Written evidence submitted by The Children’s Society (CYP0048)
About The Children’s Society
The Children’s Society supports vulnerable children and young people aged 10-18 in England. We address the mental health and well-being of the young people we support in a variety of ways. Some of our projects are entirely focussed on mental health and well-being whereas others look to safeguard children effectively or to support them to exercise their rights. All of our work however, aims to overturn the damaging decline in children’s well-being we have seen in recent years, and set a path for long lasting growth.
We provide counselling services, therapeutic interventions for children who have experienced trauma, group work, drop-in services, advocacy and advice services and work with a range of young people including looked after children, care leavers, young carers, unaccompanied and asylum seeking children, children who are at risk of child sexual exploitation, children using drugs and alcohol and those with mental ill health.
We also have an extensive programme of research, policy work and advocacy around improving the mental health system for children and young people. We are leaders in children’s subjective well-being and provide developing insight into the lives of children and young people facing multiple disadvantages.
The following response to the Health Committee inquiry on child mental health, draws on both our direct practice and our research and policy work.
Our response to the inquiry focuses on improving the performance data and evaluations regarding the various efforts made by government to improve mental health in schools. Improvements need to be informed by COVID impacts as well as the existing criteria. This refers to ensuring recovery reflects children’s experiences of the pandemic in school and in the delivery of NHS Children and Young People’s Mental Health Services (NHS CYPMHS).
We also recognise that mental health services need to be accessible, flexible and centred on choice. Mental health support should move beyond schools and the NHS and be relocated into communities where young people live and grow up. Our own research finds low well-being a risk factor to mental health conditions such as anxiety and depression. Regular and comprehensive national measurement of children and young people’s well-being and a commitment to roll-out emotional health and open access services should be part of the strategy to improve children’s mental health and well-being.
We have addressed all the bullet points in the terms of reference except for ‘provision of support for young people with eating disorders’. We have kept our response in the same order as the terms of reference.
Key areas of focus for the Health and Social Care Committee
Although the Government have been clear on the geographical areas they have rolled out the provision of Mental Health Support Teams (MHSTs) in, it is unclear how many schools are engaged and how many children are actually being reached through this provision.
How has the rollout of Designated Mental Health Leads been effective and how has it affected school budgets and staff workloads?
As the Government are yet to announce the replacement for Public Health England, how will a public mental health approach for children and young people be enabled in any new architecture?
The Prevention Green Paper 2018 aimed to outline a new government approach to the prevention of ill-health across society. How are the Government committing to prevention being at the forefront of national and local policies, particularly for child mental health and well-being?
What progress have the Government made on children and young people’s mental health, including but not limited to:
The Green Paper commits to Mental Health Support Teams (MHSTs) to be supervised by the NHS CYPMHS staff and linked to groups of schools and colleges. By working with the designated mental health leads in these educational settings, they will increase capacity to address locally, moderate to low mental health issues and provide the link to NHS specialist mental health services, where required.
Mental Health Support Teams
Whilst the government have been able to keep to the timetable for rollout of these teams in trailblazer areas, we have observed that in areas where they do operate, certain groups of young people appear less likely to receive support. In trailblazer areas in the north of England, we have seen that BAME and specific religious communities have been very difficult to engage with. For example, in an area of the North East where The Children’s Society operates, we are aware of a religious school which has placed barriers for engagement as they remain sceptical of trailblazers discussing mental health. There needs to be an increased dialogue between schools that are sceptical of the rollout to ensure that provisions are reaching as many children and young people in need of support.
There have been positive examples in the North East, where children that have been identified at the most vulnerable, are being prioritised to receive the support they need. However, there remains a lack of transparency from Government, how many children across the local authorities they are working within, are being reached. We know that in many trailblazer areas not every school is engaged in the work of the MHSTs. We need clear data on how many children are being reached and how many schools are engaged.
Within schools that are engaged with MHSTs, we know the teams are not always fully utilised by schools and staff are often unclear on how best to work with them. For example, staff still struggle to differentiate between behaviour needs, mental health needs and learning needs. This can result in children not receiving the right help from the right service at the right time.
Multi-agency working is often required to support groups of young people such as care leavers, who often experience multiple disadvantages such as high levels of trauma and poor mental health, to navigate the various points of intervention they need. We have seen instances of a young person trusting an NHS worker, but the official responsibility may not lie there and so they have been prevented from getting the support they need because different systems are not working effectively together. We need a holistic approach, a team around the child, to identify who is best-placed to support the young person.
The pandemic has considerable impact on school staff capacity through illness and bereavement faced by both staff and pupils. There are areas across the country that have disproportionately affected by the pandemic due to cases of infection that have affected resources and learning in schools. The evaluation of the mental health and schools support link expanded programme shows, the early programme development included targeting schools using a geographical criteria as well as schools with higher levels of socio-economic disadvantage. The Government should now ensure the impact of the pandemic on local areas is also considered when identifying schools that are in high need of support.
Designated Mental Health Leads
The Green Paper outlines the Designated Mental Health Leads to have two main roles – identifying and supporting children who do require support with their mental health and also championing and embedding a whole school approach to mental health.
Designated mental health leads have a high number of children on their caseloads and are responsible for navigating the intricacies that come with working with young people. To help embed this role in to the MHSTs, the Government should provide advice on best practice for work loads and responsibilities for this role.
Where there are clear single points of access in place and MHSTs in place, we have observed how the provision of MHSTs and Designated Mental Health Leads work well as early help measures. In areas where there is not a clear referral pathway, and schools and colleges are unable to identify the organisations where young people need to be sign posted to, they slip through the gaps in provision, often leading to escalation and reaching crisis point.
The pandemic has meant that schools and services have been closed, making it increasingly important to have clear referral pathways. Local authorities and Clinical Commissioning Groups (CCGs) should work together to provide comprehensive information about local services to schools so that they can direct children to the appropriate services to meet their needs.
There have not been significant publications on how effective the rollout of MHSTs and Designated Mental Health Leads have been. Whilst we understand the difficulties in measuring such impact, data and analysis are key in ensuring the government meet its target in effectively increasing capacity locally and providing links to specialist NHS services.
During the pandemic, we have seen through our Children’s Services reporting form, that frontline workers have consistently expressed a concern for children and young people’s mental health over the pandemic and specifically over lockdown. The Green Paper commits to national roll-out of creating MHSTs and reducing waiting times – to at least a fifth to a quarter of the country by the end of 2022/23. It is evident that the exacerbated mental health concerns caused as a result of the pandemic, seeks an accelerated roll out of these programmes.
Shorter waiting times
Waiting times are known to introduce pressures into stretched systems and can result in perverse outcomes like higher thresholds, or quick assessment followed by lengthy treatment waits. The logic in the Green Paper is that earlier intervention, through schools and the MHSTs will result in fewer, and more appropriate, referrals to NHS CYPMHS. The government have brought waiting times for NHS CYPMHS down since publishing the green paper, 30 local areas now have average waiting times of less than 30 days, while 34 local areas have average waiting times of more than 60 days. Overall, average waits across England range from 8 days to 82 days. Consistency of shorter waiting times needs to be improved across local areas.
A short waiting time for NHS CYPMHS may unavoidable, but the approach to shorter waiting times should also focus on creating a better experience for young people while they are waiting. Unless young people seek out support from charities or organisations that can offer interventions whilst they wait for NHS CYPMHS, they are not provided support in the waiting period. Longer waiting times can lead young people to reach crisis point. If children and young people are not meeting the threshold for NHS CYPMHS, there needs to provision to ensure escalation is avoided to the point where they require NHS CYPMHS.
Improving waiting times, increases the access children and young people have to mental health services. Before the pandemic, referrals to specialist NHS CYPMHS have risen over recent years, with the Education Policy Institute estimating referrals have increased by 26% in the last five years from 2019. Analysis by the Office of the Children’s Commissioner highlighted in 2017/18, there were 125,277 children not accepted into specialist treatment or discharged after an assessment appointment. The most common reason a young person will not be able to access support from NHS CYPMHS is because their condition is not deemed serious enough for clinical intervention.
This is likely to have been exacerbated over the course of the pandemic. We have been hearing directly from frontline workers, what some of the main concerns have been for children and young people. We are hearing that capacity in appropriate services is extremely inadequate. Professionals are worried about the long-standing lack of capacity in NHS CYPMHS as well as insufficient availability of community services and early help. Where they exist, they are struggling because of unnecessary barriers such as thresholds for face-to-face help, contracted targets based on provision of face to face services and lack of clarity from government guidance.
Mental health of 16-25 year olds
The Green Paper commits to developing a national partnership between universities, colleges, local authorities and health services. However, rollout of this partnership has been slow and in light of the pandemic we recommend that wherever possible, transitions between child and adult mental health services should be delayed for the next 12 months. Where transitions are occurring, there needs to be improvements in the way that local support services work together to improve the mental health support on offer for young people.
The Children’s Society service, Pause, at the University of Birmingham works within the Forward Thinking Birmingham framework, the city’s mental health partnership, demonstrate ways of joint working that work for young people aged 0-25 and identifying needs for better communication in the transition of care and information sharing.
At Pause, we have observed that young people receiving low-level intervention from NHS CYPMHS in their local area are often discharged without the transition of care having taken place to their new local area at university. Unless they require a service immediately after moving, there will be a waiting period before they have any contact with support services. Ideally, when children become 18, a discharge would not be closed from NHS CYPMHS if there is a necessity for intervention to continue, without the transition of care having taken place first.
Some young people view moving to university as a fresh opportunity to start a new phase in their adult lives. At Pause, we have seen that university experiences can bring unanticipated stress for young people. This can often re-surface pre-existing mental health conditions from low level symptoms to those who have had specialist intervention for eating disorders, requiring young people to seek extra support. Not all young people choose to go to university so it is important to remember multi-agency working between local services should not exclude those groups of 16-25 outside of university.
The transition of information to occur between primary and secondary support can be extremely time consuming. Pause is now looking at ways to have students disclose their mental health conditions prior to them starting their courses, so the service can get a support mechanism in place to gather data and project the level of support they will be required to deliver.
It is not only partnerships between universities and local areas that need to improve. There are many groups of young people experiencing multiple vulnerabilities, such as care leavers, presenting higher need for mental health support. In Birmingham, the local NHS provision have seen a large number of care leavers seeking support due to a range of issues, but the socio-economic impact of the pandemic is identified as one of the contributing factors over the last year. There are many services that are often attached to GP surgeries, such as the Health Exchange, that can help prevent young people and their families reaching crisis point, which have been very well utilised.
Forward Thinking Birmingham, is a service for 0-25 year olds. We have observed that 18-30 year olds are at high risk of emerging mental health conditions, so the transfer of information becomes more important between child and adult services. For services that extend support to 25 years of age, they are able to effectively continue with intervention and the there is a less disruption in support. Despite the ambition for NHS CYPMHS to continue services for children and young people up to the age of 25 as set out in the NHS Long Term Plan, many services continue to have a cliff-edge at age 18, leaving those young people without support.
Internet and social media
Research on the internet and social media is overly focused on time spent rather than the quality of children and young people’s use of the internet and social media.
The Green Paper commits to a commits to a report on the impact that technology has on young people’s mental health. Overall, the Chief Medical Officer’s commentary on screen based activities and children and young people’s mental health and psychological well-being report concludes evidence to be lacking.
Although a relationship has been observed between increased screen based activities and negative effects such as anxiety and depression, the cause and effect are still not understood.
Actions such as the formation of a Social Media Working Group are important in ensuring cross sector working to maximise keeping children safe online. Online harms such as bullying, child sexual abuse, sexual grooming, trafficking and other legalities can inadvertently cause children and young people to experience low well-being and mental health difficulties.
However, without the relevant research and evidence on the cause and effect of screen based activities and children and young people’s mental health, these actions are piecemeal and require stronger evidence to create policy that prevent mental health difficulties and low well-being in relation to use of the internet and social media.
Researching how to support families
The Green Paper commits to using research to produce guidance for local areas on the best parenting programmes, allowing for greater support and value for money.
The research should focus on families where parents, carers or guardians are experiencing mental health difficulties. This is an underlying disadvantage for children and young people. The Government should invest in this research to further understand the disadvantage children can face and how to translate this in to policy to ensure they can be minimised and to inform parenting programmes.
Supporting parents, carers or guardians with mental health issues and their children is important in preventing their children from developing mental health issues too. There is comparatively little research on how families and their children can be supported in a preventative manner.
Researching how to prevent mental health problems
The NHS Mental Health Survey for Children and Young People, 2020 (MHCYP 2020) is an important piece of research that explores mental health of young people, experiences of family life, education and services.
We are able to compare mental health between 2017 and 2020 through the Strengths and Difficulties Questionnaire (SDQ). The MHCYP 2020 survey also examined the anxieties and worries during the COVID-19 pandemic and the implications this has had on family dynamics, anxiety, access to education and health services and changes in circumstances and activities.
We also welcomed the state of the nation report by the Department for Education, which has provided useful insights into the state of well-being. The range of research being conducted needs to be brought together in a comprehensive strategy against which we can properly measure our progress.
Our own research, finds that low subjective well-being and mental health conditions like anxiety and depression are linked. Well-being and mental health are related but are distinct concepts. Policy focus on well-being, alongside improving mental health support could ensure that regardless of whether they have a mental health condition, children can live happy lives because of their ability to manage their condition and weather life’s ups and downs. A focus on well-being provides an important mechanism for improving the lives of young people struggling with mental ill-health. A robust measurement of children’s well-being would be useful for a range of policy and decision makers at both the local and national level.
There are many ways in which measurement could be achieved, but a regular survey delivered in education settings is likely the best way. A survey would provide data at the level of the education setting which they can use to respond to emerging issues, at local authority level where wider decisions about policy and service delivery can be made, and at national level where government departments can use this to help develop policy seeking to address a multitude of issues.
Whole school approach
We welcome the roll out of MHSTs and Designated Mental Health Leads in school and the value they bring in addressing moderate to low mental health issues and signposting to external support. The Government need to look at the cost of provision for MHSTs and Designated Mental Health Leads place on schools and create a dedicated funding stream, so that schools can ensure provision on a long term basis. By integrating the provision in to school funding formula, schools can commit to the promotion of positive mental health and well-being being integrated into the school day.
Currently, the funding for Designated Mental Health Leads is borrowed across a range of different budgets that are set out for schools. If we want schools to deliver a whole school approach, The Government must ensure that there is dedicated funding designed to allow schools help pupils, by improving their mental health and well-being. This should be similar to the pupil premium grant, where grants are targeted in supporting pupils.
Good quality counselling support in schools and colleges can play an instrumental role in the promotion of positive mental health and well-being. School-based counselling is seen as accessible, non-stigmatising and effective by children and pastoral care staff, with school management reporting improvements in attainment, attendance and behaviour of young people who have accessed services. Indeed, it has been found to reduce levels of school exclusion by around 31 per cent.
Vulnerable groups of young people such as children in care and care leavers and those who have experienced abuse and neglect are not being adequately supported in their journey through NHS CYPMHS. For example, less than half (47%) of trusts have clear pathways set up for referrals of children who have experienced sexual exploitation despite the recent national focus on child sexual exploitation and its impact.
Further work, such as increasing the provision of school counselling through extra funding or statutory provision, will increase access to these services. They can form a crucial part of a whole-school approach where counsellors can work alongside other health and social care workers, MHSTs and Designated Mental Health Leads in schools as well as teachers and parents.
Recovering from the COVID-19 pandemic
During the return to school in March 2021, the role of the Designated Safeguarding Lead, and senior mental health leads will be particularly important in ensuring schools provide support and links to external partners from, social care and mental health support. Close attention should be paid to unexpected and disrupted behaviours. These could be an indication of underlying needs and linked to difficulties caused by lockdown, especially if this change is out of character for the child. If not properly supported, this behaviour could lead to an increase in children being unfairly excluded from school.
Children and young people must be given the time and space to re-establish their friendships, given the social isolation which they have experienced. In a recent survey, four out of five primary school pupils and three out of five secondary school pupils said that they are most looking forward to seeing their friends when they return to school.
This should form part of a whole school approach to well-being, where staff receive the training and development necessary to understand their own, and children’s, well-being so they can confidently support children and colleagues during the recovery period and over the longer term.
Clinically informed youth work
From a young person’s perspective, a clinical approach to mental health and well-being support for young people is often found to be lacking. Young people want to be viewed as a young person first rather than by their mental health issues. In order to deliver this type of service, at The Children’s Society, we combine the expertise of our clinicians and youth workers to build teams that deliver what we describe as ‘clinically informed youth work’, whereby, in our services we deliver interventions to high clinical standards whilst utilising the skills of youth work to ensure our services are accessible, welcoming and relatable for young people.
NHS services do not generally operate using this model and the structure of the delivery models can be rigid in practice and prohibitively expensive for the voluntary sector to emulate. This type of a youth centred and blended delivery model enables the existing workforce to be utilised, and an opportunity for development for staff. The NHS needs to reconsider how it works with and commissions partners to address children and young people’s mental health. Its current rigidity and adherence to a medical model of mental health is often a barrier to innovative working and to reaching more young people to improve their lives.
One way of expanding the workforce would be to draw on more youth workers. There needs to be increased access routes for youth workers in to clinical services as well as increased opportunities for clinicians to be trained in the skills of youth work. When the two disciplines interlink youth centred services can be delivered that young people find accessible and engaging.
Open access hubs
Much of the government’s focus has been on mental health provision in educational settings and the NHS. A wider social offer of support needs to be made available that extends support within the community through services like open access, to ensure young people are able to access support at an early stage.
Open access hubs are designed to offer easy-to-access, drop in support on a self-referral basis for young people with emotional health and well-being needs, up to age 25. These services can be delivered through the NHS, in partnership with local authorities, or through the voluntary sector. A mix of clinical staff, counsellors, youth workers and volunteers provide a range of support on issues related to well-being, while a range of services can be co-located under one roof; offering wrap-around support across, for example, psychological therapies, housing advice, youth services, employment support and sexual health. If left unaddressed, these areas are known to have an impact on mental health and well-being.
Hubs of this kind would greatly increase access to early intervention support for emotional health and well-being needs, and prevent escalation to later mental ill-health. Furthermore, these services are youth-led. Research has shown that young people respond better to services that are youth specific. Many of these services take a youth work approach to support, where work is centred on the young person in terms of their strengths and needs, and listening to their voice. What is more, involving young people in the systems that relate better to their needs has been noted as an important step in engaging them in their mental health treatment.
These services are also perceived as highly accessible. A previous evaluation of the one stop shop model stated that these services were largely described as having characteristics in line with those typically credited with increasing access, including offering walk-in sessions and self-referral, and being located centrally or close to transport. The drop-in element of these services facilitates an accessible service, where young people can get support in times of need. Many of these of these services do not require referrals meaning that young people can access support without high thresholds and long waiting times.
Responsibility for the provision of these services is shared between the NHS, schools, local authorities and the voluntary sector. Emotional health and well-being support can also be provided via family hubs and youth services. Yet, there is a significant lack of accountability and transparency across CCG’s, local authorities and Public Health as to who is responsible for ensuring provision is available for all young people with emotional health and well-being needs.
How inpatient care can be improved so that it is not creating additional stress on children and young people, and how the use of physical and medical restraint can be reduced
Our service, Safe zones, provides vital early intervention for young people at risk, reducing pressure on local A&E services and young people’s mental health services. It is a step down service from crisis rapid referral team and All Age Mental Health Liaison and is complementary support to NHS CYPMHS.
Inpatient care can be improved by providing a step-down approach to formal medicalised interventions within the crisis care pathway, models such as Safe Zones bridges the gap between continuity of clinical care within a safe and robust framework with a community based, young person-focused offer.
In cases where young people have had to have their cases escalated to receiving inpatient care, Safe Zones have actively sought out to be a part of their discharge plans to allow for continued support and ensuring professionals are aware of this. Despite being a short and intensive intervention service, they recognise that children and young people value being able build trust and relationships with professionals.
The Safe Zones team made is up of mental health professionals, social workers, therapists and youth workers, modelling a clinically informed youth work delivery. They are able to work with individuals and their families to deliver trauma informed, holistic and needs-led packages of care in psychologically informed, young person-friendly environments. This has seen 93% of all young people Safe Zones have worked with, reporting a decrease in general distress.
The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing
There needs to be a public mental health approach for children and young people that focuses on prevention and early intervention whilst working to reduce health inequalities. There are indications that some groups of children and young people have lower personal well-being than others. Children with special educational needs or a disability, disabled young people, children and young people with disadvantaged family backgrounds and some children from Black, Asian and Minority Ethnic backgrounds reported (or were reported by their parents as) being more anxious than children and young people without these characteristics.
Our research found that, young people from BAME communities and certain religious communities, worried about not being taken seriously, which further impacts their mental health. One young person even told us that she personally felt that sessions between NHS CYPMHS and parents, especially for BAME parents, should be made compulsory because of the benefits of having her own parents more closely involved in her care and support.
This should be achieved by extending support in to the community for children and young people and collecting clear data on children’s well-being. Open access services appear to reach marginalised groups who may not be accessing other services. The Youth Access and BACP study found that there was a higher representation of ‘older’ clients, females and those from Black, Asian and Minority Ethnic backgrounds accessing VCS support as they can be more accessible and perceived as less stigmatising than statutory services.
Clear data on children and young people’s well-being can help to inform the inequalities they face. A comprehensive mechanism to collect this data not only helps to inform the types of mental health and low well-being that are being experienced, but it would provide greater clarity on who these young people are. This type of comprehensive data is intrinsic in providing solutions to health inequalities.
Public Health England (PHE) works to improve the lives of people with a mental health problem and reduce inequalities. Since the announcement of PHE to be replaced by a new agency, there has been a lack of clarity as to what this agency will look like and how this function will continue. Evidence clearly shows that health inequalities are faced by children and young people, it is concerning that without a national body that takes a public health approach to mental health, how wider systems changes can be achieved.
How the Government can learn from examples of best practice, including from other countries?
Commitments from government, such as the state of the nation report and NHS Digitals Mental Health Survey for Children and Young People are of critical importance and reflect rising concern about children’s well-being. However, this patchwork of announcements is unlikely to be successful unless it is consciously brought together into a comprehensive strategy against which we can properly measure our progress.
The idea that well-being should be at the centre of national policy making is not new. In the UK well-being economics is often talked about by decision makers but the country has had less success putting into practice. Without a reliable and comprehensive mechanism to collect well-being data we are unlikely to make significant progress in designing and implementing improved policies for children and young people.
The UK education system based on academic attainment. However, due to increased scrutiny of children’s emotional health, Ofsted has recognised that wider issues need to be considered. In South Australia, data from well-being measurement is regularly used to apply for funding for additional support or learning programs, determine where to allocate existing resources, set priorities, plans and goals in school, advocate for children’s health and to ascertain programs and services required.
Our case for national measurement briefing presents a strong case for how measurement of child well-being can improve the policy response to issues in education policy, social care, mental health and sports and physical activity. National measurement is utilised by other countries to advocate for children’s mental health and well-being in policy making.
Open Access Hubs
Open access models are an effective way of rolling out emotional health and well-being support in the community to children and young people. The government have also recognised the importance of these services forming part of the universal local offer by recommending in its Future in Mind strategy that the number of one-stop shop services in the community should be increased. The open access model is one that is recognised internationally with a network of these kind of services being established in Australia, Ireland, Israel and Demark.
The latest findings (2017/18) from the Health Behaviour in School-Aged Children Survey (HBSC) in Europe and Canada also found that across scores for life satisfaction for 11, 13 and 15 year olds, England scores below the HBSC average.
When the well-being of children in the UK is compared to the well-being of children other countries, our research suggest that children in the UK may be faring less well than their counterparts in Europe. Data presented in The Good Childhood Report 2020 shows that at age 15, children in the UK are less happy with their lives across a range of well-being measures when compared to other European countries.
We know that low well-being can be a risk factor to children and young people. Whilst mental health and well-being are the not the same, our research has found that low subjective well-being and mental health conditions like anxiety and depression are linked.
At The Children’s Society, our Beam service is a drop-in service that supports young people’s emotional health. The service provides therapeutic support, as well as educational resources and online learning. One young person told us that ‘1:1 chats helped me explain my worries that I'm facing in my day to day life’.
What measures are needed to tackle increasing rates of self-harming and suicide among children and young people?
Our Good Childhood Report 2018, found that over 15% of children who responded to our survey had self-harmed in that past year. Our research found a strong link between children with low well-being or poor mental health and the average risk of self-harming. Each of the three measures of subjective well-being and mental health significantly predicted the likelihood of self-harming. Over 60% of children with high depressive symptoms, almost half of children with low life satisfaction and over 30% of children with high emotional and behavioural difficulties had self-harmed, compared with the average of around 15%.
More notably, our life satisfaction measure, based on a single question, was a higher predictor of self-harm than a 20-item scale of emotional and behavioural difficulties reported by parents. It may be that a similar list reported by children would be more closely linked to self-harm. There is a stronger link between child reported life satisfaction and depressive symptoms than between either of these and emotional and behavioural difficulties, reported by the parent about the child.