21
Examination of witnesses
Kadra Abdinasir and Dr Elaine Lockhart.
Q152 The Chair: Good afternoon, everyone, and welcome to this public evidence session of the Children and Families Act 2014 Committee. I thank both our witnesses for coming along to talk to the committee this afternoon on the very important issue of mental health, which we have been very conscious of throughout our deliberations on how the implementation of the Act is going. Before we move on to the formal questions, could I just ask both of our witnesses to introduce themselves please?
Dr Elaine Lockhart: Good afternoon and thank you very much for the invitation. I am a consultant child and adolescent psychiatrist. I am currently working with children and young people who have intellectual disability and mental health disorders, but I spent over 20 years working in a children's hospital as a child psychiatrist. I am here as chair of the child and adolescent faculty of the Royal College of Psychiatrists.
Kadra Abdinasir: Good afternoon, everybody. I am associate director for children’s and young people’s mental health at the Centre for Mental Health. As part of my role, I am also the strategic lead for the Children and Young People's Mental Health Coalition, which is a network of about 260 organisations that campaign on children's mental health. Thank you for inviting me.
Q153 The Chair: I will just start, if I may, with quite a general opening question. During our deliberations, the committee has certainly heard a lot from witnesses about the intersection between the Act and the mental health of children and young people, particularly when we have been engaging directly with parents and young people, professionals and others about the difficulties that many young people have faced in obtaining the mental health support they need, primarily through NHS CAMHS.
This is what we want to explore further today. It has been a cross-cutting theme throughout our deliberations on adoption, the family justice system, SEND and other issues. With a particular focus on CAMHS, why do you think children's mental health services are often described as being in crisis? Certainly, previous witnesses have used those very words. What can be done to improve the service?
Kadra Abdinasir: First, from our perspective, it is really important and helpful to contextualise the current crisis in children's mental health services and to recognise that it is the result of decades of underinvestment in children and young people's mental health services. We have also had significant gaps in data on the prevalence of mental ill health and on children and young people's access to services.
It is also important to recognise that there has been a lack of investment in and access to alternative early interventions and community-based services, which means that specialist child and adolescent mental health services often become the first port of call. That is reflected in rising referrals to CAMHS. Recent data from one of our Coalition members, YoungMinds, shows that we have had the highest ever recorded levels of referrals to specialist CAMHS at 103,865, which is significant. As part of that, we have also seen a sharp rise in referrals relating to specific issues such as eating disorders and self-harm, some of which can be explained by the additional pressures children and families have been facing because of the pandemic.
I know Elaine will say more on this, but we need to recognise the workforce challenges that the system faces. From our perspective, transforming the mental health workforce is a critical part of boosting capacity in the system. We recognise that need has risen sharply, but the workforce expansion has not really kept up with that pace, so we would like to see some of the commitments already made by government through things like the NHS Long Term Plan to expand support with urgency for all young people aged zero to 25. Within that, there is a laudable ambition for services to reach 100% of children and young people in need of support. We would really like to see a breakdown of what that would look like with a road map to support that.
The Chair: In preparing for this afternoon, to be honest I was quite shocked when I read that the current commissioners, the clinical commissioning groups, spend less than 1% of their overall budget on children's mental health, but 14 times more, I think, on adult mental health. I would like your take on why there is such a disparity between the amount of spending on children's mental health and the amount spent on adult mental health.
Kadra Abdinasir: I think it comes back to the lack of parity of esteem between physical and mental health. Although what we spend on adult mental health is probably not good enough, children's mental health services continue to get referred to as the Cinderella of Cinderella services. However, I wanted to point the committee to the fact that this tells us about only one element of the system—the NHS system. The children’s and young people's mental health system is broader than that, and we really struggle to get up-to-date information about spending across the entire system. What do the police, local authorities, the VCS and the broader NHS put in? They are all part of the system. We focus specifically on specialist services, but of course we would like to see increases in spending across the whole system.
The Chair: That is very helpful, and the distinction you have just drawn between CAMHS and the wider children’s and young persons’ mental health system is really important. Elaine, could I have your general take on this issue?
Dr Elaine Lockhart: To add to what Kadra has said and to set the scene, historically children's mental health has been neglected, and part of that is that their needs are far less visible. We argue that we should be beginning from conception and thinking about infants, because we can identify who will be more vulnerable than others. A lot of that is to do with social background, poverty and inequality, having any chronic physical conditions or having parents with mental health conditions, addictions or their own history of a difficult upbringing. Even in services where we receive 6% of the total mental health spend, a lot of that will be focused on teenagers because they are presenting in crisis and are more likely to ask for help than previous generations were. They are struggling, but we are not paying sufficient attention to infants and children under 12. Part of the discrepancy is the invisibility of children's mental health problems and their inability to articulate for themselves.
A group of children I am working with have intellectual disability and severe autism and other neurodevelopmental disorders, and their families have to commit so much time and energy to looking after them that they find it difficult to lobby and articulate for better services. There is inequity even within the age range that we are thinking of. As Kadra described, their mental health is deteriorating, and part of that is because of social inequality, which has increased over the last 30 to 40 years. Social inequality is particularly toxic to mental health and well-being for all children and young people. Even amongst those who are most comfortable and privileged, the UK scores lowest on the happiness index for children and young people. We know that the mental health of the most vulnerable has been really poor and is getting worse, and we know that social media has probably played into that.
Before the pandemic, specialist services in particular were struggling to meet need. According to the long-term plan, we are seeing a quarter of those with mental health problems, and the aim is to see a third and build up to 100%, as Kadra said. We were struggling even before the pandemic, even though we are not an expensive service in that all we need is a trained, skilled workforce and comfortable facilities. Occasionally, we will use medication and need access to physical investigations.
We do not need big theatres or big hospitals, but the trained workforce is really problematic. There has been investment, and a lot of people coming into the workforce in the last five or 10 years may have one year’s postgraduate training and so can deliver psychological therapies for children and young people who have mild to moderate difficulties. In psychiatry, however, we have to think about those who are most unwell. We are really struggling with the workforce across psychiatry—senior clinicians, psychologists and nurses—and we are now experiencing lots of unintended consequences. Experienced people are leaving because of the tax arrangements, because of burn out, and people are more now likely to think about leaving the NHS or leaving the country altogether and working in the private sector, which means that we are having to work very hard on recruitment. We have about a 14% vacancy in consultant psychiatrists at the moment and we have filled about 80% of our higher training placements.
The other challenge for the workforce is that it is mostly female, so obviously there is then a need to think about the numbers of trainees and consultants et cetera who may want to take time off to have children and to work less than full time, and, increasingly, male colleagues are also asking for this. When we think about our training numbers, we need to realise that we are living in 2022 and to recognise the things that people are looking for. We need to have whole-time equivalents, not just one person who might work 0.6 of a whole-time equivalent job, and we need to think about how we retain our skilled workforce. At the moment, the pressure on services is immense, and, as Kadra said, we have a whole lack of services across the piece—services that could be there to intervene earlier. A lot of mental health can be tackled in non-clinical settings, and unfortunately we have seen retrenchment on what can be offered in schools and communities over the last 20 years.
The Chair: There are a lot of important issues there, particularly with regard to the workforce.
Another thing that rather shocked me when I was preparing for the session was that the number of children and young people referred to CAMHS between April and June 2021 was up 134% on the previous year. We all know about the impact of the pandemic and all of that, but did that figure shock you, and what did you put it down to?
Dr Elaine Lockhart: I put it down to the increasing prevalence of mental health problems. When the big UK survey was carried out in 1999, one in 10 had a probable mental health problem. The most recent study, from 2021, reports one in six. The pandemic has had a really negative effect on children’s and young people's well-being. Allied to that, we have had a loss of services during the pandemic. A lot of other services closed down or stopped providing face to face input. Schools are an important source of support for children and young people. That may be partly through seeing friends and having access to trusted adults, but families also often get quite a lot of support from teachers in parenting and supporting children and young people. The increase was shocking, but it was not surprising.
The Chair: Thank you. That is very clear.
Q154 Baroness Wyld: Good afternoon to the witnesses. I want to ask about those figures. You both mentioned increasing awareness. How would you respond to people—not me, I stress—who might say that we are medicalising normal adolescent feelings and putting ideas into children's heads?
Dr Elaine Lockhart: I do think there is a risk of that. Sometimes young people medicalise what we might see as absolutely normal and appropriate levels of anxiety. We know that during the pandemic nearly every child and young person struggled at times, as did families, and that most children and young people are resilient and bounce back. The problem is the lack of capacity in communities and schools to contain what the child and young person might be struggling with. It could be quite a short-lived episode of anxiety or low mood, but currently the default position is to refer to specialist CAMHS due to the lack of other services. GPs will say, “I don’t know of anything else that’s out there”.
We know that there are lots of really good services out there, but it is patchy and inconsistent across the country. It is a reasonable thing to flag up. I do not think that we in special services want to medicalise anything, but there is a worry that that might be happening due to a lack of capacity in the system to call things out and to say that it is absolutely normal to be feeling anxious when you have not been in school for six months.
Baroness Wyld: Yes, that is helpful. Thanks.
Kadra Abdinasir: I echo Elaine's points. Obviously one thing to acknowledge is that we have made significant strides in society in tackling the stigma associated with mental health. Lots more children and families feel confident about seeking support for mental health services. To me, that is a positive thing. The figures that Elaine shared show a tangible increase in prevalence. We have seen that, and it is real. For many children and families, their gateway to specialist CAMHS is through other professionals. Where professionals can meet that need before a referral, and are equipped with the tools they require, they will do that. If not, then, as Elaine says, often the result is just referring on to CAMHS. The levels of referrals vary across the country. You often hear about a postcode lottery, which can be seen in local areas where there are high levels of deprivation and where they have been impacted most by things like cuts to youth services and other provisions in the area. There is a strong correlation there.
Q155 Baroness Prashar: Good afternoon everybody, and thank you for your responses so far. I would like to pursue a little further the question of the increase in numbers. Is the pandemic the root cause of the rising numbers, or did the issues exist pre pandemic with CAMHS?
Kadra Abdinasir: As we have mentioned, there definitely has been an increase over the last few years, and some of that can be attributed to the pandemic. The NHS data shows, for example, that the issue of families living in households that fell behind on bills during the pandemic was closely linked to poorer mental health outcomes for young people. However, from our perspective, many of these concerns predate the pandemic, and there are other factors that come into play, such as the growing levels of child poverty in this country, which we know is closely linked to mental health.
It is also important to state that headlines often talk about a tsunami of mental health caused by the pandemic, but it is a lot more nuanced than that. We like to think of it as like a rising tide in some ways. Analysis that we did at the Centre for Mental Health suggests that, because of the pandemic, 1.5 million children and young people under the age of 18 could need new or enhanced mental health support linked to things like depression and anxiety, post-traumatic stress disorder, trauma and complex bereavement. We need to see this as potentially stored-up demand, as this distress may take some time to be seen in children. There are not just direct short-term impacts of the pandemic, some impacts will be seen in the coming years.
Other issues that have negatively impacted children's mental health that we have heard about from some of our coalition members include things like disruption to sleep patterns and education, which has impacted young people's mental health, especially young adults’, and their outlook on their future prospects. Household pressures such as financial instability and hidden abuse and neglect in the home are also damaging and impact on young people's mental health.
It is also important to note that, on the flip side, some children and young people have actually observed some improvements to their well-being during the pandemic. For example, some have really benefited from flexible and remote learning at home, some have experienced respite from school-related pressures such as exams and bullying, and many have benefited from spending more time with their families. As we continue to come out of this pandemic, we have to think about those groups of young people and how we can continue to support them.
Baroness Prashar: It is very interesting that some have benefited.
Dr Elaine Lockhart: There was a delay in repeating the 1999 study I mentioned earlier, which reported a figure of one in 10 children and young people having a probable mental health disorder. It was not repeated until 2017, and at that stage the figure was one in eight, which shows that we had already seen a change for the worse before the pandemic. As Kadra has described so well, there will be an impact on children at the hard end of any social inequality and any pressure in families, but what we saw during the pandemic was, if you like, a shift in the curve to the right. Children who had previously been well became quite destabilised by the lockdowns associated with the pandemic. For the majority, that was short term, but anxiety and depression became more prevalent.
We saw a significant increase in the number of children and young people with eating disorders and disordered eating. We all know about anorexia nervosa, but we have also seen children who were just not eating enough. That was more anxiety-based, and these are often children with neurodevelopmental vulnerabilities like autism. We also saw an increase in self-harm and psychosis. There has been a significant increase in self-harm, again often among the most vulnerable children and young people who were perhaps looked after and accommodated or where family circumstances were the least stable. Psychosis, again, often relates to what is happening in a child’s or young person's life, but the lack of routine and usual structure also meant that some young men in particular started using substances like cannabis, and heavy use sometimes tipped them into developing psychosis. So we have seen that increase, but there were already worrying trends before this all started.
Baroness Prashar: Are you saying that it was exacerbated by the pandemic?
Dr Elaine Lockhart: Yes, and if I can just pick up on Kadra’s point, some of our patients found that lockdown made life easier, but that is a really sad indictment of what life is like for some children and young people, and these were generally children and young people with learning disability and/or autism who find the world a really difficult place to be and for whom going to school is so stressful. We would hear from their families about how they were actually quite happy. They were in the house, no one was putting any pressure on them, the rules on screen times were naturally abandoned and they were being left to their own devices. With the school return, the increase in stress levels was tremendous. We are also aware of a significant number of children and young people who have not made it back to school since the lockdowns were eased, which, again, is probably a very complicated psychological and social challenge.
Baroness Prashar: It is interesting to see that the pandemic was positive for some because they did not have to go out, while others, of course, suffered. Is anybody doing any work in this area? Has this been monitored or documented in terms of the pandemic?
Dr Elaine Lockhart: NHS Digital is carrying on repeating its surveys. When it repeated the 2020 finding in 2021, it found roughly the same incidence of one in six children and young people having a probable mental health disorder. That is the study I am aware of, and I know that it will carry on reviewing that.
Kadra Abdinasir: One of our members, the Royal College of Paediatrics and Child Health, has a web page where it has been collating all the studies related to the impact of the pandemic. I can share the link to that, as it is very useful.
Baroness Prashar: That would be very helpful.
The Chair: Can I just reiterate how useful it will be if you could share that link with us? Thank you very much for that.
Q156 Baroness Massey of Darwen: You both have vast experience of children’s and young persons’ mental health services, and you have already tackled and addressed quite a number of the huge social issues, education issues in particular, and complex needs. I want to dwell for a minute or two on the importance of prevention and early intervention. We talk about prevention and early intervention for all kinds of things, and it is really important. Is the current mental health system able to provide early intervention in the state it is in now, and do you have any examples of good practice of that being done? I am thinking in particular of things like children's houses. I think we have a few of those, but I am not sure, so maybe you could comment on that.
Dr Elaine Lockhart: One of the reasons why we will press for better investment in children’s and young people’s services is that we know that by intervening early in life and early in the development of illnesses we can achieve better outcomes. In terms of prevention, the Royal College of Psychiatrists is developing a position statement on zero to fives, because we know that if we focus in at the time of conception, we can target families who we know will be more vulnerable for various reasons and we can intervene to support those families from the very beginning. Infant mental health teams are being developed in some areas of the country, but so far they are rare.
By intervening early, we can do a lot of good for the most vulnerable. Parenting programmes have also been shown to be effective across the piece for all families. There are different versions of that according to the age of the child, and there are some for particular needs, such as intellectual disability, that have good outcomes. There are school-based programmes that we know are effective and can get good outcomes. The Royal College of Psychiatrists has a paper that I can share with you, and its Public Mental Health Implementation Centre has looked at the research and pulled together the evidence for preventative interventions, which I can share with you if you would like me to.
Baroness Massey of Darwen: That would be marvellous. Do you have any comment on things like children's houses?
Dr Elaine Lockhart: Could you be more specific?
Baroness Massey of Darwen: They started, I think, in Iceland and then spread to various other parts of Europe, certainly. The children come to a hub, a house, that has been specially tailored to them, and they sit and talk to somebody very informally and then go on to specialist intervention if they need it. I think there are two in this country, but I am not sure. Forget that anyway. You have done enough already.
Dr Elaine Lockhart: Thank you. I think Kadra might refer in her answer to the accessible services that we might be looking at for young people.
Kadra Abdinasir: Yes, absolutely. Prevention and early intervention are critical in lots of areas relating to children and young people and children's mental health. First, I just want to mention that we have a lot of evidence about social determinants and the drivers of poor mental health such as poverty, racism, and discrimination. Lots of children and families at the moment are concerned about the cost of living crisis and its likely impact on children's mental health. Just a couple of days ago, YoungMinds released some figures showing that children as young as 11 are beginning to feel worried about this. From our perspective, none of these things are inevitable. There are things that policymakers can do to address the known determinants for poor mental health so that is a first step in action that we can take on a cross-government and local level.
In another model that we have been looking at as part of our Fund the Hubs campaign, we have been calling for the Government to invest in a network of early support services, early support hubs, for children’s and young people's mental health. These are just open access hubs where young people can self-refer. They are community based and can be delivered in a range of different settings. They work with young people with emerging mental health problems alongside other factors that we know impact their mental health, such as financial support, sexual health and substance misuse, all under one roof.
An example of a hub that uses the Youth Information Advice and Counselling Services model—YIACS—is the Mancroft Advice Project in Norfolk. It offers an open access hub in the town centre addressing the multiple difficulties that young people may be facing but it takes a whole family approach as well. It is able to provide facilitated joined-up support when young people and families are struggling with some of those tensions in the household.
Baroness Massey of Darwen: I would be very interested, and I am sure other people would too, to look at some examples of these hubs or houses—whatever they are called—because they are a really interesting model. Can you give us a link to that?
Kadra Abdinasir: Of course, yes, I am very happy to.
Baroness Massey of Darwen: That is really helpful, Kadra. Thank you so much.
Dr Elaine Lockhart: I am sorry, I could stay here all afternoon talking about this. The new integrated care systems provide an opportunity for prevention and early intervention. We will need the infants, children and young people to be recognised as being really important in the system, which may well be focusing on older adults and secondary healthcare systems for good reasons, but we know that we could facilitate much earlier intervention if we could join up what we can offer. Specialist CAMHS is overwhelmed, but there is a lot of expertise there and people could be freed up to support what can happen in schools, paediatric hospitals and community settings, other community organisations and children’s units, et cetera. Secondary prevention is where there is a problem, but you really reduce the impact of whatever illness or disorder is present. The challenge with ICS’ is about how we can get traction in this new system to make sure that the mental health needs of infants, children and young people are not forgotten.
Baroness Massey of Darwen: That is very interesting.
Kadra Abdinasir: I just wanted to touch on mental health support teams in schools. This programme is part of the Government's Green Paper on children's mental health that is being rolled out at the moment. There is a commitment as part of that to roll out what they call mental health support teams in schools to about a fifth to a quarter of children and young people across the country. Again, like the ambitions on access to CAMHS, we do not think that is good enough. It should be full coverage. We would really welcome the committee endorsing messaging about securing further funding to deliver that because these teams really do play an important role in helping pupils and teachers to navigate the mental health system. They are able to support children in care or in contact with children's services in the education setting themselves. If not, they are able to make those referrals to elsewhere in the system.
Baroness Massey of Darwen: Are all these services linked up in some way?
Kadra Abdinasir: The idea is to set these up so that they help to link up the system so they are a bridge between primary care, specialist CAMHS and schools.
Lord Mawson: I suppose I was worrying a bit about your overconfidence about what the state can do. Having lived a lot of my life in these communities and in this kind of work—I am now about to enter my 11th Government—I have found that Governments are totally unreliable when it comes to these kinds of issues. They chop and change—here we go again, with another one here today, gone tomorrow—with half-baked ideas that never happen and all the rest of it. What no one ever does, including our journalists, is pay attention to the unintended consequences of all that chaotic stuff on some of our poorest families.
I have also noticed that the state is not very good at noticing the blindingly obvious that is right in front of them. Even all their researchers do not notice. For example, in Tower Hamlets many years ago, we noticed that many Bengali women were trapped in flats, mainly by their husbands for cultural reasons, and were becoming mentally ill. We were regenerating a park at the time that had been derelict land, and no one in the system—social workers, researchers—had even noticed that these people were all farmers from Sylhet in Bangladesh, and that if you connected the land to them for free it brought them out of their flat and they started gardening and growing little allotments. That is what we did and it cost next to nothing. That is how a whole health programme begins to happen, but it is not called health; it is called gardening and farming.
As I said, my problem, I suppose, is your overconfidence about what the state can do. I suggest to you that the state might be part of the problem, and I also wonder whether your model will ever be affordable in the present climate. I wonder whether there needs to be innovative thinking about what might be possible here, because I am not sure we will ever be able to afford again an army of professionals to sort out all our mental health. Maybe something else needs to happen—something our grandparents and others knew more about than we do—in a society like ours, aided and abetted by the internet, which is increasingly atomising and increasingly about me, me, me rather than us.
My experience of mental health, having been involved in mental health management for many years, is that a lot of mental health is to do with isolation and disconnection from families, communities and relationships. We are social beings, and I am not sure that the state is very good at dealing with that. I would be interested in your comments, because it seems to me that there needs to be new thinking in this space, not, “If only the state would give us more money, everything will be fine”. I am not sure that is realistic.
Dr Elaine Lockhart: You make lots of good points there. If we really want to change things, as you say, the most effective change starts in communities. We have seen some lovely examples of young people, when they are struggling, being much more likely to talk about their mental health in different arrangements set up in schools and their own different groupings. It is about peer to peer support. It is not about medicalising what is happening, but saying, “You know, sometimes things are a bit difficult. Let’s talk together”. The impact of having safe green spaces to go out in and children and young people having access to regular exercise will come down to the communities in which they live. That does not need to be provided by the state, but there needs to be thinking about what the children and young people need to thrive.
A lot of our interventions do not necessarily need to focus on how they feel or think. Actually thinking about their behaviour and their physical well-being can be hugely effective. For children and young people coming from really deprived communities where they are really up against it, no antidepressant or psychological therapy will fix that. So I think you are absolutely right. It is not just that the state cannot fix everything, but that medicine cannot fix everything unless we look at the whole psychosocial environment that families live in.
Kadra Abdinasir: I would echo Dr Lockhart’s points. One thing the state can do is minimise by taking actions on things that threaten people's mental health in the first place and thinking about mental health and well-being across all levels of policy development. The fragmentation and confusion at the top filters down locally, and we find that quite challenging in the mental health space.
When it comes to things like prevention and early intervention, everyone locally points the finger at each other in terms of who is leading on a piece of work, but there has definitely been lots of learning from the voluntary and community sector and the private sector, which we consistently try to take to the state in order to show examples of good practice, and many of these things are affordable. It is estimated that at the moment mental ill health in society costs the state around £114 billion a year. Investing in early support hubs would cost £103 million a year. The cost-benefit analysis show there are clear the savings that could be realised with some of these programmes of work.
Q157 Baroness Wyld: I have a specific question about children in care and children who leave care, are adopted or go into the care of a special guardian. My prepared question was about how well CAMHS is servicing them, but given the wider context, how well are mental health services in general working for children who are in care or coming out of care?
Kadra Abdinasir: In recent years there has been growing recognition in the mental health sector of adverse childhood experiences like the impact of emotional, physical and sexual abuse, neglect and other sorts of household challenges like parental separation. We know that these things lead to a higher risk of children developing poor mental ill health and other negative outcomes in their lifetime. Generally, we would like to see all services in contact with children aware of the impact of ACEs on their lives and thinking about ways of adopting trauma-informed approaches. That is even more important given the effects of the pandemic and some of the increased safeguarding concerns that have been reported.
Again, this is about thinking about school settings, primary care services and other services that children might come into contact with. CAMHS overall has not really been set up to respond to complexity and trauma. Many of these young people are known to have more complex needs. This was highlighted in the recent independent review of children's social care as one of the top issues, and we would like to see some changes picked up as part of that. When children enter the care system, there is a statutory duty to undertake a health assessment within, I believe, 21 days. Often it is quite difficult. It should be holistic and include their emotional health and well-being, but it is not always carried out for many young people who have faced more recent traumatic events that might not be picked up in assessment.
The Department for Education funded a pilot that worked across, I think, nine local authority areas to look at different ways of assessing mental health and well-being upon entry into care. The evaluation found that there needs to be further research and evidence on this to think about ways of screening for poor mental health in the first place. We know that children in care, care leavers and adopted young people are disproportionately impacted by mental health, and there are particular groups of young people who we have been concerned about recently—for example, unaccompanied and separated children, especially in London.
There has been a spate of deaths by suicide amongst those young people, who have to navigate not only a very complicated mental health system but an immigration system that is perhaps not as child friendly as it could be for many young people, and I wanted to draw attention to that. Similarly, there are groups of young people who reside in the secure state system, and often their mental health needs are overlooked. We did a piece of work, which I can share with the committee, on girls in the secure state and their high levels of unmet mental health needs.
Baroness Wyld: I could ask you so many questions, but I know we are up against the clock, so thank you.
Dr Elaine Lockhart: Kadra has spoken clearly about the impact of trauma. Children who come into care have often been exposed to abuse and neglect, and the challenge for specialist mental health services is if children and young people have post-traumatic stress disorder or recurrent self-harm because of what has happened to them in the past, it is really difficult to provide good psychological therapeutic and/or medication input if their home setting is insecure and some containing adult is not there for them, because part of the psychological therapy for processing trauma involves asking a young person to bring that trauma to mind. Sometimes, if they have flashbacks or nightmares, that is a really distressing process to go through. We then end up with that horrible chicken and egg situation where their home situation might be insecure having left care and psychological therapy is not very safe, and they can just end up presenting in crisis all the time.
Returning to what we talked a bit about earlier, it is crucial to set up non-mental-health aspects of their care, such as living in a safe community, having education or training, a job to go to or volunteering, because, as we heard earlier, finding meaning to your life and a purpose, and helping other people, can be incredibly helpful. Often children and young people who come into care are those who are outwith parental control on account of their behaviour. We are increasingly seeing children in this situation, who have been abused and neglected, who have neurodevelopmental vulnerabilities such as ADHD or autism that have not been recognised. Forensic psychiatrists seeing 16 or 17 year-olds for abuse and neglect are often only then assessing and diagnosing for ADHD, which, if it had been identified and treated earlier in their life, could have prevented years of missing out on education and home life.
So, again, how do we intervene early, but, also, how do we make good services for care leavers so they are not falling off a cliff? In the Royal College of Psychiatrists, we are looking at improving transitions between CAMHS and adult mental health services, but we are also thinking about adult mental health services up to 25 that are accessible for young people who may be living quite chaotic lives for whom a clinic-based approach is often not that effective.
Baroness Wyld: This issue of transition between young people's mental health and adult mental health has always been a problem, has it not? You say that there is work going on to improve that. What is your assessment of it, and what progress is being made? What changes have you seen?
Dr Elaine Lockhart: We have just started a working group in the college. Across the UK we have good transition care plans, good documents, so we know exactly what good transition looks like and they have been informed by young people who have made these transitions. The issue is how we implement them. We need capacity in the young people's mental health service to support a good transition, and young people themselves will say that they need three to six months for this to work.
We also need the parallel work to happen in the adult mental health system and to recognise this as important. The majority of young people we see in our services do not transition as they are discharged, so they do not need follow-up from adult mental health services. But if we do not have transition care workers to support this and joint clinics, and if we do not make this a young person-centred process where they progress and they and their families are included, it will not work well. So there is still work to be done. It is about the implementation; it is not about needing yet another good document.
Baroness Wyld: Is it about workforce capacity, essentially.
Dr Elaine Lockhart: Yes.
Baroness Wyld: That is helpful, thank you.
Q158 Baroness Lawrence of Clarendon: Thank you to our witnesses for being here today. My question is about policies. Is enough consideration being given to the mental health of children and young people when developing policies that directly impact on them—for example, education policies?
Kadra Abdinasir: Overall, children’s and young people's mental health is increasingly being talked about, and in some ways it remains on the national agenda. We have developed many strategies and policies such as Future in Mind, which came out seven years ago, but we hear that the progress on the ground continues to be slow and inconsistent. We still hear about a postcode lottery in waiting times.
Going back to the point about investment, we cannot really establish how much funding goes into the system. From our perspective, there really is a great opportunity here to put in place an approach that considers mental health in all the policies as I mentioned earlier. Thinking about actions that we have taken in the past, the two-child limit for child benefit is an example of a policy that had indirect consequences for children’s and young people's mental health.
In terms of education, again, there has been much more of a focus on mental health in schools, but over the last year in particular we have been really concerned about the mixed messaging that schools have been receiving on mental health versus behaviour and the emerging divergence between the two. We know that children in contact with children’s services are much more likely to face discipline measures in school settings for whatever reason. We really do want to promote the whole mental health and well-being approach in schools to overcome this issue.
Our message will be to adopt and implement a mental health approach in all policies and to think about ways of embedding coproduction and putting children and young people and families’ voices at the heart of policy making, because opportunities for them to have direct influence have not always been clear or consistent.
Dr Elaine Lockhart: I think Kadra has covered it. I am just thinking about the whole challenge of good policies versus implementation. I think maybe that is my theme for the afternoon. For example, I think teachers have recognised the increasing mental health burden of the children and young people they are looking after and they have tried to be innovative, and some have brought in counselling themselves, some have mental health support teams. But at the same time, since 2010, there have been real effects of cuts to funding for supporting those with additional support needs which was leaving teachers often having a few children in each mainstream class who really need extra help and support and they are being asked to provide that as well as providing for the rest of the class so it is a bit of a mixed bag. Considering children and young people and policies of course makes sense, but we have to follow through with having people on the ground to deliver useful interventions and support for children.
Baroness Lawrence of Clarendon: Do you think that a lot of black minority children especially are being placed in pupil referral units? Do you think that maybe consideration should be given to the fact that sometimes children act out when they are not being challenged or given the right support they need in the classroom? Is that a possibility?
Dr Elaine Lockhart: Again, Kadra’s organisation has been active on looking at the management and approach to behaviour in school. It just seems unhelpful to sometimes use sanctions and a punitive approach to challenging behaviour when it may be that a young person is really struggling for example with a learning disability or difficulties, or with autism or ADHD—I come back to that again and again, because it is really underrecognised—or it may reflect what is happening in their home.
Sanctioning or punishing children is not a useful approach at all particularly for children from black minority ethnic backgrounds. Obviously, there are different populations in that. Some will do very well, but some will definitely seem to have an adverse experience of education which then has a negative effect on their engagement, and on their willingness to come back and engage, if they are not being understood or supported enough. I will pass back to Kadra here because of the work her organisation has been doing to look at this.
Kadra Abdinasir: Earlier this year, we launched an inquiry into behaviour and mental health in schools just because we wanted to create a platform for children’s and parents’ voices to be heard in this debate, because it is debated at a policy level. We have been concerned about things like the zero-tolerance approach and the rhetoric around it, including a crackdown on attendance in education.
Going back to the earlier point about some young people having seen and reported improvements to their mental health because they have been out of school, sanctioning and fining parents is not the right approach. There is a lot more nuance behind this in trying to unearth and provide the right support for families to ensure that their child can attend school and that, if they need to access alternative provision, that opportunity is provided.
Baroness Lawrence of Clarendon: There is another point that I would like to ask you about. There is sometimes a cultural stigma when mental health is identified by the police or even by GPs themselves. It is like young people are in a double whammy, in school and outside school. Are there any issues that you can tell us about that?
Kadra Abdinasir: Since 2020, and with your review on the impact of Covid, mental health services across the country have been having lots of conversations about embedding more culturally sensitive approaches in mental health services so that they are a key part of the response. In some of our messaging even today, we really need to think about the diversity of the workforce as well. Some young people experiencing multiple disadvantages or from different backgrounds are less likely to engage with services they do not see themselves reflected in. It is part of the workforce challenge to think about how we can further diversify this. Sorry, what was your other point?
Baroness Lawrence of Clarendon: I was talking about GPs and the police and cultural stigma.
Kadra Abdinasir: I mentioned that we have reduced stigma associated with mental health in some ways. Some groups continue to face stigma, and I would say that stigma is perpetuated in some communities—for example, in a black community—but is also placed on the community by services. The Child Q example is something that we should never see happen in any school. It is really great to see the changes in guidance from the Department for Education last week on strip searching children in schools. Unconscious biases that impact all these systems also contribute to that stigma.
The Chair: Thank you so much for that.
Q159 Baroness Bertin: We have been talking a lot about schooling, and as a mother of three primary school-age children it strikes me that we are expecting a huge amount from children. The amount of homework and level of academic achievement they are supposed to be getting to is far higher than when I was a four, five or nine year-old. Is that adding to some of the problems? You talked about the happiness scale and that we are the unhappiest of all our European partners. In Europe, they start school a lot later. I wondered if you had a view on that.
Dr Elaine Lockhart: Yes. One of the unintended consequences of more than 50% of the population now going to university has been that in primary and secondary school there is more focus than ever on academic achievement, which does not suit everybody. Some children and young people feel despairing about their ability to progress in a system that seems to be set up for people who go to university. Teachers have pressure about the testing, which then takes away the time in primary school when they should just be able to access sports, music, play and develop themselves. That is getting pushed more and more to the side.
Kadra Abdinasir: We hear a lot from children and families about the “teaching to the test” culture and examinations, and the detrimental effect that has. From our perspective, well-being and attainment go hand in hand, so promoting well-being in schools leads to better educational outcomes for pupils.
Lastly, thinking about all the learning that we have done over the last couple of years, we were forced to implement remote learning and different ways of conducting assessments, and there are things we do now that we once thought were once impossible to do. If there are pockets of good practice that have boosted and maintained pupils’ well-being, we should consider implementing these things.
Baroness Massey of Darwen: Is there any provision in teacher education or in service education for teachers to get to know more about the symptoms of what might be a disorder which they mistake for bad behaviour?
Kadra Abdinasir: A module on mental health has now been introduced as part of initial teacher training, and the behaviour programme that is currently also running is looking to make changes to the teaching curriculum. As part of the Green Paper on children’s and young people's mental health, the Government have been rolling out a training programme for senior mental health in schools whereby each school has access to a budget and a training offer to appoint one staff member to undertake this training. This is in addition to things like mental health first aid, which is also offered to all secondary schools. We will be following that closely to see how that works.
Dr Elaine Lockhart: Thinking about people who work with children across the full network of services, even in health the newly qualified paediatric nurses I was teaching had never had any teaching on depression, which, as we know, is common in young people. We need to be thinking about what happens outside school as well, which, of course, is a really important place for children. Anyone who comes into contact with children should have some basic training on recognising neurodevelopmental vulnerabilities and common mental health disorders like depression.
Q160 Lord Mawson: What would a really good mental health system look like for young people as far as you are concerned? I have not heard anyone on this call use the word “community”. School, in my experience, is a community that, if it does it well, links all sorts of things together in all sorts of interesting ways that no siloed system of the state will ever do. What does doing it well look like?
Dr Elaine Lockhart: Anyone who cares about children should be connected to other people. If you are involved with work where you might see children because you are a teacher or a social worker or running a community child health clinic, you should have some training in mental health and know who to go to for help if you are worried about a child.
I would think about the community in services as well as the communities in which people live. I have seen really good examples of mental health training, like first aid training in football clubs and destigmatising mental health in youth clubs, and that goes for the adults as well as the young people who are part of it. Working in silos is incredibly inefficient and unhelpful, so I would completely support and hope that the ICS system can help us build much better integrated working.
Kadra Abdinasir: Before we consider what needs to happen in systems and communities, I want to reinforce the point about prevention and making that a priority of national and local agencies, whether they are statutory or not. We all need to be thinking about ways in which we can create the conditions for good mental health for all infants, children and young people in the first place, eliminating those known risk factors. We would really like to see a fully resourced mental health system. The NHS Long Term Plan commits to investing in children's mental health at a rate that is faster than overall NHS spending, which is positive.
We also need better data about need, experiences and outcomes, especially for the group of children and young people you are focusing on as part of your work—a system and a community that really offers people choice and flexibility that is not restricted by bureaucratic thresholds and eligibility criteria, and one where children and families are easily able to access the advice, information and the support they need. There is a SEND local offer available in every local community, and we would love to see something like that for children’s and young people’s mental health.
Lastly, I come back to the point that developing a system that really recognises the links between mental health and inequalities is critical, especially in the times we live in. We would like to see that system embedding principles of anti-racism, equality and diversity as part of that, and, of course, recognising the need that all trusted adults around children and young people are supported in their mental health and well-being, whether they are professionals or not, because parents, carers and foster carers all play such a critical role and are facing increasing demands and pressures themselves.
The Chair: Thank you very much. I am sorry we were a little bit rushed towards the end, but it has been an excellent session. I think you can see the degree of interest the committee has in this issue and how it relates to all aspects of implementation of this Act, so thank you very much indeed. You have given us lots of really interesting specific examples. In a number of areas I think you kindly said that you would supply us with some follow-up material, which we would welcome, and I am sure the secretariat will be in contact with you for that. Thank you again for your time. We really appreciate it.
