It’s Children’s Mental Health Week, and of course, as the paediatric mental health guy, I love the fact that this issue is getting airtime. I do worry, though, that the image of young people’s mental health problems portrayed by campaigners and the media is distorting our understanding of the issue.
Of the estimated 850000 children and young people with mental health conditions, it’s natural that the eloquent and telegenic ones are most prominent in the media. So most of the coverage is of well spoken young people who have suffered with anxiety and/or depression, with a few eating disorder survivors. Their stories are compelling and their needs are real, but if you look at this 850000, half of them don’t have these conditions; they have conduct disorders. Conduct what? Well, exactly. Broadly, these are persistent patterns of anti-social or defiant behaviours that really get in the way of people’s lives.
There are lots of pathways, but one common one is to struggle with your family and school at primary, and react by digging your heels in and refusing to cooperate, or avoiding demands, a pattern known as oppositional/defiant. Then in adolescence these kids take on a delinquent identity, and develop a pattern of truancy, stealing, violence and damage that is a big ‘screw you’ to the adult world.
It’s not a surprise that these kids are not the poster boys for mental health, but their needs are massive, and largely unmet. They have very high rates of depression, substance misuse, ADHD, special needs, and importantly, suicide. Imagine a busy A&E department. In one cubicle sits Clare, a 15 year old who has cut herself, then, in panic, told her mother and has been brought in. She’s upset, and talking animatedly with her mother. Next to her is Kyle. Kyle, also 15, has been stabbed in a fight outside a youth club, and sits sullenly alone waiting to be patched up. The evidence, as far as it exists, is that, of the two, Kyle is at a far higher risk of suicide. But it is Clare who will be admitted for a psychiatric assessment, while Kyle is stitched up and sent on his way as soon as his furious mum arrives.
And here’s the problem. It wouldn’t matter if there was a bias in the media and campaigning, if that bias wasn’t also extraordinarily strong in actual services. Increasingly, CAMHS (Child and adolescent mental health services) don’t regard conduct disorder as their business. In a sense this is understandable: as professionals, we all like ‘complex cases’- they allow us to feel clever and like we can solve problems no-one else can, but what we like is for the complexity to be within what we regard as our own domain. We also like our patients to be grateful and compliant. Finally, we work in a system that rewards discreet, delineated ‘episodes of care’, rather than, um, care.
And the conduct disordered kids, all 400000 or so of them, don’t conform to this, or to anything. Their kind of complexity spreads beyond health to education, social care and, sadly, the justice system. They will (at least to start with) tell you where to stick your concern for them. And they cannot be sorted by a single agency in a few visits. They CAN be helped, there are programmes in the US with good evidence base, but here in Britain we (mainly) don’t seem able to take any approach apart from the increasingly rigid discipline of schools, and the police.
In the borough where I work, the secondary special school for emotional and behavioural problems has a resident policeman, but no CAMHS worker. In our prisons up to 80% of inmates have undiagnosed learning and mental health difficulties.
This is not the only gap in CAMHS provision- there’s not enough done for very young children, children with disability, those with physical problems, and many more areas in a vast ‘missing middle’ between universal services and specialist CAMHS, but this is the most statistically stark lack. Mental health campaigners are fond of pointing out how unfair it is that these problems aren’t treated as well as, say, cancer. Well, to turn it back onto those responsible for mental health provision, what if a cancer service didn’t see half of the population’s cancer because it was ‘the wrong sort of complex’? That may be pushing the analogy, but the neglect of conduct disorder is a stain on all the progress that we have made in young people’s mental health in the last few years.
It’s simply not fair to argue for the importance of mental health on the basis of the famous 1 in 10 statistic, and then ignore half of the people contributing to that number. Time for change, indeed.