Written evidence submitted by CUSP (CYP0105)


1.1 Who are CUSP?

We are academics from the University of Cambridge with representation from many disciplines that contribute to applied research relating to child development; individuals are listed at the end of the document for reference.


Our collaboration aims to optimise the application of evidence to policy and practice for the benefit of children, young people, their families/carers and the practitioners working with them. For each issue, we present research evidence that identifies likely challenges for education and children’s services, as well as any recent direct evidence of these challenges, and an effective policy response might be.


1.2 Summary of Key recommendations from CUSP



2. Overview of mental health provision in schools

2.1 The evidence

Since the publication of the Green Paper[2] in 2017, there have been a number of systematic reviews regarding mental health provision in schools. Below, we highlight several key reviews within the areas of mental health promotion and prevention, identification, and intervention.


2.1.1 Mental health promotion and prevention

Despite two recent systematic reviews, the evidence base around the effectiveness of school-based mental health promotion and prevention programmes remains unclear.


A systematic review and meta-analysis of school-based interventions to prevent depression and anxiety included a wide variety of programmes across universal and targeted prevention levels[3]. The authors concluded that there was little evidence that school-based programmes prevented depression or anxiety. However, this finding is not without controversy: concerns were raised regarding the inclusion criteria, which were not necessarily representative of ‘prevention’ in its truest sense (e.g. the review included studies with high proportions of participants with existing mental health difficulties and excluded many other types of relevant programmes, including those that address bullying)[4]. An example of a programme with promising results is the Penn Resilience Programme[5], which aimed to reduce depression and anxiety. It has been widely used internationally and in the UK, with two Local Authorities opting to implement the programme.


Another systematic review focused specifically on universal school-based mental health programmes in the UK setting, providing much-needed local evidence[6]. Interventions from the 12 studies reviewed included psychoeducation, mindfulness, and CBT-based interventions. The authors found mixed results for mental health and wellbeing outcomes; there was either no effect or a small positive effect, with higher quality studies more likely to report no effect. Barriers to implementation included fidelity, attrition, and costs. However, the study falls prey to some of the same limitations raised above in terms of inclusion criteria, including the omission of studies that may promote positive mental health/prevent negative mental health that are not specifically ‘branded’ as mental health (e.g. anti-bullying programmes).


2.1.2 Identification of need

Two systematic reviews focused on the identification of mental difficulties in the school setting.[7],[8]. Mixed evidence makes it difficult to recommend any one identification model for widespread use in the UK. Screening programmes were by far the most common type of programmes represented, with much smaller numbers of staff training, mental health education for pupils (curriculum-based models), identification based on administrative data, and ad hoc identification by school staff (staff nomination). There was no strong evidence to support the superiority any one of these methods over the others.7 Whilst there was some evidence that screening may be more effective than less systematic models (e.g. ad hoc identification by school staff), many screening programmes still had high rates of false positives and false negatives. The reviews found that school-based identification was generally acceptable to school staff and parents, but also identified significant barriers in terms of costs, time, and resources.8


Across the reviews there were only three UK studies, indicating a paucity of local evidence. The reviews further highlighted the importance of cross-sector collaboration and stakeholder engagement in the design, implementation, and evaluation of identification programmes.


2.1.3 Interventions for Children and Young People with mental health difficulties

Two systematic reviews focused on school-based mental health interventions to address anxiety and depression.[9],[10] A meta-analysis of the effectiveness of multiple types of interventions showed a small effect for reducing depression and medium-sized effect for reducing anxiety, although these effects were not sustained at longer-term follow-up times (>6 months post-intervention).9 A paired review of barriers and facilitators to implementing such interventions highlighted the importance of choosing appropriate interventions, considering the unique contexts of schools, and providing high quality training and supervision, all of which must be supported by structural and environmental support.10 Like the reviews of identification programmes, these reviews encouraged cross-sector collaboration and involvement of young people and school staff in the selection and implementation of interventions.


2.1.4 Whole School Approach

We were unable to find any (pre- or post-2017) review of the evidence for the Whole School Approach. This is an important omission, and a review of the evidence would be useful for guiding policy and practice. Below, we review evidence and provide recommendations regarding the individual domains of the Whole School Approach.


The Whole School Approach[11] is a common theme throughout the Green Paper. However, as mentioned above, we were unable to find any systematic review of the effectiveness approach as a whole. Below we discuss the state of evidence and on-the-ground progress for individual domains.


School cultures that value mental health and wellbeing

Whole School Approach domains:


These domains are crucial for promoting positive mental health and wellbeing[12],[13] and should serve as the foundation for all mental health programming in schools. According to the results of the 2017 Department for Education (DfE) survey,[14] it seems that these are domains where schools are fairly confident: 92% of schools reported that they believed to have an ethos promoting mutual care and concern. For the minority of schools where this was not the case, the Public Health England report[15] offers examples of best practice for these domains.


Promoting positive mental health and wellbeing through curriculum and staff training

Whole School Approach domains:


The Green Paper made the commitment that ‘every child will learn about mental wellbeing’. As of September 2020, the mental health elements of Personal, Social, Health and Economic (PSHE) and Relationships and Sex Education (RSE) are compulsory[16]. This is a welcome change. Care needs to be taken, however, to ensure children and young people (CYP) learn about mental ill health as well as mental wellbeing to give a balanced and holistic view. The DfE guidance on RSE[17] is more comprehensive in terms of lesson content than is the Green Paper, and includes expectations for schools to teach about risk factors for mental ill health (e.g. bullying), how to recognise the early warning signs of mental ill health, and how seek help when needed. This more comprehensive curriculum can help support the other domains of the Whole School Approach, such as identifying mental health need. Mental Health Support Teams (MHSTs) and Senior Leads may be particularly helpful in guiding decisions around the curriculum and integrating teaching into lessons outside of PSHE/RSE.


The Green Paper also states that ‘a member of staff in every primary and secondary school in England [will receive] mental health awareness training’. This is a step in the right direction; however, we would argue that this is not enough. To truly encourage a Whole School Approach, all school staff should receive some form of mental health training. This is in line with a recent Delphi study conducted in the UK, which showed that school staff, parents, and mental health practitioners and researchers agreed that all staff should receive training when it comes to mental health initiatives[18]. Furthermore, it is important that all staff training is based in the most current, high-quality evidence. For example, whilst the Green Paper highlights Mental Health First Aid training as a potentially useful training for school staff, evidence from UK schools shows that such training is not necessarily effective in improving teacher or pupil mental health[19]. Again, MHSTs may be useful evidence brokers to help schools select evidence-based training. Finally, there must be funding allocated to staff training such that schools do not have inequitable access based on ability to pay. Training teachers in classroom management has a growing evidence-base as a behavioural management tool but also as a public mental health intervention.[20] Importantly, it seems to have a biggest impact on primary school children with poor mental health.[21]


Identifying and responding to mental health difficulties

Whole School Approach domains:


Working in partnership with parents and pupils

Whole School Approach domains:


The importance of working in partnership with pupils and families cannot be overstated. And, while many schools undoubtedly strive to ensure pupil and family voice are central to mental health and wellbeing policies, we know from our work with parent and carer advisory groups that this is not always the case.


As CYP are the main intended beneficiaries of school-based mental health programming, it is crucial that their views are used to inform interventions and services[22]. Studies of CYP’s perceptions of school mental health programming can offer key insights on how to ensure programmes are acceptable and sustainable. For example, studies have found that CYP believe that policies around mental health and wellbeing are often inconsistent, and that mental health is not prioritised/emphasised enough[23] [24]. This is incredibly value information for schools that can allow them to tailor programmes to their pupils.


Recent studies have also examined the acceptability and feasibility of school-based mental health programmes from parents’ point of view[25]. Parental support of programmes is key, yet it has been noted that parent and carer involvement in school-based interventions can be challenging to achieve and that many interventions that do aim to involve parents suffer from low engagement. This indicates the need to identify and address barriers to collaboration with parents and carers to ensure all are working together to promote mental health and wellbeing programming.


CYP and their families want to have a voice in school mental health programming, so it is of utmost importance that we provide them that opportunity in designing, implementing, and evaluating school-based programmes. Fortunately, including stakeholder voices is slowly becoming standard practice in research, and there are many examples of best practice within mental health research (e.g. the Emerging Minds Network) that can guide everyday practice within schools.




2.3              What is provided in practice

A DfE survey from 2017 reports some of the most comprehensive and recent data on provision currently offered in schools. The survey reported what schools are doing to promote positive mental health and wellbeing as well as identify and support pupils with mental health needs. Below we outline the on-the-ground provision in each of the three categories reviewed above.


2.3.1 Mental health promotion and prevention

Nearly all schools (92%) indicated that they had an ‘ethos/environment that promoted mutual care and concern’ yet less than two-thirds (64%) integrated mental health promotion as part of the school day. Specific mental health promotion activities included skills sessions (73%), support programmes (70%), worry boxes (68%), peer mentoring (53%), and activities to reduce stigma around mental ill health (24%). Only 59% of schools had opportunities for pupils to guide decisions around mental health provision.


2.3.2 Identification of need

Fewer than half of schools (48%) collected data on pupils’ mental health to inform provision. Nearly all schools (99%) reported efforts to identify mental health needs. However, the most common method (82%) was ad hoc identification by school staff, which is not the most effective.7 The other common methods were use of information from external agencies (76%), assessment of mental health ‘alongside other assessments’ (65%), and use of administrative data collected for other purposes (50%). These methods also lack an evidence base. Many fewer schools used universal (15%) or targeted (24%) screening. In terms of tools used to identify need, half of schools (48%) used bespoke, unvalidated questionnaires, which therefore have unknown validity and reliability.


2.3.3 Interventions for CYP with mental health difficulties

Schools offered a broad range of support for pupils with mental health difficulties. The most common types of support were educational psychological support and counselling services (each 61% of schools), one-to-one support (55%), support groups (44%), peer support (36%), cognitive behavioural therapy (18%), and clinical psychological support (14%). The specific interventions are not described in detail, so it is difficult to determine whether the individual interventions are evidence-based, although the evidence for peer support in particular is sparse[26]. Importantly, the majority of funding for these types of support comes from the schools themselves, which risks leading to inequalities across schools.


The results from the DfE survey indicate that schools are working hard to promote positive mental health and wellbeing and support pupils with specific mental health needs. However, there are several areas where schools are using methods not supported by evidence (e.g. peer support, ad hoc identification of need, unvalidated measurement tools). As the Green Paper recommendations are rolled out, there is scope for the Mental Health Support Teams (MHSTs) to serve as ‘evidence brokers’ to guide schools in choosing evidence-based approaches to improving mental health. MHSTs can also help schools to evaluate the impact of their mental health provision.


2.3.4 Recommendations


2.4               Uptake

Schools are one of the most common places where CYP to seek support for their mental health[27], [28]. The 2017 national survey of CYP’s mental health found that teachers are the most common source of support for CYP with a mental health disorder, with nearly half of CYP with a disorder seeking support from teachers[29]. This suggests that, on the whole, CYP feel comfortable accessing support in the school setting.


There is still a great deal of work to be done in terms of making school-based mental health services accessible and acceptable for CYP. The OxWell School Survey found that while three quarters of CYP knew how to access mental health support at school, only one quarter would seek out these services if they felt they needed support for their mental health. This indicates that school-based services in their current form may not be acceptable to CYP, and that it is crucial that researchers, practitioners, and schools work closely with CYP to create services that are meaningful and relevant for them.


There is also a significant proportion of CYP who will not be able to access school-based services due to exclusion or non-attendance at school. In 2018-2019, 7,894 CYP were permanently excluded from school and a further 438,265 had fixed-term exclusions[30]. The 2017 national survey of CYP’s mental health showed that exclusions are far more common among CYP with a mental health disorder than among those without (6.8% vs. 0.5%). These findings highlight the importance of ensuring that CYP who are excluded from school do not ‘slip through the cracks’ in terms of service provision and that, as we improve school-based services, we also tailor services specifically for this group.


2.4.1               Recommendations


3. Progress toward key goals set out in the 2017 Government Green Paper

The 2017 Green Paper called for an expanded role of schools in mental health promotion and prevention. The three key proposals in the Green Paper were (1) incentives and support for schools to identify and train Designated Senior Leads for Mental Health, (2) funding for MHSTs to provide extra capacity for intervention and provide links with Child and Adolescent Mental Health Services (CAMHS), and (3) reduced waiting times for NHS services. The Green Paper further committed supporting mental health training for select school staff members and mental health education for all pupils.


Below we review what is known about local and national progress toward the goals laid out in the Green Paper and make recommendations after each section.


3.1 Designated Senior Leads for Mental Health

At the time the Green Paper was published nearly half of schools and colleges had specific mental health leads. The Evaluation of the Mental Health Services and Schools Link Expanded Programme report suggested that the Green Paper may have resulted in an increase in schools designating Senior Leads for Mental Health[31]. Beyond this, however, we were not able to find much national- or local-level data to update the original figure, making it difficult to gauge progress or impact.


3.1.1 Recommendations


3.2 Mental Health Support Teams (MHSTs)

MHSTs, are intended to (a) provide early intervention on mild to moderate mental health and emotional wellbeing issues, and (b) help staff within a school or college setting to provide a ‘whole school approach’ to mental health and wellbeing[32].


At the time of writing, we were not able to find any national-level data evaluating MHSTs in the trailblazer sites. Therefore, we have used the Cambridge and Huntingdon trailblazer sites as a case study to gauge progress toward the Green Paper goals. The teams in Cambridge and Huntingdon provided us with service reports for the three most recent quarters (Apr-Jun 2020[33], Jul-Sep 2020[34], and Oct-Dec 2020[35]). These demonstrate that MHST services are used frequently, with a total of 355, 238, and 485 contacts respectively from the above quarters across both sites.


The breakdown of contact types (see Table 1 Appendix A) indicates a broad range of activities. The most common was introductions to the MHST, which decrease over time, indicating that schools gradually became more familiar with the service. Other common reasons for contact included consultation, assessment, direct intervention, and updates; this suggests that the MHSTs are being used as outlined in the Green Paper to provide extra capacity for intervention and support. The types of contact also suggest the service is responsive to local schools’ needs, as outlined by responses to the Emotional Health and Wellbeing Service’s Schools Survey of Need[36]. However, one area that received less attention was work surrounding the Whole School Approach; this is a potential area for increased support and investment.


Qualitative feedback from staff training and support sessions showed that school staff clearly valued the MHSTs’ advice, as for example in the selected quotes below, which suggest that MHST services are well-received by parents and carers, as well as school staff.


From staff

It was lovely to meet the team and to go back over some of the techniques. I did actually learn some new techniques as well,’ ‘Lots of practical advice and strategies,

‘Great to receive training in the current climate, and to raise awareness of risk and resilience’).


From a parent regarding direct intervention work

‘[Practitioner] was fantastic, she listened, she provided me with different perspectives and activities and I’ve seen a huge improvement in my son by using these! Nothing was too much trouble - brilliant!!’.


3.2.1 Recommendations


3.3 Reduced waiting times

The initial Green Paper suggested a four week waiting target to access specialist Child and Adolescent Mental Health Services (CAMHS), while the response to the consultation[37] revealed widespread concerns about unintended consequences with the growth of hidden internal waiting lists for intervention if practitioners were diverted to assessment. For this reason, the Government’s response was to pilot rather than mandate the four week target, but to our knowledge, the results of these pilots are not published. As noted above, it is difficult to comment on progress without these data.


Data collected by Freedom of Information Requests from CAMHS providers for 2018- 2019[38] indicated that the median waiting times have reduced by 11 days since 2015 (range 49 to 65), but the average time on the waiting list was two months. While maximum waits had also reduced, some areas still reported children who waited for more than 12 months.  Furthermore, approximately a quarter of all referrals were rejected (range 17 to 28%), with few other options available for these children and young people. Primary care and schools often try to support them, but these children’s difficulties are often more severe than the mild to moderate issues that MHSTs and other school services are set up to manage. Referral criteria obtained from 29 out of 56 mental health trusts indicated that 10 accepted only those with “severe” orsignificant problems, while only 6 had no severity threshold[39]. The Commissioners Annual Report[40] indicates a 35% increase in referrals last year, but only a 4% increase in the number of children and young people seen by CAMHS. These reports collectively suggest significant under-provision of specialist services and a failure to make much progress towards the proposed four week waiting time target.


The Pandemic is likely to have increased the level of need in the population. The follow up of the English Mental Health of Children and Young People in 2021 suggests a profound impact on referrals and help seeking, as well as deterioration of mental health across gender, age and ethnic groups. Some groups seem particularly badly impacted, particularly those living in families facing financial strain and those with pre-existing mental health conditions[41]. For example, 45% of 17-22-year olds with probable mental health conditions reported not seeking help because of the pandemic, with similar reports from parents of under 16s[42]. Clinicians have raised similar concerns about timely access to services, and a sharp initial decrease in CAMHS referrals was observed, which has been followed by a rapid increase that exceeds pre-Lockdown levels by the autumn of 2021[43].


3.3.1 Recommendations


3.4. Cross-cutting Green Paper theme: the need for collaboration across multiple services

Improving links between schools and CAMHS is a theme that runs throughout the Green Paper, emphasised for Designated Senior Leads, MHSTs and to all service providers and commissioners (see Appendix B for details).


We fully agree that collaboration and integration of services is vital for the successful implementation of the Green Paper recommendations and the improvement of child and adolescent mental health more generally. MHSTs represent a step in the right direction in terms of collaborative working. However, integrated services are still not the norm and there is much to be done to properly integrate services. The following section outlines current challenges to service integration and makes recommendations after each section.


3.4.1 Fragmentation of services in the UK

We applaud the aspiration for commissioners and providers across health, social care, education, youth justice and the voluntary sector to develop Transformation Plans that reflect local needs. It reflects the issues that arise because young people with poor mental health have higher rates of neurodevelopmental disorders, special educational needs, family mental ill health, adverse life events, and social disadvantage relative to their peers[44]


However, services for young people and their families remain stubbornly fractured. Most existing services do not adequately respond to the complex needs of the most vulnerable children. Indirectly, support is piecemeal, separating mental health support from any appraisal of contributing risk and protective factors and from co-occurring mediating factors. For example, support for children with difficulties in learning is often considered entirely separately from mental health support, even though we know that they often co-occur and reinforce one another.  


The most vulnerable families are least able to navigate the siloed nature of mental health, physical health, education, and social services, with the result of inequitable access and engagement [45][46]. Laborious referral procedures, gatekeeping referral criteria, and multiple assessments form barriers to integration[47]. Furthermore, interventions do not adequately reflect the interdependent and multiple needs of young people[48],[49],[50].


If successful, integrated services should improve outcomes for people with poor mental health, and boost the quality and efficiency service provision[51],[52]..  But we lack evidence about how to implement the adoption of evidence about contributing factors from population health approaches and to integrate services. Joint planning, service development, training as well as co-location and co-working are potentially useful strategies to employ, but there are many possible models and a lack of evaluation. Consideration should be given to using measures of CAMHS inter-agency collaboration and integration[53],[54].


3.4.1 Recommendations


3.4.2 Examples of good practice of mental health service integration with health, education, and social services

Efforts to overcome fragmentation represent a key theme in many examples of best practice. However, many integration initiatives are unable to achieve sustainable implementation, particularly as cross-cutting services are more vulnerable when organisational targets are set or when budgets are squeezed. For example, the annual Liaison Psychiatry Surveys of England demonstrated improved mental health provision for children and young people within acute general hospitals between 2015 and 2019. More acute hospitals had a dedicated service, and services reported more staff and faster response times. However, on close inspection some services had lost funding, and access for children, particularly out of hours” cover was much poorer than that for adults[55].


The quality of data available for appraising such initiatives has often been weak, especially for initiatives that attempt to bridge the gap between health and social care[56]. This means that a discussion of best practice in the area is necessarily quite speculative.


Headstart Wolverhampton – UK

An example of a cross-cutting service that has specifically addressed problems of fragmentation is Headstart Wolverhampton. This initiative used Big Lottery funding to set up multi-agency community bases to provide support for secondary-age young people. The service linked together youth work, school, CAMHS liaison and police liaison. The final evaluation is yet to be published, but the initial results indicate improvements in self-reported resilience for young people[57].


This project also illustrates some of the challenges of integration. Engagement from schools was uneven, in part because of a lack of clarity about respective responsibilities[58]. Furthermore, young people with special educational needs (SEN) plans did not benefit as much as their peers, suggesting limited integration in this area. The lead evaluator of Headstart Wolverhampton has questioned whether a programme focused solely on the mental health of young people, rather than also addressing community development, can really have lasting effects in the context of the deprivation faced by the city[59]. A lack of clarity about respective responsibilities is a recurring theme.


Troubled Family Initiative projects e.g. Love Barrow Families (LBF) – UK

‘Failing a Generation’ also observed that the Green Paper gave insufficient attention to vulnerable groups of children. In this regard, there may be relevant learning from some of the Troubled Family Initiative projects. One such project is Love Barrow Families (LBF), which works with families where there are safeguarding concerns or other significant difficulties in the provision of care to children. Key components of LBF included co-design with local families who used services, a keyworker for each family, and reorganisation of mainstream services to co-locate a team of workers from the Local Authority's Children’s Services, Adult Social Care, Child and Adolescent Mental Health and Adult Mental Health services[60]. A small-scale evaluation reported very positive results[61]. However, as with so many other projects that work outside of mainstream silos, LBF has faced ongoing challenges in securing funding to continue, though so far it has been successful.


3.4.5 Recommendations


4. International Initiatives – Examples of Good Practice

Here we provide some examples of good practice from other countries. According to international league tables (e.g. PISA), UK pupils have among the lowest life satisfaction and highest levels of stress and anxiety. The UK also has one of the worst gender gaps, with teenage girls reporting particular difficulties with stress and anxiety, which is echoed by the epidemiological data[62]. This highlights that there is much to learn from other countries. We have drawn from our knowledge of international examples of good practice that relate to all areas covered by this Select Committee consultation. Some of these programmes lack rigorous evaluation, and even where present, evaluation would be necessary if they were trialled in the UK as what appears effective in one context may not necessarily translate to our context.


4.1 Good practice case example 5: WHO Caring Universities initiative – The Netherlands

The Netherlands have undertaken some initiatives that should be considered as potential good practice. One is the WHO Caring Universities initiative at the Vrije Universiteit Amsterdam, Leiden University, Utrecht University and Maastricht University, with a suite of e-programmes to support students with aspects of their mental health and wellbeing. The availability of e-programmes has been especially relevant during the coronavirus pandemic[63].


4.2 Good practice case example 6: City at Eye-Level for Kids – Global

Another Dutch initiative of potential interest is the City at Eye-Level for Kids, in which urban planning initiatives are pursued with a priority given to children’s mental and physical health. This initiative has had global reach, promoting innovative urban planning around the world[64].


4.3 Good practice case example 7: Annual Surveys and Research-Policy Integration – Iceland

The Iceland model is also interesting for comparison with the UK. Central to this model is collaboration between researchers and designated leads for each municipality, including policy-makers, practitioners, and parents. An annual survey identifies relevant changes in CYP’s mental health and highlights potential key risk and protective factors. The survey results are brought to the municipality for discussion and action plans are initiated or revised. The initial focus of the Iceland model was adolescent alcohol and substance use, which fell quite steeply[65].


We have not seen a replication of the Iceland model, so findings need to be treated with a degree of caution. However, the principle of using annual surveys and integrating research and policy is worth further consideration. Despite notable exceptions, routine service-based surveys of the mental health needs and services for young people in the UK are patchy or tokenistic[66] and not well set up to identify groups with particular needs or contribute to cycles of service improvement. Efforts in Greater Manchester and Oxford offer a promising attempt to use regular surveys of young people’s mental health and wellbeing to inform policy and practice[67]. Adult mental health morbidity surveys run every seven years, but there was a gap of 13 years between the last two for children and young people[68]. Whether gathered locally or nationally, robust data on needs and provision is essential for service planning. Greater use could be made of routinely gathered data, particularly if linked to research data, but only if the problems with access experienced since the introduction of General Data Protection Regulation are solved to permit timely access[69].


4.4 Good practice case example 8: Let’s Talk about Children Service Model – Finland

The Let’s Talk about Children Service Model focuses on enhancing sensitive interactions between parents and children, and enhancing supportive teacher-parent interactions based on shared understandings of the child’s needs at home and at school. There is coordinated multi-agency involvement from an early stage. In the municipalities in which Let’s Talk was implemented, referrals to child protection services fell by 25%, in a national context in which referrals otherwise rose steeply[70]. Let’s Talk appears to have some key features in common with Love Barrow Families, including multi-professional integration and a family-centric more than child-centric focus.


4.5 Good practice case example 9: Education System – Finland

Finland is also relevant as an educational system that was quite resilient to COVID-19. Finnish education entails greater self-directed learning for students, more coursework, and greater discretion for teachers to adjust the curriculum. These all proved assets when teaching had to move online[71]. Furthermore, the Finnish anti-bullying programme, KiVa, is widely implemented and has led to a huge drop in bullying, which is our most tractable public mental health risk factor. A cluster randomised controlled trial of this programme in England and Wales is paused and about to restart after disruption by Covid-19.


4.6 Good practice case example 10: Home visits – United States

In the United States, the Attachment and Bio-behavioural Catchup (ABC) intervention is a 10-session, manualised intervention to help families meet the needs of infants and toddlers through a parsimonious focus on supporting caregiver sensitivity and reducing harsh parenting behaviours. The intervention has a strong evidence-base showing long-term effectiveness[72]. A forthcoming issue of the Infant Mental Health Journal will report findings from the remote delivery of this intervention during COVID-19. The effectiveness of the intervention was found to be equivalent to in-person delivery. Though the extent to which this success was facilitated by the manualised nature of the intervention is unknown, it is interesting that coaches were able to exceed in-person fidelity standards when delivering ABC remotely.


‘Failing a Generation’ noted that “It is disappointing that the Green Paper missed the opportunity to scale up provision of evidence-based parenting interventions”. Whilst clearly there are aspects of safeguarding assessments that are obstructed by remote delivery rather than in-person home visiting, the findings from ABC suggest that support for caregivers can be provided remotely, which may contribute to scalability, or at least open opportunities for provision for populations that might be otherwise hard to reach physically (e.g. rural locations). Similarly there was a disappointing lack of attention to pre-school children in the Green paper.


4.7 Recommendations


5. Improved access to services


5.1 Inpatient services

Our team does not include sufficient expertise about inpatient care to comment on the details of how the ward milieu should be improved. We agree that every effort should be made to work with children and young people with severe mental health conditions in the community, but there will always remain some who require admission, and there is evidence to suggest that we lack sufficient inpatient beds.


Analysis of Hospital Episode Statistics for two decades up to 2019 indicate that while admissions for adults decreased, those for children and young people increased markedly, particularly for depression and psychosis[73]. Furthermore, a separate analysis of Hospital Episode Statistics suggests that much of the recent increase in paediatric admissions is related to mental health problems[74]. This increase suggests under provision of both community and mental health inpatient services.


We are aware that there is limited data available about the numbers of young people who are admitted to inpatient units that are a long distance from home, out of their commissioning group area or to adult or paediatric wards. Routine data collate all admissions, including those to tertiary or regional units, which obscures how many other children are admitted far from home. An NIHR funded study[75] is examining this issue. Some of these admissions may be appropriate or indeed preferable for clinical reasons, particularly where integrated health and physical care can be offered. Sadly the Liaison Psychiatry Surveys for England quoted above suggest inadequate provision of mental health services in to acute paediatric units.


5.2 Increase early interventions for mental health difficulties

Early intervention for mental health difficulties is imperative as individuals with untreated childhood mental health difficulties can face a multiplicity of challenges continuing into adulthood[76]. An important caveat is that these will never be sufficient to prevent or mitigate severe problems for some young people, so should be provided in addition rather than instead of current services. Here we present examples of good practice with related recommendations.


5.3 Good practice case UK example 1: The Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) programme

The development of Children’s Well-being Practitioners within the CYP IAPT programme and of Mental Health Support Teams as detailed in the Green Paper have improved access to early interventions for mental health difficulties. In Cambridgeshire, these new roles sit within the NHS Emotional Health and Well-being Service which also houses Emotional Health and Well-Being practitioners. These practitioners consult directly to schools and are funded by Clinical Commissioning Groups.


CYP IAPT reflects good practice in many ways, by enhancing the provision of evidence-based interventions, use of outcome measures, and the participation of young people in their own treatment planning as well as the design of services (CYP IAPT)[77]. However, response rates for routine monitoring are extremely disappointing, particularly at follow up, and there is still a need for these services to be available to more CYP, particularly in light of increased rates of mental health problems related to COVID.


5.4 Good practice case UK example 2: The NHS Best Start in Life program

The NHS Best Start in Life programme follows on from the Long-term Plan, Healthy Child Programme and takes a population health early intervention approach. This approach recognises the inter-connectivity of physical health, access to learning, and the child’s attachment to parents/carers. This programme focuses on school readiness in 0-5 year-olds.  The need for this approach beyond age 5 years remains imperative with approximately 10% of children between the ages of 5 to 10 years having an emotional, behavioural, or neurodevelopmental disorder.  Many of these young children will not be able to access mental health services due to falling below referral criteria and may not have access to a MHST. Furthermore, the MHST is not aimed at assessing complex learning and developmental difficulties which may co-occur with emotional difficulties. While some children will be assessed within Community Paediatric teams, the offer of ongoing support for behavioural, emotional, learning or attachment difficulties is not available in these services. Furthermore, learning difficulties are often not identified at this early age.


5.5 Recommendations


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


This section addresses the issue of self-harm, covering its prevalence, subtypes and associated risk factors. Recommendations are outlined at the end of the section. Self-harm and suicide in adolescents are major public health problems. Rates of self-harm are high in adolescence, and suicide, whilst relatively uncommon in adolescence compared to non-fatal self-harm, is still the second most common cause of death in young people worldwide.

Self-harm is a complex mental health issue. Among adolescents in the UK, the prevalence of self-harm ranges from approximately 13.2 to 19.7%[78],[79]. Self-harm is heterogenous in nature as reflected by different subtypes of self-harming behaviour and different profiles of young people who self-harm. Not all of these subtypes are associated with recognised mental health difficulties. This suggests that whilst self-harm is strongly associated with poor mental health symptoms, like low mood or emotion dysregulation, it can occur in their absence, too. Self-harm is a major risk factor for suicide[80], and worryingly both self-harm and suicide are increasing in prevalence, even before the Covid-19 Pandemic. The heterogeneous profiles of those who self-harm also extents to the type of self-harming behaviour itself (e.g. cutting, drug abuse, etc.)[81] and the frequency of the behaviour (e.g. single, occasional, repetitive)[82].

Self-harm is hard to predict in advance. A crucial step in making these predictions is to understand the different emotional and behavioural profiles for young people who self-harm, because these profiles will likely be associated with different sets of risk factors[83]. A recent prospective study demonstrated that early risk factors for self-harm can be in evidence almost a decade earlier, and do indeed differentiate different subtypes of self-harming behaviour[84]. Prevention or early intervention programmes that target these risk factors may prevent self-harm as well as other mental health conditions. These include:

Being bullied exacerbates mental health and adjustment difficulties[85], and is one of the strongest risk factors for self-harm[86]. Bullying is perhaps our most tractable public mental health risk; it casts a shadow over adult mental health as well as child mental health and responds to prevention programmes.


Emotion dysregulation, or poor emotional control, is a prominent risk factor for self-harm. Within this context, self-harm is likely one constituent component of a broader profile of mental ill health[87].


Low self-esteem has been consistently reported as a strong risk factor for self-harm.


Recent studies have identified sleep problems, which are tied to mood and emotional challenges[88], as risk factors that may predict and/or be associated with an increased risk of self-harm[89]. Worryingly, increased sleep disruption was reported frequently by young people in the national survey follow up and a large cross-sectional survey of schools (n>19,000 8-18 year olds from 237 English schools) during the summer of 2020[90].


Compromised parental wellbeing – both in terms of mental and physical health – has also been linked to an increased risk of self-harm in adolescents.


Self-harm is a stigmatised and often private behaviour, but teachers are usually the first adults to identify a young person who is harming themselves. How this disclosure is handled is key and teachers are understandably anxious about mishandling the situation and lack training and confidence about how to do so[91]. Frequently school policy directs them down a safeguarding route. If the young person is self-harming in response to a family problem this can aggravate their distress. Designated senior Leads for Mental Health and MHSTs are well-positioned to support in these situations and teachers report benefit from training[92], although we lack data on whether the training improves outcomes for their students or whether knowledge and skills are maintained.


6.1 Recommendations


8. Collated list of all recommendations


9.  CUSP members contributing to this report


With many thanks to Holly Cromwell, who proofread this and corrected the reference list.


10 References             




Appendix A


Table 1. Number of Contacts by Reason for Cambridge & Huntingdon MHSTs

Contact Reason





Adolescent Anxiety





Adolescent Low mood










Behavioural Difficulties





Child Anxiety - Group Intervention





Child Anxiety – Parent Led Intervention










Conversation (with verbal consent)





Direct Intervention - Anxiety Primary





Direct Intervention - Anxiety Secondary





Direct Intervention - Behaviour





Direct Intervention - Low Mood





Discussion (family/referrer/young person)





Education - Termly Planning Meeting





External professional liaison





Introductions to MHST





Keep In Touch / Updates





Project Review










Referrals Received










Staff wellbeing





Support with Referral




















‘What if?’ conversations





Whole School Approach work










*Table derived from estimates included in three Quarterly Reports from the Emotional Health and Wellbeing Service. N.B. category names changed slightly across the reports.




Appendix B


Green paper statements of integration

Designated Senior Leads for Mental Health should have:


Knowledge of the local mental health services and of working with clear links into children and young people’s mental health services to refer children and young people into NHS services where it is appropriate to do so. (Emphasis added)


In terms of MHSTs:


While the value of schools and colleges playing a part in supporting young people with their wellbeing and mental health is clear, it is equally clear that this is not a challenge that they can or should meet on their own. Schools and colleges need a collective understanding and up to date knowledge of children’s mental health services provided locally, and access to specialist help, through clear links into NHS mental health services. (Emphasis added)




Such a team can be a valuable additional resource in and of itself, but can be even stronger when working closely with a range of other services. These other services include professionals who work closely with schools and colleges, such as educational psychologists, school nurses and counsellors, local authority troubled families teams, social services, peer networks, service user forums, and voluntary and community sector organisations. All of these roles play a crucial part in supporting young people with mental health problems and so we will test a range of models for putting the new teams at the heart of collaborative approaches with these professionals. (Emphasis added)


Commissioning and provision

Transformation Plans for children and young people’s mental health services provide a basis for local areas to work with commissioners and providers across health, social care, education, youth justice and the voluntary sector, bringing everyone together to plan strategically, reflecting the needs of local communities. (Emphasis added)



March 2021



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