Written evidence submitted by Dr. Gabriella Conti (University College London), Ella Johnson-Watts (Institute of Fiscal Studies) and Abigail Dow (University College London) (CYP0057)

Summary

-          Mental health problems can have strong roots in the early years of a child’s life. Since the start of the pandemic, the lack of socialisation of children and the poor mental health of parents are likely to have negatively impacted the mental health and development of young children.

-          We find evidence that reduced socialisation of young children, through childcare, seeing friends and grandparents is a primary concern to parents.

-          Many first-time parents report symptoms indicating likelihood of moderate or severe mental health problems during lockdown and a quarter of parents report worsening behaviour of young children during lockdown.

-          Health visitors are a vital component of the mental health workforce, through their role in identifying children with infant mental health problems and those vulnerable to developing mental health problems later in childhood as well as recognising cases of postnatal depression.

-          Health visiting services, however, are under severe strain due to years of funding cuts, redeployment of staff during the pandemic and increased demand due to the secondary impacts of COVID-19 and the lockdowns.

-          We recommend an increase in the public health grant to local authorities, based on local need for services, and emergency funding to help health visiting services address the backlog of missed appointments due to the NHS England COVID-19 prioritisation.

-          We support keeping nurseries open during lockdown, and the promotion of parental take up of nursery and other childcare places.

Introduction

Dr. Gabriella Conti is Associate Professor in Economics in the Department of Economics and the Social Research Institute at University College London. Dr. Conti is also co-Investigator of the National Child Development Study, and Research Fellow at the Institute of Fiscal Studies, Centre for Economic Policy Research and IZA Bonn.

Dr. Conti’s research draws on both the biomedical and the social sciences with the aim of understanding the developmental origins of health inequalities, the role of child development as input in the production of lifecycle health and the behavioural and biological pathways through which early life shocks, investments and policies affect well-being throughout the life course.

We submit evidence concerning the following terms of reference:

-          Ambitions laid out in the 2017 Green Paper

-          Addressing capacity and training issues in the mental health workforce

-          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

Families with children at risk of developing mental health problems

1. Mental health problems can have roots in the early years of a child’s life. A child’s attachment to the parent, development of emotional and behavioural problems, brain development and socialisation are some of the predictive factors of mental health issues later in childhood and the adult years (National Scientific Council on the Developing Child, 2012).

2. Limited socialisation because of lockdown and social distancing restrictions is concerning for infant mental health. In a survey of first-time parents, we asked which forms of childcare parents had used pre-lockdown, during the first lockdown and currently (survey fielded 12 July to 6 September). Figure 1 shows a clear reduction in the use of grandparents, nurseries, playgroups and other relatives as methods of childcare during lockdown. Conversely, the number of respondents reporting ‘Myself’ or ‘My partner’ as a childcare option increased. This implies a substantial reduction in the number of individuals children are interacting with through childcare. Whilst the distribution of childcare shifted towards pre-lockdown levels during the summer, it did not return to normal. Further details about the use of childcare since the start of the pandemic can be found in Conti and Johnson-Watts (2021).

Figure 1: Changes in childcare usage pre-lockdown (23 March), during lockdown (23 March to 1 June, 2020) and during the summer (July to September 2020)[1]

Figure 1 shows the types of childcare reported as being used by respondents over different periods during the pandemic. “Other” category includes the percentage of respondents that report using any of the other categories given: Pre-school, Creche, Childminder, Non-resident parent, Nanny/ Au Pair, Friends or Neighbours, None of these, Don’t know.

3. Many parents also did not plan to take their child to the playground or organise playdates. When asked in July, 24% said they had no plans to take their child to the playground/ playdate and a further 7% of respondents hadn’t yet decided.

4. Parents surveyed expressed clear concerns about the lack of socialisation of their child. When asked what dimensions of development they considered when thinking about how many children may fall behind, 89% of parents considered social development, followed by 69% considering language development, 64% considering cognitive development and 4% considering other development.

5. Furthermore, we asked respondents to rank areas that they have been most worried about since lockdown began (Figure 2). ‘Lack of socialisation’ was ranked the highest, followed by ‘My child’s learning and development’. Concern for lack of child socialisation may be especially poignant given that our sample are first-time parents. Therefore, most children will not have other children to interact with in their household.

Figure 2: Areas of concern respondents have been most worried about since lockdown began[2]

6. We find evidence of mental distress in the majority of first-time parents surveyed. Maternal psychological distress is associated with a range of adverse child outcomes (National Scientific Council on the Developing Child, 2012), such as an increased genetic risk for psychopathology (Goodman, 2007), or having ADHD at school age (Lesesne, Visser & White, 2003, Flouri et al. 2019). Respondents completed the Kessler-6 Psychological Distress Scale, a commonly used validated measure of mental distress. Between July and September 2020, 19% of respondents had a score of 13+ indicating probably or serious mental distress (Kessler et al., 2003, 2010), and 52% had a score between 5 and 12, indicating moderate mental distress (Prochaska et al. 2012).
    
7. Despite respondents showing a high incidence of mental distress, Figure 2 shows ‘How my/my partner’s mental health may impact them [the respondent’s child]’ was of relatively average concern to respondents, indicating that parents may not be aware of the impacts of parental mental health on infants. Indeed, when asked “Has your relationship with your child changed since lockdown began?” 43% of respondents stated it has stayed the same and 46% of respondents stated it had improved. Conversely, only 5% of respondents stated it had worsened.

8. A quarter of respondents stated that their child’s behaviour has worsened since lockdown began on 23 March 2020. It is possible that respondents’ children’s behaviour was being affected by their parents’ mental state. In our sample there is a significant correlation between respondents reporting a higher Kessler-6 score (indicating a higher probability of mental distress) and respondents reporting their child’s behaviour had worsened. Using a sample from the UK Millennium Cohort Study and the Kessler-6 scale, Flouri et al. (2019) find that psychological distress in both fathers and mothers increased the incidence of problem behaviour in their children (hyperactivity, conduct, emotional and peer problems).
    
9. The Government expressed their desire to better support families with children and young people at risk of developing mental health problems in the 2017 Green Paper. The COVID-19 pandemic has caused a significant negative shock to the mental health of families and young children. In the easing of social distancing restrictions, promoting the socialisation of young children and the return to childcare places should be a first priority in helping the mental health of these groups.

Improving local support for families with children vulnerable to mental health problems

10. In the 2017 Green Paper, the Government promised to “encourage local areas to improve their existing support of families”. Health visiting services, commissioned by local authorities and provided to all families with children under five, are a vital part of the local offer to families.
     
11. Health visiting teams identify children with emotional and cognitive development problems and recognise families where the child is vulnerable due to poor parental attachment, parental conflict, or domestic abuse. Childhood exposure to traumatic or abusive events is associated with depression and suicide attempts as an adult (Felitti et al., 1998).
     
12. Health visitors are trained in identifying and supporting mothers with postnatal depression. As discussed above, maternal and infant mental health are linked. Maternal depression is also associated with poor development of child brain function in the early years (Dawson et al., 2003).
     
13. Health visiting services are a key in the response to supporting children with early infant mental health issues and children at risk of developing mental health problems later in life. A family-centred approach to intervening early is essential. The evidence on parent-child attachment, maternal depression and childhood trauma and abuse that we have highlighted shows that infant mental health and development of more serious mental health problems are closely linked to the home environment and parents’ mental health.
     

Capacity and workload issues within the health visiting workforce

14. Health visiting services, however, are under severe strain after years public health funding cuts to local authorities.
    
     
15. Prior to the pandemic, in 80% of local authorities, caseloads were greater than 250 children per full-time equivalent (FTE) staff, the maximum caseload size recommended by the Institute of Health Visiting. In 22% of local authorities, caseloads were greater than 500 children per staff; and in 10% of them, caseloads were greater than 700 children per staff (Conti & Dow, 2020b).
     
16. COVID-19 has exacerbated existing pressures faced by health visiting services, both in the ensuing redeployment of health visiting staff to support COVID-19 efforts and in the increased demand for health visiting services due to the secondary impacts of the pandemic and lockdowns.
     
17. There has been widespread redeployment of staff in health visiting teams (both health visitors and clinical skill mix staff such as nursery nurses and community nurses). 65% of local authorities redeployed at least one FTE member of health visiting staff. Redeployment of FTE health visitors ranged from 0% to 63%, with 11% of local authorities losing over 25% of their FTE health visitors. Redeployment of FTE clinical skill mix staff ranged from 0% to 100%. 13% of local authorities redeployed over 50% of their FTE clinical skill mix staff (Conti & Dow, 2020b).
     
18. There was significant variation in the level of redeployment across local authorities (see figures 3 and 4) (Conti & Dow, 2020b). The variation in redeployment means that young children and families received different levels of care and support based on where they lived, an inequitable outcome that undermines the universality of health visiting in England.

19. Redeployment of staff started in the early stages of the pandemic, from 19 March 2020, and was sustained, until at least 1 September. In 95% of local authorities that redeployed staff, redeployment started before May. This means that not all families were receiving support from health visitors during a highly challenging period - the first Government imposed lockdown. This period was particularly difficult for new parents.[3]
     
20. Redeployment of staff meant that in many cases the number of children a health visitor was responsible for increased. Our survey of health visiting professionals (n=740) during the first COVID-19 wave reveals that 38% of respondents reported an increase in the number of children they were responsible for between 19 March to 3 June 2020 (Conti & Dow, 2020a).
     
21. Even after staff returned, health visiting services would have been facing higher workloads due to the knock-on impacts of the pandemic for families, repercussions of limited face-to-face contact and a backlog of missed appointments due to the NHS England COVID-19 community health services prioritisation[4] (during which, 3/5 mandated Healthy Child Programme contacts were paused).
     
22. Furthermore, a large proportion of health visiting staff we surveyed were worried about vulnerable children having their needs missed during the first lockdown. 96% of respondents were concerned about domestic violence and abuse, 86% about child safeguarding, and 82% about child neglect (Conti & Dow, 2020a). As evidenced above, vulnerable children are at high risk of developing mental health problems.

Recommendations based on our findings

23. First and foremost, increased funding for health visiting services to boost workforce size is necessary. The Government must increase the public health grant to counteract the funding cuts of 2015-2020, and funding must go beyond this shortfall given the erosion to health visiting services and consequences of COVID-19 on infant mental health. The 2020 Spending Review stated that the public health grant will be maintained – but maintained in either cash or real terms is not enough.
     
24. The Government must provide additional emergency funding to local authorities to help health visiting services address the accumulation of missed appointments, built up during the NHS England COVID-19 prioritisation plan. Funding should account for the level of redeployment in a local authority, given the significant variation found.
     
25. We support a return to the use of a revised ACRA[5] public health formula, which estimates funding to local authorities based on the need for different services (including other mental health services) in the local population. A revised formula is necessary to account for the transfer of children’s 0-5 public health services to local authorities in 2015[6].
     
26. The socialisation of children in their early years must be prioritised, through encouraging parental take-up of nursery places, preschool and other types of childcare, and the easing of social distancing restrictions that apply to young children, such as outdoor play with friends.

February 2021

References

Conti, G. and Dow, A. (2020a). “The impacts of COVID-19 on Health Visiting in England (first results)”. Unpublished manuscript, University College London. Available at: https://discovery.ucl.ac.uk/id/eprint/10106430/8/Conti_Dow_The%20impacts%20of%20COVID-19%20on%20Health%20Visiting%20in%20England%20250920.pdf

Conti, G. and Dow, A. (2020b). “The impacts of COVID-19 on Health Visiting in England: FOI Evidence for the First Wave”. Unpublished manuscript. Available at: https://dl.orangedox.com/HEALTHVISITINGNEWBRIEF

Conti, G., Mason, G. and Poupakis, S. (2019). “Developmental Origins of Health Inequality”. In Jones, A. (Ed.), Oxford Research Encyclopaedia of Health Economics, Oxford University Press.

Conti, G., Johnson-Watts, E., (2021). “COVID-19, Childcare Attendance and Child Development in England” Issues in English, The English Association, Paper number 15.
 

Dawson G., Ashman S.B., Panagiotides H., Hessl D., Self J., Yamada E., Embry L. (2003). “Preschool outcomes of children of depressed mothers: role of maternal behavior, contextual risk, and children's brain activity.” Child Dev. Jul-Aug;74(4), 1158-75.
 

Department for Education (2020). “Schools, colleges and early years settings to close”. Available at: (https://www.gov.uk/government/news/schools-colleges-and-early-years-settings-to-close).

HM Treasury (2020). “Spending Review 2020”. Available at: https://www.gov.uk/government/publications/spending-review-2020-documents/spending-review-2020

Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., Marks, J. (1998). “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study”, American Journal of Preventive Medicine, 14(4), 245-258.

Flouri, E., Sarmadi, Z., Francesconi, M., (2019). ‘Paternal Psychological Distress and Child Problem Behaviour From Early Childhood to Middle Adolescence’. Journal of the American Academy of Child & Adolescent Psychiatry. 58(4): 453 – 458.
 

Goodman, S.H. (2007). “Depression in Mothers”. Annual Review of Clinical Psychology. Vol. 3:107-135

Goodman S.H., Rouse M.H., Connell A.M., Broth M.R., Hall C.M., Heyward D. (2011). “Maternal depression and child psychopathology: a meta-analytic review.” Clin Child Fam Psychol Rev. 14(1), 1-27.
 

Kessler, R.C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfroerer, J.C., Hiripi, E., Howes, M.J, Normand, S-L.T., Manderscheid, R.W., Walters, E.E., Zaslavsky, A.M. (2003). “Screening for serious mental illness in the general population”. Archives of General Psychiatry. 60(2), 184-189.
 

Kessler, R.C., Green, J.G., Gruber, M.J., Sampson, N.A., Bromet, E., Cuitan, M., Furukawa, T.A., Gureje, O., Hinkov, H., Hu, C.-Y, Lara, C., Lee, S., Mneimneh, Z., Myer, L., Oakley-Browne, M., Posada-Villa, J., Sagar, R., Viana, M.C. & Zaslavsky, A.M. (2010). “Screening for Serious Mental Illness in the General Population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative”. International Journal of Methods in Psychiatric Research. 19, 4-22.

Lesesne C.A., Visser S.N., White C.P. (2003). “Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources”. Pediatrics. 111(5 Pt 2), 1232-7.

National Scientific Council on the Developing Child. (2012). “Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood” Working Paper No. 6. Updated Edition. Retrieved from www.developingchild.harvard.edu.

Prochaska, J. J., Sung, H.‐Y., Max, W., Shi, Y., & Ong, M. (2012). “Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization.” International Journal of Methods in Psychiatric Research. 21, 88–97

Sibley, C.G., Greaves, L.M., Satherley, N., Wilson, M.S., Overall, N.C., Lee, C.H., Milojev, P., Bulbulia, J., Osborne, D., Milfont, T.L. and Houkamau, C.A., 2020. “Effects of the COVID-19 pandemic and nationwide lockdown on trust, attitudes toward government, and well-being.” American Psychologist. 75(5), 618–630

Twenge, J. M., Joiner, T. E., (2020). “Mental distress among U.S. adults during the COVID-19 pandemic”. Journal of Clinical Psychology. 76, 2170-2182.

Wang H, Xia Q, XiongZ, Li Z, Xiang W, Yuan Y, et al. (2020). “The psychological distress and coping styles in the early stages of the 2019 coronavirus disease (COVID-19) epidemic in the general mainland Chinese population: A web-based survey.” PLoS ONE 15(5)

Annex:

Data collection: Parents and children survey

1. We collected primary survey data on first-time parents, living in England, with one child less than five years old who had not started primary school pre-lockdown (n=560).
2. Our baseline survey ran from 31st May to 9th June. We followed-up on the respondents for a second round between 12th July and 6th September, and will follow-up respondents again.
3. Our data is geographically representative of England. 32% of the sample are key workers. This is slightly higher than the 22% figure reported in Farquharson et al. (2020), which refers to all UK working-age individuals. 79% of survey respondents were female, and 21% male. The age of respondents varied from 19 to 49, with an average age of 31. 88% of respondents were White British, Irish or other. 72% of the sample were employed and working and 61% of the sample had a partner that was employed and working at the time of data collection.
    

Data collection: Health visiting

1. We collected data through Freedom of Information (FOI) requests to the providers of health visiting services across all Upper-Tier Local Authorities (UTLA) (n=151) in England. The first FOI requests were submitted on 19-20 August 2020, and the remaining between 2-7 September. Responses were received between August 27 and January 26. We have received complete data on FTE staff numbers and redeployment of staff for 140 local authorities (93%).
2. We collected primary survey data between 19th June to 10th September 2020 on a sample of adults working in the health visiting profession in England (n=740) who are on the membership and wider profession email databases held with consent by the Institute of Health Visiting.