Written evidence submitted by Agenda (CYP0102)

Summary

1. Agenda is an alliance of over 100 organisations working in England and Wales to build a society where women and girls are able to live their lives free from inequality, poverty and violence. Through its Girls Speak programme of work, Agenda campaigns for some of the most marginalised, misrepresented and misunderstood girls and young women (aged 14 to 24) in society –  those who face multiple disadvantage.

2. Agenda welcomes the opportunity to respond to this inquiry into Children and Young People’s Mental Health, and are encouraged to see the prioritisation of issues including barriers to accessing support, the use of restraint and growing rates of suicide and self-harm – areas of concern which disproportionately impact or are disproportionately experienced by girls and young women at the sharpest end of inequalities.

Key points

3. Experiences of abuse, poverty and other forms of disadvantage and discrimination are a significant driver of poor mental health in young women.

4. Despite this, prevailing narratives and research tend to focus on pressures at school, body image and social media as primary causes of mental ill-health for girls, and the true extent of problems facing girls’ and young women is often overlooked, leaving many girls and young women without the right support.

5. Through a review of existing research and data, in addition to new research undertaken by Agenda with girls and young women and the services supporting them, mental health and the lack of adequate, safe and holistic provision has emerged as a key concern.

6. Young women struggling with their mental health have told us they have felt afraid to seek help, have faced significant barriers to accessing services and support, and have even been re-traumatised by mental health services designed to help them.

7. To address the root causes of girls’ and young women’s poor mental health and avoid missing opportunities to intervene, we must recognise and respond to their experiences of trauma, discrimination and poverty.

8. Access to a spectrum of support, including age-appropriate, gender-specific provision in statutory services and specialist girls’ and young women’s services which respond to the underlying causes of girls’ poor mental health can have a significant, positive impact on girls’ and young women’s lives.

Key recommendations

9. Development of a national women and girls’ mental health strategy led by the Department of Health and Social Care delivered through both statutory services and gender-specialist youth provision. This must:

1. reach across children and adolescent and adult mental health services, including transitions when girls enter adulthood;

2. prioritise early intervention and incorporates wrap-around support for girls and young women at risk of poor mental health embedded in a range of community settings, including education and care, as well as the youth and adult criminal justice system;

3. take account of inequalities in access to and experiences of mental health care;

4. and recognise and fund the critical role women and girls’ services play in improving mental health and wellbeing, including specialist services led by and for minoritised groups.

10. A central government commitment to take a cross-departmental and gendered approach to addressing the social and economic challenges facing girls and young women in order to prevent the development of poor mental health and reduce the risk of self-harm and suicide, with a focus on advancing equalities across all protected characteristics. This should be overseen by a named Minister with a new responsibility in their brief for girls and young women at risk.

11. The Home Office’s forthcoming Violence Against Women and Girls (VAWG) strategy to ensure the mental health impacts of VAWG and the full range of ways in which girls and young women experience VAWG is recognised and responded to in a joined-up way across government departments.

12. Training for professionals in contact with girls and young women to understand the links between girls’ and young women’s poor mental health, experiences of trauma, and discrimination and inequality to ensure an approach prioritising prevention and early intervention across all services girls come in to contact.

13. Introduction of ‘routine enquiry’ as standard practice across mental health services, where trained staff ask patients about their experiences of violence and abuse, accompanied by age-appropriate, gender-sensitive support and pathways into care.

14. Every mental health trust to have a clinical lead for women and girls’ mental health and a women and girls’ mental health strategy, with holistic girls’ and young women’s services to provide a safe, therapeutic space to address girls’ and young women’s mental health needs and the experiences that drive poor mental health.

Full response

About this submission

15. This submission of written evidence draws on Agenda’s evidence-base relating to poor mental health experienced by girls and young women as one of several forms of disadvantage. This includes:

16. Struggling Alone: Girls’ and young women’s mental health (November 2020) – briefing paper on girls and young women’s mental health and the underlying causes of this.

17. Often Overlooked: Young women, self-harm and poverty (May 2020) – report based on analysis undertaken by the National Centre for Social Research focused on the connections between poverty and non-suicidal self-harm in young women.

18. The Women’s Mental Health Taskforce (December 2018) – final report from the Women’s Mental Health Taskforce co-chaired by Agenda and the Department and Health and Social Care, setting out the need for and key principles for gender- and trauma-informed care.

19. Young Women’s Justice Project Literature Review (January 2021) – on young women (aged 17-25) in contact with the criminal justice system, outlining core components of an age-appropriate, gender-sensitive and trauma-informed response to girls and young women facing multiple disadvantage.  

Girls’ and young women’s mental health

20. Poor mental health is a serious and growing problem for girls and young women.

21. Over a quarter of young women have symptoms of depression or anxiety, experiencing this at three times the rate of their male counterparts and at higher rates than older women.[1]

22. Self-harm rates have tripled amongst girls and young women since 2001 and suicides of girls and young women have doubled in the last 7 years.[2]

23. Almost a quarter of girls and young women experience post-traumatic stress disorder (PTSD) and 1 in 10 has been diagnosed with a personality disorder.[3]

24. Young women have experienced the highest levels of distress during the coronavirus crisis,[4] with particular concerns raised about Black and minoritised young women’s mental health.[5]
25. Experiences of abuse, poverty and other forms of disadvantage and discrimination on the basis of gender, ethnicity and sexual orientation are significant drivers of poor mental health for girls and young women.[6] Despite these connections, however, policy makers often focus on the adverse impact of pressures at school, body image and social media as the primary causes of girls’ mental health problems. This means the true extent of their problems are often overlooked, leaving many girls and young women without the right support.

What progress have the government made on children and young people’s mental health, including but not limited to:

1. The ambitions laid out in the 2017 Green Paper

26. In our response to the Green Paper in 2018, Agenda raised concerns about its lack of recognition of the role gender plays in mental health, despite research showing that young women are a high-risk group for mental health concerns. 

27. Recent guidance from Public Health England (2019) calling for professionals to consider experiences of gender-based violence, trauma and childhood neglect as factors impacting mental health in prevention work is encouraging.[7] Similarly, the development of new services for children with complex trauma including experiences of sexual assault as outlined in the NHS Long Term Plan (2019) is welcome. However, these developments do not recognise girls and young women as a distinct group in need of tailored support. Without specific and sustained attention, girls and young women in vulnerable groups remain at risk of falling through the gaps in otherwise positive developments.[8]

28. The final report from the Women’s Mental Health Taskforce, co-chaired by Agenda, made a clear case for the development of an age-appropriate, gender-sensitive and trauma-informed response to girls and young women.[9] Without central government ‘ownership’ of issues facing girls and young women, and without policies, strategies and funding streams which recognise the needs and experiences of girls and young women as distinct from those of boys and young men, progress in this area remains limited.

2. Provision of mental health support in schools

29. Girls and young women often attribute their struggles in education to poor mental health stemming from issues which they felt were overlooked and went unaddressed at the time.

30. Marie is now 23. After a sexual image was shared without her consent at school, she was excluded on the basis of her consequent behavior. She explains:

31. “I just felt like I gained a stereotype… And instead of [being asked] “What’s going on... are you okay?”... they ask[ed] me about school counselling once... It was a while after... It was just too late.”

32. Once outside of mainstream education, girls are at greater risk of other forms of disadvantage associated with poor mental health, including increased risk of coming into contact with the criminal justice system,[10] as well as further experiences of sexual harassment and abuse in male-dominated pupil referral units where girls report feeling unsafe and outnumbered.[11]

33. Guidance for schools on the impacts of trauma should consider and respond to the gendered nature of violence and abuse. The Department for Education’s 2018 guidance for professionals responding to sexual violence and sexual harassment between children in schools and colleges in 2018 is a welcome development, but does not include any discussion of the mental health impacts of experiencing this kind of abuse, and there is no discussion of gender-specific responses to these incidents.[12] 

34. We would like to see the Government respond to these trends and patterns more widely and ensure proper support is in place for children who have faced violence and abuse, which responds to the complexity of needs they may have. This should include the introduction of ‘routine enquiry’ within mental health services and specialist services for children and young people. This involves training professionals to sensitively ask about experiences of violence, abuse and exploitation and must be accompanied by age-appropriate, gender-sensitive support and pathways into therapeutic care.

35. Over half of all women who have a common mental health condition have experienced violence and abuse, with this starting in childhood for a quarter of those impacted.[13] In updating the Violence Against Women and Girls (VAWG) strategy, the Home Office should also ensure that the mental health impact of VAWG, and the full range of ways in which girls and young women experience VAWG, is recognised and responded to in a joined-up way across government departments.

3. Addressing capacity and training issues in the mental health workforce

36. As a result of the problems they face, young women who experience poor mental health are likely to be in contact with a range of institutions and services. These staff need to be equipped to be able to support them.

37. Speaking with Agenda, girls and young women note it is apparent that over-stretched professionals do not always the time or ability to engage with the complexities of their lives.

38. “I think they need to bring more workers in… so that people actually have time to listen… Someone’s always missing out because they’re so busy.”                     – Amelia, 19

39. Girls and young women also tell us that the extent of the challenges they face is often overlooked by professionals. Where additional vulnerabilities are considered, risks tend to be looked at in isolation – for example, young women’s experiences of abuse and poverty may not always be identified as linked with their experiences of poor mental health.[14] 

40. Lucy is 19 and spoke with us about how her mental health deteriorated after the abuse she was experiencing was not picked up quickly enough.

41. “My mental health stemmed from home life… I was asking to move away from the domestic violence... Because that was happening my mental health got really bad and I was taking lots of overdoses… I thought that would have given them an indication…”.

42. In statutory services, practitioners’ lack of knowledge relating to identification of and responses to ‘root causes’ of poor mental health, particularly violence and abuse, has been identified as of concern[15] underscoring the need for the introduction of ‘routine enquiry’ within mental health services and services for children and young people. Implementation of this must involve training for mental health professionals developed in consultation with specialist girls’ and young women’s services, with a focus on age-, gender- and trauma-informed responses to children and young people.

4. Improving access to mental health services

43. Through research undertaken by Agenda with girls and young women and the services supporting them, the lack of adequate, safe and holistic provision for girls and young women experiencing mental ill-health has emerged as a key concern. Young women struggling with their mental health have told us they have felt afraid to seek help, have faced significant barriers to accessing services and support, and have even been re-traumatised by mental health services designed to help them.[16]

Being overlooked

44. Girls and young women report feeling worried that they will be dismissed and patronised by professionals. Emma is 21 and has struggled with her mental health, attributing this to her experience of care at a young age, and experiencing abuse in a relationship. Concerned she would be disbelieved due to her age, she described being “scared to go to the doctors” when experiencing abuse.

45. This lack of trust and understanding between professionals and young women may prevent young women reaching out for support around issues impacting their mental health.

Stigma and blame

46. Due to the complexity of the issues they face, girls and young women often find themselves bounced between services or excluded from accessing support. Sometimes labelled as ‘risky’ or ‘hard to reach’ by services, a harmful narrative develops whereby girls struggling with their mental health are blamed for their lack of engagement with a service which is unsuited to their needs.

Transitions to adulthood

47. Girls turning 18 and moving from children’s to adult services can face an arbitrary cliff-edge in support at a time when they are experiencing a lot of change and may be facing new risks and harms.[17]

48. Danielle is now 21 and had support from CAMHS from the age of 13. She describes the transition from youth to adult mental health services as something she felt unprepared for. Without mental health support for a year after turning 18, her mental health deteriorated and she was hospitalised several times.

49. “It was probably the worst I’ve been with my mental health… I was struggling but I was struggling alone… I was still a young person… I do have workers now and it looks like I will do for a while because I do have diagnoses that are quite serious...”

Lack of specialist provision

50. Despite pockets of good practice, there is limited provision for girls and young women tailored to their age- and gender-specific needs. Girls and young women report feeling alienated from both youth services and services for adult women, describing both as “not for them”.

51. There is also little specialist provision for girls and young women with intersecting, marginalised identities, including Black and minoritised girls and young women and/or LBTQ+ girls and young women struggling with their mental health, despite these groups facing additional barriers to accessing mainstream mental health services.[18]

52. Specialist women and girls’ services, including those led by and for minoritised groups, play a critical role in improving mental health and wellbeing for girls and young women facing multiple disadvantage, and are often best-placed to deliver preventative and early intervention work.

53. Where these examples of age-appropriate, gender-specific local practice exist, girls and young women feel that this should be developed and maximised.[19]

54. “There should be more clubs for girls. I think there should be more youth centres for us women to open [up] and talk about our personal stuff... [T]his place has helped me, I’d be lost without it.” – Anonymous, 17

55. This underscores the need for specialist, independent provision to become a core component of responses to young women experiencing poor mental health, and for gender- and age-informed practice to become embedded in statutory provision. 

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

56. With clear links between gendered violence, trauma and poor mental health for girls and young women, it is imperative that responses to those with acute mental health problems in inpatient care, particularly in CAMHS, take into account experiences of trauma and abuse.

57. Agenda has previously revealed significantly greater use of face-down restraint on girls than boys in Child and Adolescent Mental Health Services (CAMHS) facilities.[20] Girls and young women do not feel that staff always try to de-escalate a situation prior to using restraint and have raised that restraint can feel punitive and be re-traumatising.[21]

58. Agenda recommends the following measures to reduce the use of physical restraint on girls and young women:

59. Girls’ and young women’s age- and gender-specific experiences, including their history of trauma, to be taken into account in mental health services and support given to tackle the underlying issues they face, including frontline NHS workers receiving training to understand that girls’ and young women’s mental health and experiences of trauma and abuse are often closely linked.

60. Implementation of the Mental Health Units (Use of Force) Act or ‘Seni’s Law’ statutory guidance to ensure all staff in mental health units receive trauma-informed training.

61. ‘Routine enquiry’ as standard practice across mental health services, where trained staff ask patients about their experiences of violence and abuse. This should be accompanied by age-appropriate, gender-sensitive support and pathways into care.

62. Every mental health trust to have a clinical lead for women and girls’ mental health and a women and girls’ mental health strategy, with holistic girls’ and young women’s services to provide a safe, therapeutic space to address girls’ and young women’s mental health needs and the experiences that drive poor mental health.

63. For further discussion of the impact of restraint on girls and young women, see Agenda briefing on the use of restraint against women and girls (March 2017).

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

64. Despite the clear gendered difference in mental health needs and experiences of girls and boys, mental health support is rarely gender- and trauma-informed. To respond appropriately to the mental health needs of children and young people, any new approach must consider the gendered trends and manifestations of mental ill-health and ensure that pathways and treatment meet the needs of both young women and young men.

65. Girls and young women experiencing mental distress as one of several forms of disadvantage must have access to a spectrum of support, including gender-specific provision in statutory services and specialist girls’ and young women’s services, including those led by and for marginalised groups. This must be available flexibly, accessible over time and offer holistic wrap-around support. Girls and young women must be involved in the design and development of this support, with their experience and knowledge of what works placed at the centre of responses to the challenges they face.

66. To address the root causes of girls’ and young women’s poor mental health, services must recognise and respond to their experiences of trauma, poverty and discrimination. If these underlying causes of poor mental health are not understood, services are unable to build a full picture of the experiences and needs of girls and young women facing multiple disadvantage, missing crucial opportunities to intervene. Services must also be aware of the differing impacts of factors such as ethnicity, sexual orientation and dis/ability on children and young people’s experiences of poor mental health. Support for girls and young women with intersecting, marginalised identities must reflect this and be appropriate to their needs.

67. Girls’ and young women’s needs should also be explicitly recognised in youth, women’s and mental health policy, strategy and funding streams. One way to address this is through the development of a national women and girls’ mental health strategy led by the Department of Health and Social Care and delivered through both statutory services and gender-specialist youth provision. This must:

1. reach across children and adolescent and adult mental health services, including transitions when girls enter adulthood;

2. prioritise early intervention and incorporates wrap-around support for girls and young women at risk of poor mental health embedded in a range of community settings, including education and care, as well as the youth and adult criminal justice system;

3. take account of inequalities in access to and experiences of mental health care;

4. and recognise and fund the critical role women and girls’ services play in improving mental health and wellbeing, including specialist services led by and for minoritised groups.

How the Government can learn from examples of best practice, including from other countries?

68. Conversations with girls and young women and findings from existing research indicates that effective support for girls and young women experiencing poor mental health as one of several forms of disadvantage tends to be characterised by work which:

1. centres girls’ and young women’s lived experience and perspectives in the design and development of services intended to support them;

2. provides safe, girl- and young woman-only environments run by gender-specialist services with expertise relating to the challenges faced by girls and young women with intersecting, marginalised identities, including for Black and minoritised and/or LBTQ+ girls and young women;

3. focuses on developing and sustaining positive relationships with professionals, including having a trusted point of contact as girls and young women transition into adulthood;

4. prioritises a strengths-based approach to empower girls and young women and address risks and vulnerabilities including identifying and responding to root causes of poor mental health, including experience of trauma, discrimination and poverty.

69.            For further discussion of the core components of an age-appropriate, gender-sensitive and trauma-informed response to girls and young women facing multiple disadvantage and examples of specialist girls’ and young women’s provision, see the Young Women’s Justice Project Literature Review (Section 5 and Annex 4).

What measures are needed to tackle increasing rates of self-harming and suicide among children and young people?

70. The most marginalised girls and young women face a range of disadvantages which can negatively impact on their mental health.

71. Young women (aged 16–34) living in the most deprived households are five times more likely to self-harm compared with those in the least and 1 in 5 young women with severe money problems has self-harmed in the past year. [22]

72. Rates of self-harm are higher amongst Black young women than any other group, but they are less likely to receive support for this.[23] South Asian young women are significantly more likely to self-harm than white young women.[24] 

73. Girls’ and young women’s deaths by suicide were the highest on record in 2019. Whilst young men continue to die by suicide at higher rates overall, there has been a 72% increase in rates of suicide amongst girls and young women over the last 10 years, compared to a 28% increase amongst boys and young men.[25]

74. Research also shows that girls and young women attempt suicide at higher rates than young men, with one fifth of girls and young women aged 17–19 having self-harmed or tried to kill themselves, compared to one in 10 boys and young men of the same age.[26] 

75. The current strategic focus on boys and men in suicide prevention can risk overlooking girls and young women facing multiple disadvantage who are also at high-risk, with girls who die by suicide more likely to have experienced abuse and have experience of the care and criminal justice systems than boys who die by suicide.[27]

76. The challenges facing girls and young women at risk of self-harm and suicide span a range of key policy areas, including mental health, violence against women and girls, criminal justice, education, care, poverty and racialised inequalities.

77. In addition to the development of a national women and girls’ mental health strategy as outlined in response to question 3, an effective response to increasing rates of self-harm and suicide amongst children and young people is necessarily a joined-up one. It must involve collaborative working between a number of governmental departments, including but not limited to the Department of Health and Social Care, Home Office, Department for Education, Ministry of Justice and Government Equalities Office.

78. A central government commitment to take a cross-departmental and gendered approach to addressing the social and economic challenges facing girls and young women to prevent the development of poor mental health and reduce the risk of self-harm and suicide, with a focus on advancing equalities across all protected characteristics, is also needed. This should be overseen by a named Minister with a new responsibility in their brief for girls and young women at risk, and prioritised as the UK enters the recovery phase of the coronavirus crisis.

79. Training for professionals in contact with girls and young women to understand the links between girls’ and young women’s poor mental health, experiences of trauma, and discrimination and inequality to ensure an approach prioritising prevention and early intervention across all services girls come into contact with. This should be developed and delivered in partnership with specialist girls’ and young women’s services.

About Agenda

Agenda, the alliance for women and girls at risk, is working to build a society where women and girls are able to live their lives free from inequality, poverty and violence. We campaign for women and girls facing abuse, poverty, poor mental health, addiction and homelessness to get the support and protection they need. We work to get systems and services transformed, to raise awareness across sectors and to promote public and political understanding of the lives of women and girls facing multiple disadvantage.

www.weareagenda.org

February 2021

For more information, please contact:

Maggie Bridge, Senior Policy and Engagement Officer

March 2021

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