Written evidence submitted by the Mental Health Foundation (CYP0061)
The Mental Health Foundation
Our vision is for a world with good mental health for all. Our mission is to help people understand, protect and sustain their mental health. Prevention is at the heart of what we do, because the best way to deal with a crisis is to prevent it from happening in the first place..
- The Mental Health Foundation welcomes the Committee’s Inquiry into children and young people’s mental health. We welcome in particular its consideration of whether government policy and action in this area could be reformed toward a more holistic approach that prioritises early intervention and prevention as well as crisis care and its exploration of how to tackle worrying trends in self-harm and suicide in this age group.
- Our response begins with sharing our latest quantitative survey data on the impact of Covid-19 on teenagers’ mental health, which we consider to be vital context for the Inquiry and any recommendations the Committee will make in this area. We follow this with a case study from our care leavers project to illustrate the mental health impact of the pandemic. We then address three specific parts of the terms of reference: wider changes needed to the system as a whole; preventing self-harm; and reducing the use of restraint with learning disabilities which provides learning for restraint in mental health settings.
- We would be pleased to provide further information and/or to give oral evidence to the Committee if this would be helpful to its consideration of these issues.
Current context: The impact of the pandemic on the state of children’s mental health
- Over the course of the coronavirus pandemic, we have run two surveys of adolescent mental health to complement our repeated cross-sectional survey of 16+ mental health.
- The findings from our latest adolescent YouGov poll of 13-19-year-olds (in the field between 17 November 2020 and 1 December 2020) show the effects of living through the pandemic on their mental health. Loneliness was a particular concern for young people, with 69% of teenagers in our survey reporting that they feel alone often or sometimes, while 59% felt that they had no one to talk to often or sometimes.
- Young people were also more concerned about the effects of the pandemic on their mental health (40%) than on their physical health (30%).
- One of the most concerning findings from our survey was that 57% of teenagers expect their future to be worse as a result of the pandemic. This feeling was particularly experienced by those around the age it is most common to leave school, with 64% of people aged 17 expecting their future to be worse.
- Across the board, teenagers in more advantaged social grades were proportionately experiencing lower levels of distress than those in disadvantaged social grades. For example, 17.8% of children in the C2DE social grade reported feeling nervous, anxious, or on edge “nearly every day” compared to 9.9% of those in the ABC1 social grade. The same was true for feelings of depression low mood and hopelessness, with 12.9% of teenagers in the C2DE social grade feeling down, depressed, irritable, or hopeless “nearly every day” compared to 7.8% of teenagers in the ABC1 category.
Care leaver case study
- It is important to remember that, behind these statistics, are the real experiences of children. The following case study is a composite of the experiences of care leavers involved in the Foundation’s Feeling Our Way project in Nottingham, which aims to support young people transitioning out of the care system.
- Malik is 19 years old and has been in the care system since he was 8 years old. He was taken into care while his stepdad was out of the house. His mum cried and screamed when the police and social workers came to remove him and his little brother from the home. Remembering the experience makes Malik angry and he doesn’t like to talk or think about it.
- Malik was never quite sure why he was taken from his family home. He thinks it had something to do with the violence his mum experienced but he was never able to discuss this with anyone. He often worries that he will end up like his dad or his stepdad. He doesn’t want to be like them, but he often feels angry.
- Since Covid-19 hit, Malik feels it’s impossible to think of the future. He feels there is no point in doing anything. He feels overwhelmed whenever he tries to do anything. He’s not kept up with payments for electricity and rent on his flat. His Personal Advisor (PA) is worried that Malik will be evicted if he doesn’t maintain these payments.
- Malik rejected mental health care despite having several offers of help. He thinks that talking about problems is a girls’ thing. He told his PA that if he talks about things, it just makes it worse. He gets angry and worries even more about what he might do while he is angry. Sometimes he walks to the bridge in the city centre and thinks about jumping into the river. He feels that the world might be better if he wasn’t in it.
- Malik agreed to be part of the Feeling Our Way project run by the Mental Health Foundation. He doesn’t like being called ‘a care leaver’ and he doesn’t want people to know that he was taken into care. He liked the project because it didn’t involve talking to anyone about his personal life. Malik receives ‘Wellbeing Kits’ every month at his doorstep. Every two weeks he also receives a ‘Digital Pack’ which covers different topics about mental health like sleep, worry or kindness. He likes some Digital packs more than others.
- Malik started using the free phone from the project to chat on an online forum with other people who also think about suicide. He finds it helps him when he realises that he’s not the only one who feels angry and worried. Another young man in the online forum suggested to Malik that he calls Samaritans when he’s on the bridge; he tells Malik that it feels good to discuss what he’s thinking, instead of thinking it over and over again. Malik wasn’t sure he liked the idea, but he figured he may as well try it once, while he has this free phone from the project.
- Malik found it really helpful to talk to Samaritans. He didn’t think it would help, but it was nice having someone who was interested in what he was thinking. Now, Malik is having his first meeting with a counsellor from Base 51 (a local mental health charity for young people). Malik and the counsellor are exploring options of what might help. There is a gym that he can access – his counsellor says that exercise will help him manage his anger and feelings of worry. Malik hopes that going to the gym will increase his confidence. The counsellor says they can visit the gym together on the first visit to help Malik feel more comfortable, so that he can continue going by himself afterwards.
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
- The system as a whole needs to pivot towards being one that focuses much more on prevention and early intervention. A whole-system, preventative approach can help to take the pressure off acute services while delivering a range of benefits that will reduce the prevalence and impact of mental health problems.
- The replacement of Public Health England with a body which focuses on infectious disease control leaves us without a clear future for PHE’s public mental health functions. In the absence of any reassurance to the contrary, we are concerned that PHE’s valuable public mental health work may be deprioritised. This would have serious implications for moving towards a system which better prioritises prevention and early intervention.
- It is important that public mental health remains a key part of discussions about the future of public health in this country. In many ways, we were facing a mental health crisis even before the Coronavirus pandemic and we already knew that it is not possible to treat our way out of this crisis. However, public health funding in local authorities had already seen cuts year on year. Alongside the new National Institute for Health Protection, the country needs a national world class organisation dedicated to issues of population health – with a particular focus on mental health. We need to see parity in funding and focus between physical and mental health, in public health as well as in services, and a national plan well integrated with local action.
- Investment in prevention and in addressing the social circumstances that clearly lead to mental ill-health is one of the most important tasks of any modern government because so much of a country’s potential is dependent on its citizens’ collective wellbeing.
Children and young people’s mental health as a public health issue
- Children reaching the point of crisis can be a tragic expression of an unmet need. Meeting these needs earlier, and preventing their associated mental health impacts, can help to take demand out of the system, with obvious economic and budgetary benefits, but also - crucially - support the healthy development of children.
- We advocate that the Government takes a “mental health in all policies” approach, embedding policies that promote good mental health and mitigate against risks to mental health across government departments, local governments, school systems, and care systems. To make this aspiration a practical reality, the Government should develop a cross-government plan on mental health that sets out specific, measurable objectives for each government department to contribute to mental health promotion through their specific policy areas. There should additionally be a duty on government departments to perform a mental health risk assessment on each new policy to ensure that mental health and wellbeing is at the heart of decision-making.
- The Government should take a proportionate universalism approach, with policies that aim to build individual and community resilience in the whole population as well as specific interventions targeted to those with the greatest mental health need. Interventions do not need to be explicitly “mental health” interventions: the most important thing is to use child wellbeing and health emotional development as the motivation and measure of success when designing interventions.
- Children and young people’s mental health policy also needs to be seen through an inequalities lens. The strongest determinants of mental health remain the social, economic, environmental, and cultural factors that shape the course of a child’s life. Findings from the UK Millennium Cohort Study show, for example, that having severe mental health problems was strongly related to parental education, parental occupation, and family income. In 2012, 17% of 11-year-olds from families in the bottom fifth of the income distribution were identified as having severe mental health problems compared to 4% in the top fifth. Directly addressing these inequalities is therefore central to making progress on children and young people’s mental health. These considerations must be central to the reformed public health system following the abolition of Public Health England.
- The Government needs to reinvest in community services and resources. A child’s resilience is not only an individual asset; it is drawn from the child’s family, networks, and local community. Cuts to local authority budgets, and particularly to the Public Health Grant which has fallen by 15% since 2015, have weakened these community resources, including health visiting support to parents of very young children. In addition, analysis by the YMCA has found that youth services have experienced a 70% funding cut over the last decade, resulting in the loss of more than 750 youth centres. Children’s services and public health need funding to build supportive, resilient communities, which are a prerequisite for resilient children.
A whole-school approach to mental wellbeing
- While wellbeing should be at the heart of all government policy, one area that is particularly important for a child’s wellbeing is education. Children and young people spend a significant proportion of their time in schools, colleges, and universities. Their experiences here can have a profound effect on their mental health, both positive and negative. Schools are particularly important for mental health policy because they are a universal provision and can be a vital safe space for some children, away from challenging home circumstances.
- All aspects of school life have the potential to influence a child’s mental wellbeing and all school staff should have a role in identifying, signposting, and supporting children. Schools should adopt a “whole school approach” to mental health and wellbeing, where mental health is everybody’s business, to ensure that children are supported by the whole school system.
- In England, the term “whole school approach” appears in government policy papers (such as the Prevention Green Paper) but it has never been well defined in statutory guidance, nor is it an expectation that schools follow this approach. A whole school approach to wellbeing needs to move from being good practice to universal practice. The Government should develop a statutory framework for a whole school approach, following the example of Wales, and Ofsted should include a whole school approach to wellbeing in its inspection framework.
- As well as intervening early in the development of a mental health condition, the Government needs to ensure that support and interventions are available early in the life course.
- An infant’s early experiences of safety and attachment are fundamental to their healthy emotional development. The All-Party Parliamentary Group on Conception to Age 2’s report Building Great Britons, reported that providing positive childhood experiences early in life could reduce hard drug use in later life by 59%, incarceration by 53%, violence by 51%, and unplanned teenage pregnancies by 38%.
- Too many government policies – including the flagship Transforming children’s mental health provision green paper – overlook the 0-5 age group, and within this the 0-2 age group is most neglected. CAMHS services in 42% of areas in England do not accept referrals for children aged two and the Parent-Infant Foundation found only 27 examples of specialised parent-infant teams in the whole of the UK.
- The Committee has already carried out an inquiry into the first 1000 days of life and we encourage it to restate these recommendations as part of a vision for whole system change. We urge the Government also to consider the needs of the infant in addition to the parent, as many early years interventions are focused on the parent’s needs. Although these can be a good proxy for the infant’s mental health and are important to address, the infant should still be at the centre of the intervention; this is often defined as parent-infant work, as it is essentially the relationship between the parent and the infant that is the focus of the intervention. A child being pre-verbal is not a good reason for them not to benefit from a child-centred approach.
The importance of preventing self-harm
- Self-harm is a sign of serious emotional distress. It can be used as a way to try to cope with difficult emotions, but is ineffective in the long-term. It can carry real physical risks, and can also cause young people to develop a higher tolerance towards damaging their own bodies. Although predicting suicide is extremely difficult and most people who self-harm do not go on to take their own lives, self-harming behaviour in young people is a strong risk factor for it, and is an important indication that someone needs urgent support with their emotional wellbeing.
- From a financial perspective, the overall cost of hospital management of self-harm is high: it has been estimated as being £162 million per year (across all age groups).
Young people (16+)
- The latest figures available show that rates of self-harm are increasing amongst males and females in every age group. However, this data is now significantly out of date: it is from the Adult Psychiatric Morbidity Survey (APMS), which was published in 2014. We understand that the Government has recommissioned this study after a delay (and that an announcement on this is upcoming). Whilst the APMS provides excellent and high-quality data, it only takes place around every seven years.
- Whilst data on self-harm amongst young people is out of date, the picture is worse with regard to children. We do know that the rate of 9-12-year-olds being hospitalised for self-harm has doubled in the last six years, according to BBC analysis, with hospital admissions in this age group averaging 10 a week. Hospital admissions will only represent be a tiny proportion of all the self-harm taking place in the community, though. Indeed, leading academics describe self-harm presentations using an ‘iceberg’ model, where hospital presentations represent only the tip.
- DHSC (or the new public health structure) should consider how it can develop accurate, up-to-date figures on the level of self-harm in the community for all age groups. Sharing this knowledge with local authorities would allow them to better develop and implement the self-harm elements of their local suicide prevention plans. Having this real-time, or near real-time, understanding will be more important than ever as we begin to recover from the pandemic, given the possibility of people turning to unhealthy coping mechanisms such as self-harm as they recover from trauma and deal with what may be a difficult economic situation.
- In line with our recommendation in this evidence that the system must become much more focused on prevention, a recent inquiry report from the APPG on Suicide and Self-Harm Prevention found that the system needs to be ‘flipped on its head’, moving from its current focus on crisis support, to intervening far earlier.
- A public health approach is required. Given that self-harm is used as a coping method for serious emotional distress, many of the broader points on public mental health made in this submission will help to prevent it.
- However, specific public health preventions are also needed, for example ensuring that technology companies act to control the spread of information which encourages or glamourises self-harm. The measures outlined in the Government’s response to its consultation on online harms are welcome, and now must be implemented as quickly as possible. More research is also needed to understand what kind of content is dangerous, and what the most effective protective measures for young people might be.
- There is an important role for schools in teaching about self-harm in a sensitive and responsible way, explaining the reasons it is not an effective, long-term solution. It is crucial that this is taught alongside mechanisms to manage one’s emotions more effectively and sustainably.
- Not everyone in the population is at the same risk of self-harm. A report by Agenda states that self-harm is more common among people who face poverty and disadvantage, and that this appears to be particularly the case for women, with young women living in the lowest-income households being five times more likely to self-harm than those in the highest-income homes. As outlined elsewhere in this submission, a proportionately universal approach would allow the most resources to be put into communities most at risk, including those from low incomes.
- Young people who self-harm
- Many young people who self-harm will need clinical support. We know that this often arrives too late, or not at all. In addition to reforms which are needed generally to children’s mental health services, including reduced thresholds and waiting lists, we know that young people can sometimes be banned from services because they are self-harming. This is unacceptable, and clear national guidance is required to end the practice.
- In addition to clinical support provided through the NHS, the voluntary sector will sometimes be able to create more innovative responses that are tailored to children and young people’s particular needs. Local and central Government both have a role in investing in and encouraging voluntary sector organisations as an alternative to NHS support where it is appropriate.
- Everyone in society has a role to play in preventing self-harm and making sure children get the support they need, whether this is simply knowing how to raise the issue and help a young person discuss their feelings as a non-professional, or how to ensure, as a professional, that young people get access to appropriate assessment and clinical services. The Government should carry out sensitive awareness-raising work to ensure that everyone knows what they can to do help. It is particularly important that this reaches GPs, schools, and statutory and voluntary services working with children and young people. It is important, though, that any such work does not inadvertently normalise self-harm or spread information on methods that can be used to carry it out.
- Any young person who presents to A&E must receive a full psychosocial assessment to determine what support they need. The All-Party Group’s inquiry found that practice can fall far short at present, for example with young people being denied anaesthetic when their wounds are being attended to. DHSC/NHSE should develop a clear plan for addressing such poor behaviour by clinicians. All parts of the medical establishment, including the Royal Colleges, have a part to play in ensuring that people who are self-harming are treated with the compassion and kindness that they need.
- Few people who self-harm are engaged with services, and so a public health approach is just as important for this group as it is for those who are at risk of self-harming. Parents, carers, teachers and medical professionals are often unsure what to do or say when they come across someone who is self-harming. There is a role for the Government in facilitating awareness campaigns aimed at those with responsibilities for young people, perhaps in partnership with voluntary sector experts. Depending on the results of the Government’s public health reforms, we would presume that responsibility for this would sit between DHSC and any new public health body.
Suicide amongst young people
- Thankfully, suicide amongst young people is rare, but the latest available figures (from 2019) for England and Wales show that rates among the under-25s have generally increased in recent years. This is particularly true for 10- to 24-year-old females where the rate has increased significantly. Since 2012 the rate has increased by 93.8% from 1.6 deaths per 100,000 females (81 deaths) to 3.1 in 2019 (159 deaths).
- The reasons behind this rise are not clear, and DHSC should commission research to understand and address this extremely worrying development.
- The Government has made progress in recent years in ensuring local authorities have suicide prevention plans in place, but the increasing prevalence amongst some groups shows the importance of not losing momentum as we recover from the pandemic and the public health system is in flux. Our recommendations for reform of the public health system are set out above.
- When DHSC publishes its upcoming update on the National Suicide Prevention Strategy, it should include specific guidance for local authorities on how to ensure they are intervening early to respond to the distress in their communities which is leading to increasing levels of both suicide and self-harm in this age group. This specific suicide prevention work must be connected to their plans to reform the public health system and to the broader Mental Health Recovery plan.
- Given that self-harm is a risk factor in future suicide, efforts to prevent suicide amongst young people must also address self-harm (see recommendations in previous section).
- Mental Health Support Teams are a welcome innovatio and have the potential to lead to earlier intervention for children and young people with mental health problems. The current intention, as set out in the Long Term Plan, is for them to be in 20-25% of schools by the end of 2023. Although there will be welcome continual evaluation of the effectiveness of the teams, which will inevitably slow their roll-out, we hope that the Committee can investigate whether there is scope to speed up their development in order that all children and young people across the country can benefit from them.
How the use of physical and medical restraint can be reduced
- Although we are a public health charity, our work with the Foundation for People with Learning Disabilities has given us some insights into the steps necessary to limit the use of physical restraint, something that is significantly detrimental to the mental health of children with learning disabilities. The use of restraint can be a traumatic experience which undermines the intended therapeutic benefit of being in a care setting. Some good practice on reducing restraint for children with learning disabilities will also be applicable in mental health settings.
- The restraint of children with learning disabilities is fundamentally a result of not meeting the needs of the child. Children with learning disabilities should not be subject to distressing Out Of Area placements, away from their families and familiar settings. Where possible, children with learning disabilities should be treated in the community.
- Restraint also stems from poor training of staff. Staff need to be able to effectively use proactive de-escalation techniques and should have regular training to keep these skills up to date. Agency staff need to be paid to undertake training. Too often it is the case that agency staff are expected to do training in their own time, without pay.
- Understaffing also contributes to the use of restraint, as staff are tired, over-stretched, unable to participate in training, and, under these circumstances, restraint can appear to be the easiest thing to do. There is a need for workforce planning to deliver the necessary number of staff to provide a safe environment in which to treat children with learning disabilities. Alongside this, the Government should set minimum staffing requirements for the treatment of children with learning disabilities.
- Tragedies such as Winterbourne View have taught us that there is a clear need for staff to be monitored beyond their attendance. In addition to formal monitoring, there needs to be a culture that encourages whistleblowing to safeguard vulnerable children with learning disabilities. In tragedies such as the scandal at Winterbourne View, there have clearly been the wrong people hired to look after people with learning disabilities. There should be a values-based employment process in which people’s reasons for wanting social work jobs are discussed at interview and form a central part of the decision-making process.
 All of our coronavirus research, key findings, briefings, and press releases can be accessed at: https://www.mentalhealth.org.uk/our-work/research/coronavirus-mental-health-pandemic/
 All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 2,395 UK teenagers between the ages of 13 and 19. Fieldwork was undertaken between 17th November and 1st December 2020. The survey was carried out online. The figures have been weighted and are representative of all UK teenagers (aged 13-19).
 We have coproduced policies on loneliness with young people based on these research findings: https://www.mentalhealth.org.uk/sites/default/files/Loneliness-policy-young-people.pdf
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 This is the notion of ‘acquired capability’, set out in, for example: Joiner, T. E., Jr., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., & Rudd, M. D. (2009). Main predictions of the interpersonal–psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of Abnormal Psychology, 118(3), 634–646.
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