shows referrals to CAMHS between May 2013 and March 2014. The
number of referrals is stable overe this period, however, nationally it is recognised that in
recent years referrals to Tier 3 CAMHS services have risen greatly and that there has been
an increase in both the severity and complexity of cases119.
Figure 13: Number of referrals into CAMHS by CCG
The numbers of referrals by CCG are stable. The highest number of referrals is from West
Hampshire CCG as we would expect as this CCG has the largest population of children.
Figure 14: CAMHS Caseload by Gender
There are more boys than girls on the CAMHS caseload. The ratio is about 1: 1.3. From the
reported prevalence of mental health disorders in males and females we might expect the
ratio to be a little higher at 1: 1.4. This may suggest a small under referral of males to the
service.
119
The evidence base to guide development of Tier 4 CAMHS Zarrina Kurtz 2009
66
Figure 15: CAMHS Caseload by Age
The majority of children on caseloads were aged between 11 and 15 years.
Figure 16: CAMHS Caseload by ethnicity
As expected for the make up of the Hampshire population the vast majority of children on
caseloads are of White British ethnicity.
Services to support children who have mental health problems that are not severe enough
to be managed by CAMHS are available from a variety of sources including third sector
67
organisations, schools, youth services, health services, including primary care and school
nurses and Hampshire County Council provided children’s services (see appendix 1).
Many of these services have developed over time and due to changing health and social
care structures and responsibilities some of this development has been piecemeal.
Maintaining up to date mapping of the services that are available across Hampshire is
challenging but we know from work with users and professonals working with children that
there is unmet need for some services at Tiers1 and 2 which requires further investigation. .
7.2.1 Hospital Admissions for mental health disorders
The hospital admission rates for children with mental health disorders in Hampshire are
significantly higher than the England rate and the rates of our comparator authorities. The
Child Health profiles for Hampshire for the years 2012, 2013 and 2014 report crude rates
per 100,000 in children aged between 0-17years as follows; in 2012, 271 per 100,000 (
England Average 93.7) ; in 2013: 230.2 per 100,000 (England Average 91.3) and in 2014
120.8 per 100,000 (England Average 87.6). Admission rates have reduced over the three
years however they remain above the England average
Figure 18: Hospital admissions for mental health conditions age 0-17 years
Source: Hospital Episode Statistics (HES), prepared by CHIMAT (http://atlas.chimat.org.uk/)
Inpatient admission rate for mental health disorders per 100,000
population aged 0-17 years.
Rate per 100,000
300
250
England
200
Central Bedfordshire
150
Hampshire
100
North Somerset
South Gloucestershire
50
West Sussex
0
2010/11
2011/12
2012/13
. . The significant fall in the admission rate between 2011/12 and 2012/13 is not fully
understood and is the subject of further investigation. It may be explained partly by changes
in coding and/or reconfiguration of out of hospital mental health services that are
successfully preventing hospital admissions, for example the introduction of the Hampshire
wide intensive home treatment service.
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Section 8: Stakeholder Views
8.1 Findings of Local Consultation (see appendix 2)
Children and young people in Hampshire have told us that good emotional wellbeing and
mental health means ‘feeling safe and secure’, ‘being satisfied with life’ and ‘feeling
worthwhile’.
In October 2013 No Limits were commissioned to undertake a consultation to find out about
stakeholder’s experiences of children and young people’s emotional wellbeing and mental
health services and the Specialist Child and Adolescent Mental Health Service in
Hampshire.
The target audiences included:
 Children and young people, including over 18s.
 Parents and carers.
 Professionals working with children and young people outside CAMHS, who refer
into the service.
 Professionals working with children and young people within CAMHS.
A variety of methods were used including questionnaires, focus groups and one to one
interviews. There were 1,647 responses to the questionnaires, just over half of which were
from children.
The key findings of the consultation are set out below.
Children and young people said that they want people to:
 Communicate with them well.
 Be inviting.
 Have a sense of humour.
 Be trustworthy and available.
They want to be involved in decisions that involve them and be treated as individuals.
Overall they wanted to make sure that whatever we do we ‘make it worthwhile’.
Parents and carers reported that the difficulties their children faced were anxiety,
depression, autism and self-harm. The majority of parents/carers said that the first place
they would go for support if their child was having mental health difficulties would be their
GP, with the next choice being their child’s school or college. Most would choose to have
support provided by a specialist mental health service, closely followed by voluntary sector
organisations. Just over half of parents/carers who had experience of accessing emotional
wellbeing and mental health services for the first time for their children felt that the service
had improved their child’s emotional wellbeing. Where an additional service was accessed,
this increased to two-thirds. Parents/carers felt that there were gaps in services for children
suffering from ‘low-level’ mental health difficulties, including the need for more access to
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counselling services and more support with attachment difficulties and transition.
Parents/carers reported that their children generally had to wait too long to access services.
Professionals had experience of referring to a wide range of support agencies, about a third
of which were to the Specialist Child and Adolescent Mental Health Service. There was a
mixed response when professionals were asked to comment upon how easy it was to make
a referral, with half saying it was easy and half saying it was difficult. Some raised concerns
about the capacity of specialist services to meet current demand. It was reported that it was
easy to refer into other emotional wellbeing services, although professionals identified that
there are some gaps in the availability of appropriate services. Generally professionals
reported that services were in accessible locations and had convenient appointment times.
They identified a need for better communication and information for both professionals and
families about both specialist and non- specialist services. They wanted more information
about the best way to support those children with mental health needs who do not require a
specialist mental health service to help ensure that their health does not get worse.
Full details of the methodology and findings of the consultation can be found on the
Hampshire County Council website.
8.2 ’What do I think?’ Survey
Each year Hampshire County Council provides children in school with the opportunity to say
what they think about a variety of issues through the ‘What do I think?’ survey120. The last
survey was conducted in 2013 and over 16,000 responses from children aged 5-14 were
received.
The results of the survey have helped us to understand how supported those children who
responded feel when they are in school if someone is being unkind to them or if they need to
talk about their feelings.
Children told us that mostly they enjoy being at school. While most of the younger children
always have an adult in school to talk to who will do something if someone is being unkind
only a third of older children thought that they had an adult who could do something. A third
of children did not think that there was anyone in their school that they could talk to about
their feelings.
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Section 9: Recommendations
Action can be taken to improve mental health in children at a societal level, community level
and at an individual and family level.
Interventions should be evidence based and cost effective.
Action is needed at all levels to improve the mental health of children.
The recommendations from the 2013 JSNA remain highly relevant and are supported by the
findings in this needs assessment. There should be an increased focus on implementing
them:
 Promoting maternal mental health
Ensure that the health visiting contract continues to include the responsibility to
identify mothers at risk or in early stages of postnatal depression, and then offer
appropriate support and treatment.

Promoting positive parenting
Enable access to evidence based parenting programmes for those at highest
risk.

Ensuring access to mental health services
Enable access to effective services to diagnose and treat conduct disorders in
childhood, especially amongst first time entrants to the youth justice system.
Ensure that child and adolescent mental health services meet the breadth of
need of our young people and are readily accessible to them and are nonstigmatising.

Looked after children
Ensure there is adequate support for young people leaving care, particularly
transition to adult services.
In addition the findings of this needs assessment lead to the following recommendations:
 Awareness raising
Raise awareness of the importance of good mental health in children amongst all
those who work with children to improve early recognition and intervention as
appropriate.
Evidence-based mental health training for non-mental health professionals. This
could include training for midwives, health visitors, school teachers and staff,
those working in the voluntary sector, police and probation staff in acute and
community settings.
High quality information about child development, emotional wellbeing and
mental health and where to get help should be readily available to parents,
carers and young people.
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
Promoting mental health
Organisations should work together to promote good mental health in children by
building protective factors and reducing exposure to the risks for poor mental
health wherever they can.
Encourage schools to adopt a whole school approach to promoting resilience
and good mental and physical health, including tackling bullying.
Ensure that programmes aimed at promoting resilience, emotional wellbeing and
mental health are both girls and boys.

Universal services
Investment is needed in universal and targeted services (Tier 1 and 2) to
address the unmet needs of children with mental health conditions at an early
stage to help to prevent progression to more serious illness and to reduce the
future social, health and economic costs associated with poor mental health

Vulnerable children
Action should be taken to ensure that those children and young people who are
at a higher risk of mental health problems are identified so that they get the right
support at the right time – for example looked after children, children with
learning disabilities and children in contact with the Criminal Justice System.

Specialist mental health services
Ensure all children, young people and families have timely access to timely,
evidence- based high quality specialist mental health support when it is needed
Ensure that our Specialist Child and Adolescent Mental Health Service can meet
the needs of the increasing numbers of vulnerable children in a timely manner.

Parenting
Undertake a review of parenting provision to quantify the reported gaps so that
action can be taken to address unmet need.

Prevention and early intervention services ( Tier 1 and 2)
Commissioners should review the capacity of and strengthen prevention and
early intervention (Tier one and two) services to ensure they are adequate to
meet the needs of children and young people, particularly vulnerable children
and those children at increased risk of developing mental health problems.
Self Harm
Investigate the high rate of admissions for self harm.
Review strategies for the prevention of self harm.
Review and improve the pathway of care for young people who self harm.


Wider determinants
Encourage all organisations to consider the impact on children’s mental health of
their strategies, policies and initiatives.

Information
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Continue to build on and support the Hampshire pupil’s attitude survey with a
view to obtaining a more representative view of attitude and emotional health
and wellbeing across the County.
Advocate for better information about children’s mental health needs so that we
can quantify the issue.
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Appendix 1: Further examples of local CAMHS tier 1 and 2 services
Children’s Centres – There are 54 children’s centres in Hampshire. These services
however are not specifically for mental health concerns. Children's centres aim to give every
child the best possible start in life by giving families with children under the age of five
access to a range of different services to support them, including:
• Information and advice on family support services
• Drop-in sessions for parents, carers and child-minders
• Access to early education and childcare for children under five
• Access to child and family health services
• Links with Jobcentre Plus, further education and training opportunities
• School Nurses and Health Visitors
Parents and families influence child health outcomes, health visitors and school nurses are
therefore well placed to play a key role in promoting the emotional wellbeing and positive
mental health of children, young people and their families. SN and HV’s have a specific
contribution to make in identifying issues, using protective screening and providing effective
support.
Health visiting and school nursing services can also provide input in terms of prevention,
early intervention, on-going support and referral to specialist services, whilst working
collaboratively with partnership organisations. They are both well placed to identify issues,
use protective screening and provide effective support 49.
From October 1st 2015 the commissioning responsibility of health services for children aged
0-5 years will be transferred from NHS England to Local Authorities.
Hampshire Youth Offending Team (YOT) - Hampshire YOT has over 90 staff and
approximately 150 volunteers who work together to prevent young people offending or
reoffending. This service is made up of Social Workers, Police Officers, Probation Officers,
Youth Support Workers and specialists in health, education, parenting, substance misuse
and sports/arts.
Their role includes:
• Supporting and supervising children and young people who have been made the
subject of a court order because they have committed a criminal offence.
• Assessing and providing interventions for children and young people who are at risk
of offending, or who have received a youth restorative disposal, final warning or youth
conditional caution administered by the Police.
• Acting as an appropriate adult (in the absence of a parent/guardian) for children and
young people held in custody at a police station.
• Providing support for young people on bail.
• Preparing reports and other information for courts in criminal proceedings so that
informed judgments can be made by the judiciary.
• Working with parents to help them develop better parenting skills.
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• Offering the victims of crime the opportunity to get involved in the process (even to
the extent of meeting the offender) to help the young person understand the impact
of their offending behaviour.
{Source: Hampshire YOT}
Early help Intervention (Hubs): this has four elements, identification, assessment, support
and evaluation. It crosses the full range of services for children, young people and families,
provided by all Children’s Trust partners. The hubs will be piloted in Hampshire in August
2014, with a view to a full roll out across the county in 2015. The hubs will incorporate:
• Universal services: schools, children's centres, childcare providers, doctors, health
visitors and maternity services.
• Targeted services: parenting programmes, one-to-one tuition for pupils, youth
support services and Child and Adolescent Mental Health Services (CAMHS).
• Specialist services: provide high-quality specialist support for families facing specific
and potentially multiple problems, including substance misuse and offending.
Troubled Families - The programme’s multi-agency Local Coordination Groups have now
identified over 1,000 families across the County which are currently or will receive targeted
multi-agency family support. Although the programme continues to move along at a pace, it
remains on-course to provide support to at least 1,590 families by March 2015. In October
2013 the programme reported success with a further 143 families, on top of the 79 reported
in July, where there has been a sustainable improvement in school attendance, reductions in
youth crime and anti-social behaviour and helping family members towards training,
volunteering and sustainable employment.
Hampshire Primary Behaviour Service (PBS) – The Primary Behaviour Service is a team
of dedicated practitioners with extensive experience working in Hampshire primary schools
to promote children’s’ positive behaviour and emotional wellbeing. It is a referral based
service offering outreach and in reach support for primary children with behavioural,
emotional and social development needs. Their approach is to provide targeted support
early in a child’s life, helping to meet their additional needs in order to get the most out of
their education.
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Appendix 2: Stakeholder Engagement Summary
Method
Four surveys were planned with questionnaires drafted in collaboration with the target
population and stakeholders. Survey C was shown to GPs representing the 5 CCGs at the
Hampshire Emotional Wellbeing and Mental Health group, and feedback was incorporated
into the final draft. CAMHS professionals were approached by their senior management.
Schools and FE colleges were sent links to all the surveys except survey D. Target lists
were drawn up for survey C and personalised links were circulated accordingly. All 4
questionnaires were also posted on the No Limits website, with reminders about them
posted weekly on the No Limits Facebook page, Twitter feed and blog.
Posters about the consultation, paper copies of the questionnaires and boxes for children
and young people and their parents / carers to post back paper copies were displayed in the
CAMHS bases, youth information, advice and counselling services and youth clubs. Parents
/ carers who did not have access to the internet were sent paper copies of the survey, and
collected for data entry.
Interviews were conducted with parents and professionals to amplify the information
gathered through the questionnaires.
Focus Group discussions were held with 4 groups of children and young people to develop a
Pledge – what they would like to experience from emotional wellbeing support services.
The surveys remained open for response until 4pm on Friday 20 December 2013. By this
time the total number of responses were as follows:
A
B
C
D
Children and young people (all 835
ages)
Parents and carers
298
Professionals outside CAMHS
478
Professionals within CAMHS
36
Total
1647
Findings
The children and young people had a good understanding of what “emotional wellbeing and
mental health” meant to them. “Feeling safe and secure”, “Being satisfied with life” and
“feeling worthwhile” were there most common explanations. Only 25% of them said that
they had “”someone I can talk to about anything” and a worrying 6% said that there was no
one they could talk to about their emotional problems. 46% found it difficult to talk about how
they are feeling.
A significant number of children and young people report feeling anxious or unhappy
recently, with well over half of them finding it difficult or quite difficult to talk about how they
feel, and well over a third finding that how they feel has a very negative effect on their lives.
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Nearly a half of them had had been to a service for support over emotional problems, a
quarter of whom had accessed the Specialist Child and Adolescent Mental Health services.
Nearly two thirds of the parents and carers had children for whom they had experience of
seeking support services, with two thirds of these seeking help from the Specialist Child and
Adolescent Mental Health service. The most common issues their children needed support
over were anxiety, depression, and Autistic Spectrum disorders and self-harm.
Children and young people said that they would choose to look for support independently
through websites etc., or ask teachers or school or college staff. The majority of parents and
carers would choose to ask a doctor, with the next choices being teachers and
School/college support staff as where they would ask for help for their children. Parents and
carers wanted to access Specialist Child and Adolescent Mental Health services for support
for their children, closely followed by voluntary sector counselling or support services and
school or college support services. Parents and carers and Professionals (both those
working for Specialist Child and Adolescent Mental Health services and not) felt that there
were gaps in the range of support services available. The most common gaps identified
were for support for children and young people with “low-level mental health issues”,
including the need for more access to counselling and support for children with attachment
issues and those in transition.
Professionals who were not part of the Specialist Child and Adolescent Mental Health
services had experience of referring to a wide range of support agencies, about a third of
which were referrals to Specialist Child and Adolescent Mental Health services. There was
a half and half split between those finding referrals to Specialist Child and Adolescent Mental
Health services easy and finding them hard. Those who reported issues with referrals talked
about waiting times, the threshold being too high, inconsistency and a lack of feedback.
Although many were satisfied with the feedback they received, referring to letters to
themselves and parents, many others said they received no feedback, or not enough, or that
they only heard via parents, or that they only get feedback if they pursue it themselves.
These professionals overwhelmingly said that there was not enough capacity within the
Specialist Child and Adolescent Mental Health services. They reported that it was easy to
refer into other emotional and wellbeing support services, and that there was better capacity
within these services that within the Specialist Child and Adolescent Mental Health services,
although they still identified gaps in service range and availability.
Professionals working for the Specialist Child and Adolescent Mental Health services were
less likely than other professionals or parents and carers to consider the threshold into their
services too high, with comments about the thresholds being changed in order to reduce
demand, and demand being too high for capacity.
47% of the children and young people had accessed support services. They generally felt
them to be accessible, welcoming, understood what was going on and were happy with the
confidentiality. Parents and carers were happy with the accessibility and environment within
which support was offered, but were unhappy with the waiting times (see below).
Professionals who do not work for the Specialist Child and Adolescent Mental Health service
mostly felt that the service locations for both Specialist Child and Adolescent Mental Health
services and other support services were good, that services were welcoming and
appointment times were convenient. Better communication and information about services
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were identified as issues which could be improved with the Specialist Child and Adolescent
Mental Health services.
Children and young peoples’ experience of the waiting time from referral to being seen was
generally okay, with those accessing services other than the Specialist Child and Adolescent
Mental Health services reporting more positive experiences with shorter waiting times.
Parents and carers were much more negative about the waiting times, with over half finding
the waiting time much too long, and over two thirds stating that this had a negative effect on
their child’s emotional wellbeing and mental health. This concern over waiting times mostly
concerned the first services they were referred to – those with children referred onto
additional services were generally happier with the waiting time. Professionals both working
for and not working for the Specialist Child and Adolescent Mental Health service were also
concerned about waiting times for Specialist Child and Adolescent Mental Health services,
but not for other support services.
Children and young people who had accessed support were more positive about the benefits
and outcomes from support they had accessed from services other than the Specialist Child
and Adolescent Mental Health service. 30% of children and young people who had accessed
the Specialist Child and Adolescent Mental Health service said that “I learned a lot, but it
couldn’t help with other things that were going on in my life” and a further 30% said they felt
“better” or “mostly better”.
52% of parents and carers said that their children’s emotional wellbeing and mental health
improved as a result of interventions provided by the first service they accessed, 33%
remained the same and 15% became worse. Half of the parents and carers did not comment
on this, many because they were still in the process and it was too early to say. Although
many were very positive, there was also criticism of the slowness of the response, the
effects of staff turnover and misdiagnosis. One third of the parents and carers children went
on to access a second service, for these 66% reported improved outcomes.
The majority of professionals who do not work for the Specialist Child and Adolescent Mental
Health service did not comment on the outcomes of children and young peoples’ access to
Specialist Child and Adolescent Mental Health services. For those who did express an
opinion, the majority stated that children and young people were effectively supported. There
was a great deal of comment on the effectiveness of services and what could be improved.
Many felt that clear information, not just about CAMHS provision but about preventative work
and provision and strategies for children and young people not meeting the thresholds of the
service, would be helpful. Many people reported experience of poor communication from
Specialist Child and Adolescent Mental Health services and detailed ways in which it could
be improved. Some mentioned having difficulty finding support for children and young
people with very specific needs, such as Autistic Spectrum disorders, or finding services that
were close enough to their own location to be accessible. Consistency across the service
was felt to be lacking. They were concerned about the lack of resources in CAMHS and the
negative effect this might have on the quality of the services provided. They were critical of
long waiting times and identified a number of specialist areas where more services are
needed. Three quarters of them felt that accessing other support services improved children
and young people’s emotional wellbeing and mental health. They found it easy to refer and
found communication to be good. They identified a need for clear information about the
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range of services available from all sources, and what their referral criteria are. They were
concerned about the level of support available for children and young people who do not
meet the criteria for specialist services but who nevertheless need help and support in order
for their health not to become worse.
61% of professionals working for the Specialist Child and Adolescent Mental Health service
considered that the service delivered effective support. This is higher than the opinions
expressed by parents and carers (52%) or children and young people themselves (30%).
many other professionals left this question blank that comparison is not possible. The
professionals from the Specialist Child and Adolescent Mental Health service particularly
mentioned the effectiveness of the Choice appointments, multi-disciplinary teams and the
skills and experience of the staff. Their suggestions for improvements overwhelmingly
focussed on increased resources, particularly staff.
The Health Survey for England – 2012. The health and Social Care Information Centre, December
2013
i
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