Foreword
This publication has been created to assist those nurses who are not mental health specialists, who work with children and young people in a community, hospital, school, and other setting.
This publication aims to have the following learning outcomes:
- Support the reader to identify the skills and knowledge they will need to recognise and, if necessary, refer children who have problems affecting their mental health.
- Support nurses who provide care in acute hospitals and are waiting for specialist mental health practitioners to attend a particular child or young person, by both providing insights into the more common mental health problems.
- Provide relevant information and learning to enable facilitating the development of local guidelines.
- Enable those who are preparing education programmes to assist nurses in their understanding, recognition, and management of mental health problems in children and young people.
It is not intended for nurses working within children and adolescent mental health services (CAMHS) – the specialist NHS-funded community service that operates within the wider children and young people’s mental health services (CYPMHS) - although they might find some of the content of interest and value.
This resource updates and replaces two RCN publications on this topic: Mental health in children and young people: an RCN toolkit for nurses who are not mental health specialists (RCN, 2014a) and Children and young people’s mental health – every nurse’s business (RCN, 2014b). It also complements the RCN publication Child and Adolescent Mental Health. Key Facts (RCN, 2017a) which is focussed on the role of nurses within a school setting.
There have been some significant changes to how the mental health of children and young people is addressed and managed in the UK since the original RCN guides were published in 2014. The following sections provide an overview of these developments.
In 2015, the Future in Mind report (DH and NHS England, 2015) provided recommendations on how to improve CYPMHS and £1.5 billion of additional investment for CYP mental health provision was provided over a five year period. Subsequently, the Five Year Forward View for Mental Health was produced (Mental Health Taskforce, 2016) and in 2017 its recommendations were formulated into a series of planned reforms to improve CYP mental health. These included new support for schools to improve links with NHS, a review of CAMHS by the Care Quality Commission (CQC) and the Transforming children and Young people’s mental health provision: a green paper (DH and DfE, 2017). Key proposals contained in the green paper included the identification of a designated senior lead for mental health (DSLMH) and the establishment of school based mental health support teams (MHSTs) to work with NHS CYP mental health staff and provide extra capacity for early intervention and ongoing help.
Alongside these policy initiatives, the CQC published its final report Are we listening? (CQC, 2018) which found that the quality of mental health services for CYP were varied across England; that there were problems around access amid growing demand; that there was a lack of coordination between the different services; and outlined the pressures on staff and a lack of resources.
All these developments, concerns and recommendations were crystallised in the NHS long term plan (NHS England, 2019) which included a commitment to improve access to mental health treatment for 70,000 more children and young people.
Further measures in the plan included a commitment that:
- funding for CYP mental health will grow faster than both overall NHS funding and mental health funding
- there will be continued investment to improve access to community mental health services - an estimated 345,000 CYP will be able to access these services by 2023/24
- extra investment for eating disorders services would be provided
- the NHS would fund new MHSTs in schools and colleges
- the current 0-18 year service models would be extended to create a comprehensive offer for 0-25 year olds.
In September 2018 the Northern Ireland Commissioner for Children and Young People (NICCY) launched its Still waiting - a rights based review of mental health services and support for children and young people in Northern Ireland (NICCY, 2018). The review assessed the adequacy and effectiveness of mental health services for children and young people, highlighted good practice and identified barriers which prevent them from fully realising their right to the highest attainable standard of mental health. In October 2019, the Department of Health produced a draft action plan to enhance mental health services and support for children and young people. The recommendations included flexible treatment options, support for adults working with children and young people, and moving from child to adult services. NICCY is now monitoring implementation of the plan.
In Northern Ireland, the Health and Social Care Board and the Public Health Agency launched its care pathway for children and young people coming into CAMHS in 2018: Working together: a pathway for children and young people through CAMHS. The pathway outlines what should be expected when referred for treatment and provides a summary of clinical advice for all sectors of the service derived from evidence-based practice. It also includes information about accessing support before, during, and after treatment. The regional CAMHS pathway is accompanied by the publication Welcome to child and adolescent mental health services: a guide for you, which gives children and young people and their families or other carers information about CAMHS.
The Scottish government and the Convention of Scottish Local Authorities (COSLA) have identified mental wellbeing as one of six shared public health priorities for Scotland. In Scotland, the Getting it right for every child (GIRFEC) principles have applied to children and young people’s services to ensure they receive the right help, at the right time, from the right people. In addition, GIRFEC stresses the importance of care planning and collaboration between professionals as the required standard for delivery of children’s services in Scotland. Children’s mental health services are now widely run by integrated joint boards (IJBs) or are in the process of being integrated.
The Mental Health Foundation’s 2016 review of mental health services made a series of recommendations which informed the Scottish government’s Mental health strategy 2017-2027.
These recommendations included:
- a focus on prevention and early intervention
- addressing regional variations in services
- the need to tackle stigma and address Scotland’s high suicide rates compared to other UK countries
- greater workforce investment.
The strategy also included a commitment to audit CAMHS rejected referrals, which was undertaken by the mental health charity SAMH & ISD Scotland in 2018 and the creation of a taskforce that published its final recommendations in July 2019. These are now being implemented by a programme board, of which RCN Scotland is a member.
In February 2020 a new service specification for CAMHS was published and NHS boards are working on implementing this as part of their post COVID-19 remobilisation. An independent review into mental health law in Scotland has also been commissioned and, although focused on legislation which mainly affects adult mental health services, its findings will have implications for children and young people too.
Launched in 2015, Together for children and young people (T4CYP) designated children and young people’s emotional and mental health as a priority. With cross cabinet commitment, this multiagency service improvement programme aims to consider ways to reshape, remodel and refocus the emotional and mental health services provided for children and young people in Wales. The original four year programme has been extended into 2021, and the workstreams involve reviewing the roles of community and specialist CAMH services.
In light of concerns about the increase in the prevalence of mental health problems among children and young people, in 2018 the National Assembly for Wales Children, Young People and Education Committee published its Mind over matter report. Identifying that a step change was needed in emotional and mental health support for children and young people in Wales, the report advised the Welsh government to make this a stated national priority and called for a stronger emphasis on early intervention and building emotional resilience. It also recommended embedding mental health into the new school curriculum and ensuring that schools are supported by other services.
In recent years new data has emerged about the prevalence of mental health disorders (NHS Digital, 2018), indicating that mental health issues in children and young people are more prevalent than previously thought. The 2018 report found that 12.8% (1-in-8) of those aged 5-19 had at least one mental disorder, an increase on the previously estimated 1-in-10 prevalence. Other key developments that have changed the landscape for nursing staff in caring for children and young people with mental health issues since 2014 include:
- a growing awareness of the impact of social media on CYP mental health and wellbeing
- the rise of mental health issues for transgender and LBGTQ+ young people
- the concept of ‘parity of esteem’
- the impact of COVID 19 on young people’s mental health and on mental health service provision.
Children and young people with mental health issues may present at health facilities with a range of other non-mental health issues. It is incumbent on any nurse - not just those located in community, school or specialist mental health services - to be aware, sensitive to, and empathetic of these mental health issues. This updated document brings all nurses up to date with this rapidly developing and changing aspect of health care.