Our Time – Written evidence (PSC0031)

Our Time evidence submission on the role of public services in addressing child vulnerability

Introduction:

1. Our Time is a charity, formed in 2000, which supports the children of parents with a mental illness (COPMI) and their families through workshops, school programmes, training professionals, and advocacy. It is the only UK organisation dedicated to addressing this issue.
2. This response, countersigned by Dr Warren Larkin, to the Committee’s call for evidence demonstrates the crucial need to address the vulnerability of COPMI, recognise them as an at-risk group in public policy, and enable public services to address their needs more effectively. In addition, it advocates for early intervention and preventative approaches.

Summary:

3. Child vulnerability can best be defined as: ‘Children facing a range of difficulties and complex needs in multiple areas of their lives, for example, a child living with parents who are poor, facing a range of disadvantages and socially isolated. The risks range from living in families where there is long-term physical or mental illness, to going hungry; being homeless or excluded from school; being at risk of neglect10.’
4. There are over 2.9 million children and young people in the UK (20% of the student population) who have a parent with a mental illness. Their lives are impacted in multiple ways, and without early intervention they are likely to become patients of the future. This problem is both moral and economic as, without recognition of this issue in policy and provision, the burden on families and the economy will become unmanageable. The UK is one of the only developed countries with no policy or recognition of this group. 
5. There is growing evidence that parental mental illness presents a key risk for children and young people’s mental and physical health across their lifespan. It is one of a cluster of adversities (including substance misuse and domestic violence), commonly called the ‘toxic trio’, which have life-limiting consequences for children. This intergenerational cycle of mental ill health does not simply arise from genetic inheritance, but is largely attributed to family stress, including poverty, marginalisation, trauma and other environmental causes. Parental mental illness is a major risk factor for child vulnerability and often the root cause of other adversities, but there is no support for this hidden group.
6. Our Time has spent 12 years working with families to develop resilience in the face of the adversities presented by the illness. Our model of support uses integrated solutions, which are simple and low cost. We understand the issues and how to provide high quality support that works, now we need the policy to enable this to be funded.

The vulnerability of COPMI:

7. Parental mental illness is a major risk factor for child vulnerability and is often the root cause of other adversities.
8. COPMI face extensive immediate challenges: they are likely to drop out of school, have irregular attendance, find it hard to concentrate, experience difficulty with homework and their social life, and often suffer bullying because of their parents’ illness. They are often quiet and withdrawn and as a result fall behind in their studies. Due to their family situation, they may not have anywhere quiet to study or be able to bring friends home, leading to social isolation and a high risk of depression[1].
9. Most parents with a mental illness never speak to their children about it, which can lead to huge anxiety issues in a child, hypervigilance, fears of causing or contributing to their parents’ illness, or worries about getting the illness themselves. These two myths are very damaging to a child’s health and well-being. When a parent is hospitalised, the children may go into foster care unless they have relatives who can care for them. Most children and young people in our workshops are from single-parent households[2]. COPMI often take on caring responsibilities, particularly older siblings who may also adopt a parenting role for their younger siblings.
10. Parental mental illness has profound long-term ramifications for children. It can negatively impact all aspects of a child’s development and is associated with a higher risk of mental illness for the child across the spectrum of diagnosable disorders[3]. COPMI face a 70% chance of developing a preventable mental health issue, with 40% requiring treatment by the age of 20[4].
11. Untreated childhood psychosocial adversity can lead to severe adult health outcomes and is associated with elevated risk, for both mental health issues and physical illness[5]. Parental mental illness is an Adverse Childhood Experience (ACE) and listed among the 10 leading causes of toxic stress in children[6]. It frequently lies behind other ACEs, including domestic violence, neglect, substance misuse and homelessness. Adults who have experienced four or more ACEs are 37.5 times more likely to have attempted suicide than those who have experienced none[7], and two to three times more likely to develop cancer, heart disease, or respiratory disease[8]. The Early Intervention Foundation (EIF) report that low family income and parental mental health may be stronger predictors of physical health problems than other ACE categories[9]. Without intervention COPMI will become the patients of the future.
12. This is a widespread and growing issue. In the UK, over 2.9 million children live with a parent with anxiety or depression alone[10]. Covid-19 has likely increased the prevalence of COPMI, with nearly 40% of the UK’s population reporting high anxiety in March 2020, an increase from 21% in 2019[11], and parents and carers reporting higher levels of stress and anxiety than population averages[12]. Contracting the virus or experiencing financial or psychological hardship associated with the pandemic, could exacerbate existing mental illness. The pandemic may also result in illness going unidentified and untreated[13].

COPMI and public services:

13. Despite the far-reaching implications of parental mental illness on children, there is no recognition of this large at-risk group, or mention of it in any policy or mental health strategy.
14. COPMI fall between public service boundaries. Adult mental health services do not address the support needs of children in the parents’ care, and child and adolescent mental health services (CAMHS) are only available when children and young people develop mental health problems, which is too late. Children of parents with a current mental health issue are also less likely to benefit from CAMHS’s therapeutic interventions[14].
15. Public services are not set up, equipped or incentivised to address the underlying causes of child vulnerability; they are siloed, and attempts at integration and collaboration are inconsistent. The dominance of a ‘service’ model means that services operate individually, rather than collaboratively supporting the needs of a family and affected children and young people.
16. Professionals, such as doctors, social workers and teachers, frequently do not feel equipped to support COPMI. For example, mental health workers are often reluctant to discuss mental illness with children due to its complexity and a lack of agreed definitions around mental illness and its treatment. This frequently results in COPMI receiving no explanation at all.
17. COPMI also actively hide their family situation from those who might be able to support them, such as teachers, social workers and friends. This is out of loyalty and love for their parents, protecting them from interventions that might put the family at risk. This leaves the children to carry a heavy burden of responsibility alone.
18. Many families we work with have negative reactions to support from local authorities, frequently fearing interventions that are, at best disruptive, and at worst perceived to be damaging. As a result, there is very little trust between families and statutory services.
19. Our feedback from local authorities is that there’s insufficient funding available for early intervention and prevention. With tight budgets this work is not perceived as urgent and therefore not funded.
20. The accessibility of public services and day-to-day support has been further constrained by Covid-19. One of the strongest contextual factors that determines the level of adversity faced by COPMI is whether other adults are accessible, including teachers[15]. For many children, access to teachers and other adults, upon whom they rely, has been constrained during lockdown. In May 2020, over 80% of parents whose children previously received support from services – including support for mental health, emotional or behavioural difficulties, support from social services or educational support – reported that they were no longer doing so[16].
21. Together these factors make COPMI largely hidden to public services, an invisibility which results in them receiving insufficient public service support, or indeed no support at all. With the enormous number of children affected in the UK, as well as the novel pressures of Covid-19, this lack of appropriate support is reaching crisis level.
22. Alongside the social impact of not addressing parental mental illness, there is also significant long-term cost to the public purse. Prior to the pandemic, £17 billion per year was spent in England and Wales by the state on ‘late’ intervention – equivalent to around £287 per person[17]. The largest costs include those relating to child and family adversity, with the Children’s Commissioner’s Office estimating that the average public expenditure on mental health and well-being was around £24,000 per child receiving support in 2017[18]. These costs are expected to have grown during the pandemic.

Recommendations:

23. Public services target individuals and focus on treatment and acute service provision. This model is no longer fit for purpose and fails to address the complex, interrelated underlying causes of childhood vulnerability, rarely addressed in public service provision. The following recommendations detail an effective, economic family-centric approach to supporting COPMI.

Recognise COPMI in public policy and develop a national strategy to support them:

24. Government should commit to an integrated national approach to address COPMI’s vulnerability and make them visible to public services.
25. COPMI should be identified through robust statistical analysis, conducted nationally, and included as an at-risk group in official figures. Moreover, there should be mandatory reporting of COPMI in adult mental health teams.
26. A national early intervention strategy for COPMI should be developed, with Cabinet level/Ministerial sponsorship, to ensure future generations of young people are not exposed to this significant risk. The UK can emulate examples set by countries such as Norway, Australia, the Netherlands, Canada, and Denmark.
27. For example, the Norwegian government established the ‘BarnsBeste’ network in 2007, which initially aimed solely to support children of patients with either mental illness or substance abuse, before being further expanded[19]. In 2010, a new provision (section 10a) in Norway’s Health Personal Act obligated health personnel to identify and follow-up patients’ children[20]. Since its introduction, health professionals in Norway have reported high levels of knowledge and confidence in working with families and children, and there have been substantial increases in the recognition of children in parent’s health records[21]. The visibility of COPMI in public service provision has substantially increased.
28. Alongside this, a specialist team at government level should be established to provide consultancy and advice to local teams, informed by experts and those with lived experience.
29. Government should ensure every UK local authority has a plan for supporting these families, cutting across health, education, social care, and public health, with targeted offers for affected children, in collaboration with the voluntary sector. This should include providing dedicated and ring-fenced funding for COPMI as part of a long-term approach to care.
30. A workforce training and information sharing plan across health and education should be implemented. Be it school teachers, school nurses or other health professions, knowing how to speak to these children and provide the right environment in which children feel safe, supported, and free from stigma can make a huge difference.

Shift towards early intervention and preventative approaches:

31. The intergenerational cycle of ill health associated with parental mental illness is primarily caused by environmental stress. In a safe, protective family environment genetic vulnerability is a low risk for developing mental health issues. Research into familial transmission of depression observed associations between maternal and child depressive symptoms, regardless of whether mothers and children were genetically related[22]. The 2020 NHS Digital Report found that children and young people from families where there are problems with family functioning are more than twice as likely to be at risk of mental health disorders than other children (28% as opposed to 11%)[23].
32. Because of this, early intervention and preventative approaches can mitigate the immediate challenges facing COPMI and reduce their risk of developing future mental health problems.
33. In a 2020 Lancet Psychiatry article, Professor Sir Michael Marmot called for a public health approach to the impact of the pandemic, placing prevention and early action at the heart of the solution[24]. Mental health services are under huge pressure and, without multiple interventions to address disadvantaged groups, there will be a bulge in acute service demand for the next decade or longer.
34. Our Time has found success operating ‘KidsTime’ Workshops, which build resilience, reduce stress, and increase parents’ and children’s confidence and self-esteem. The workshops offer a fun, protected space where young people can express themselves, interact socially, share experiences, and learn about mental illness through discussion, games and drama. Trained staff explain mental illness to young people in a way they can understand and help them to articulate and tackle concerns or challenges. The workshops also provide adults with an informal, intimate space, where they have the opportunity to share experiences and discuss their role as parents rather than patients. Our work is based on three well-established principles: knowing you are not alone; having someone you trust to talk to; and having a good explanation of mental illness.
35. There are many case studies which demonstrate the workshop’s efficacy[25]. One child constantly worried about her mother with a bipolar disorder when she was not by her side. After attending the workshops, she became “quite comfortable being away from Mum” and “is much more settled at school”, which has had a “hugely positive impact on her education” as well as improving their relationship[26]. Evaluation of families attending Bedfordshire KidsTime Workshops in 2020 showed improvement across all outcome areas[27]. Even in extreme cases, the workshops have had success. For example, a mother, who experienced childhood trauma, domestic violence, and postpartum psychosis and depression, has seen her family grow in confidence and learn how to support her. She describes the workshops as “being like a family”, with the “culture of openness and support”[28].
36. There are 20 KidsTime Workshops in England, mostly based in London, the locations of which are determined by available funding and relationships with local service providers. For example, we have very strong relations with Westminster Council where we have trained two teams based in the Family Hubs, funded by the council and integrated with their family support service portfolio. Existing workshops are all funded differently. Several workshops are entirely funded or part-funded by the local authority, CAMHS, charitable organisations, such as Mind or Family Action, or by trusts and foundations. Many councils are not able to fund our projects.
37. Our Time also runs school programmes, which equip staff with simple but powerful skills to respond to the needs of COPMI, and create an environment where stigma is reduced and students who have an unwell parent are supported[29].
38. The proliferation nationwide of these programmes would address the vulnerability of COPMI. It is crucial that early intervention and preventative services receive greater recognition and ring-fenced funding in public services policy. Without integrated service coordination, access to support for a child caring for a parent with mental illness will continue to be a postcode lottery.

19 March 2021