This isn’t new (2014) but this UCL-authored review of resilience in school-aged children is wide-ranging, uncomfortable for government, and taught me a ton.
In a way, we are in a golden age for attitudes to young people’s mental health. Just this week, no less a figure than Prince Harry talked about his own help-seeking, both he and his brother and sister-in-law have campaigned for better services and more positive societal attitudes. Theresa May has discussed the issue in a not-entirely-bad speech.
But what if I was to ask you what the most common mental health condition is in the UK? Most people guess at anxiety, or depression. If pushed they might go for eating disorders. But it’s none of these. By a considerable distance, it’s conduct disorder.
Conduct disorder is, roughly, an established and disruptive pattern of anti-social behaviour, which impairs the young person’s life. The commonest objection is that this is not really a mental health disorder, but that in itself betrays quite a restrictive attitude to what emotions and thoughts we regard as worthy of help, and which we reject and condemn.
Imagine two girls of 14.
One, Amelia, is lonely and sad a lot of the time, she doesn’t think her friends like her, and self-harms by cutting her forearms.
The other, Charlie, is angry and alienated. She thinks her mum hates her and they row a lot, and she self-harms by drinking in the park and getting into fights.
Which girl is more worthy of our concern and care? I would argue that they are both, equally worthy of our compassion and to receive the help that they need.
However, the narrative around mental health is exclusively about the type of problems that Amelia has, and puts Charlie in the ‘broken Britain’ bin of delinquents and ‘problem families’. And it isn’t just the media- I’ve been to discussions of young people’s mental health at the Department of Health, NHS England, the Royal College of Psychiatry and innumerable charities, think tanks and parliamentary groupings. I have never seen a young person with conduct problems attending, and no-one (other than me) has ever, ever mentioned this condition which, just to remind you, is the most common mental health condition in young people. When I do mention it, everyone nods, mumbles, and goes back to what they were talking about. Usually mindfulness, or apps.
Why is this? It’s not because people in the field are stupid, or uncaring.
One problem is that these kids do not have socially acceptable mental health problems. They are routinely rude, they often undermine attempts to help them (mainly because they don’t believe they are worth helping). They are not eloquent, typically, and are often ashamed of their feelings in a way that we encourage with our condemnation.
One big focus in mental health has been the role of schools in supporting pupils with mental health problems, but hand in hand with moves to train every teacher to deal with anxiety and depression is a hardening of attitudes to anything remotely anti-social, and the return of the disciplinary culture of the 1950s will do far more damage to mental health than any amount of amateur CBT can compensate for.
Anxiety and depression are, demonstrably, no respecters of social class. Conduct disorder, on the other hand, very much is- it is vastly more common in poorer families, and so society’s attitudes to poor families are transferred to their troubled offspring.
The help they require is complex, and requires co-ordination across multiple agencies, support for the whole family, and above all, patience. They can be helped, and there is a lot of evidence of effective interventions, but ultimately they are too difficult, and give too little political reward, to be the priority.
Conduct disorder is associated with every kind of negative outcome you can think of. It is a major, treatable, public health problem. Why are we not talking about it?
On the 9th January, Theresa May made a good(ish) speech. She talked about injustice, and about how peoples’ opportunities are too conditioned by their position in life. She then turned to children’s mental health and talked about the train-wreck that is current provision.
What did she suggest?:
- A review by the CQC
- Teachers to be trained in mental health first aid.
- An end to out of area transfers (but only for ‘general mental health’ so won’t mean anything)
Now, for the issue to get prime ministerial attention is a good thing, no doubt. But how much difference will it make, really?
Let’s look at the situation. 850,000 children have a diagnosable mental health problem in the UK, of which only 25% receive a service from specialist CAMHS. The plan from NHS England is for the recent cash injection to increase this figure to…. 33% by 2020. This assumes that the money is getting through, which it pretty clearly is not. It also raises the question- even if you do manage this increase, what about the other 67%?
This is where Mental Health First Aid comes in. The idea is that teachers pick up the early signs of emotional distress and put in place simple measures, thus stemming the flow of referrals to specialist services. There are two problems with this: one is that there is no evidence that it does any such thing, and the second is that it’s only dealing with what I call socially acceptable mental health.
What is the most common mental health problem among the 850,000? Anxiety? Depression? No, it’s conduct disorder, broadly, a pattern of disruptive behaviour leading to significant impairment. These kids often have complex social, biological, psychological and educational aspects to their stories, and need complex, multi-agency intervention to get better. But the point is they CAN, but they are too tricky, and not good at advocating for themselves, and are much easier to shunt into the youth justice system. And they are HALF of the 850,000 with diagnosable problems. People talk about universal parenting course access, but anyone who works on the front-line knows that these are no panacea.
The rest of the 67% will be kids who don’t have straightforward mental health presentations- those with autism, ADHD, learning disability, or traumatised children who are too angry and fearful to look sad.
So what is needed? What should we say when CQC comes to call? Apart from handing them copies of the other three CAMHS reviews completed in the last 2 years?
You’re never going to get 100% of eligible children into specialist care, and actually you may not want to- what a lot of them need is broader, more complex and more long-lasting than a block of therapy with CAMHS. So firstly, we need to expand what we mean by mental health help, and embed it into local systems.
This will require:
- clear commissioning of a ‘local offer’ for mental health
- Support from local specialists for the rest of the sector, in terms of consultation, training and joint work.
- A children’s workforce who understand mental health and the many ways of helping.
- Inspection of what the local area provides for children’s mental health and wellbeing.
- Training and guidance in best practice across the sector.
Second, we need to ‘shift the curve’ on mental health- by improving overall mental health we can decrease the number of children requiring care. The government are still, officially, committed to a ‘life chances’ strategy, and that sounds a lot like what Theresa May was talking about- the problem is that she was talking about adult employment, and income, rather than what really matters, which is getting the best start by:
- ensuring adequate incomes
- improving early education and care
- improving homes and environments
- creating a truly inclusive education system that cares about more than exam results.
Is this ambitious? Sure. Is it possible? With the right political will, both nationally and locally, and engagement from professionals, yes, at least in part.
And the alternative is just leaving the 67% to fester into the next decade’s ‘problem families’.
Pretty much every week, we get a report lacerating our care of children and young people with mental health problems. This time, the Royal College of Psychiatrists have concluded that services are inadequate in the vast majority of areas, earlier this year Youth Access pointed out the level of unmet need, as did the NSPCC. And, as always, the government responded with two things. The ‘historic’increase in funding, and the reform programme instigated by the ‘future in mind’ report.
Let me take these in turn. The increase will, by 2020, have restored funding for CAMHS (child and adolescent mental health services) to around 2010 levels. So a historic rise will follow an unprecedented fall. In any case, given that the money is not ring fenced, or in fact new money at all, there is evidence that it’s not reaching CAMHS at all in many areas.
But even if this money got through, it’s not enough to serve the need using our current model. The consensus is that only about a quarter of young people with a mental health problem get specialist mental health care, and that’s with everyone currently in CAMHS working flat out, so you’d either have to quadruple funding, or make everyone work four times faster, to serve the population need.
But doesn’t ‘future in mind’ offer a new vision for CAMHS? Yes and no. It’s a strange document, and I say that as someone involved in writing it. On the one hand it sets up a very efficient ‘engine’ for specialist CAMHS to give time-limited, evidence based intervention via the CYP IAPT programme. It talks a lot about counselling in schools.But outside of this, it offers mainly aspirations and wishful thinking.
The reason this is a problem is not because CYP IAPT is a bad programme. For delivery of specific interventions for specific problems, it’s great. But at present it only really addresses mood disorders and offers parenting courses. Add to this the clear guidance and increased funding for eating disorders, the focus on counselling in schools, and the increased resources for inpatient CAMHS, and it’s easy to see the groups that may, eventually, do well. Broadly, it’s adolescents presenting with anxiety, sadness and anorexia. This is, in many ways, a great thing. But it’s not enough.
Most people reading this will be aware of the much used statistic that shows that 10% of children have a diagnosable mental health problem. It’s not well known, and needs to be, that half of this number have not mood disorders, but various degrees of conduct problems, in other words, behavioural problems. This group have been almost entirely airbrushed out of the picture. Also, in practice, young people whose mood problems are mixed in with social vulnerability and special educational needs usually cannot access IAPT effectively. Add in children with mental health problems presenting either as physical symptoms, or in the context of chronic conditions, and you can see that a broader vision is required.
Another thing has struck me recently. When you talk to someone who had, for whatever reason, a troubled youth, from which they recovered, treatment does figure, but care is so much more important. What I mean by this is someone, be it a parent, a teacher, a youth worker, whoever, consistently holding the person in mind, and looking out for them, consistently and unconditionally over a period of time. It’s not at all clear that the new IAPT engine is very good at this sort of care. And, in the words of one senior civil servant, it’s ‘the only game in town’.
So we have a paradox. Everyone thinks that only specialist treatment counts as help- for example the Centre for Mental Health present delays in accessing CAMHS as ‘children with mental health problems wait a decade for help’. There isn’t enough specialist treatment for everyone, there can’t be, and the services that exist are narrowing themselves into particular areas. But what actually helps long term is care.
Is care enough? Sometimes clearly not, but if informed by adequate training (of professionals or parents), integrated across agencies and informed by advice from, and consultation with specialists, then really very often difficulties can be contained outside specialist settings. However, because parents and professionals feel disempowered, opportunities are lost waiting for a magic cure that, more often than not, just isn’t there.
We need badly to empower parents, non-CAMHS professionals, and young people themselves to be able to support these needs in the long-term.
So we need specialist treatment services, but only in the context of a wider local mental health support system. I can’t give you an immediate blueprint for this, but here are some ideas:
- Mental health to be taught in schools as part of compulsory PHSE
- Universal access to parent training and support.
- All local health and well-being boards to have responsibility for promoting cyp mental health
- Commissioning budgets pooled across health and local authorities to prevent duplication and gaps in provision.
- A ‘local offer’, analogous to the local special educational needs offer, developed as an extension of current transformation plans.
- CQC/OFSTED inspection of local CYP mental health systems, focusing on collaboration and prevention
- Improve information sharing by changing professional cultures and putting parents in charge, using informed consent to bypass restrictions.
- Appropriate mental health training for all professionals working with children, building on the work of MindEd.
- Local, funded strategic networks including parent and young people, as well as voluntary sector, monitoring the offer and promoting accountability for services.
- CAMHS specialist services to be funded to provide consultation to other agencies locally.
- Work undertaken to adapt NICE guidance to educational settings e.g. for conduct problems.
- Schools exclusions guidance examined to ensure that all pupils are properly assessed for underlying difficulties before permanent exclusion.
There is work progressing in some of these areas- NHS England will be coming out with guidance on access to mental health care, and RCPCH will be pushing the ‘local offer’ idea. Watch this space.
I’ve been thinking about the EU referendum campaign, and the failure of the remain campaign to counter the emotional tug of the (illusory) freedom offered by leave. They had the facts, the experts, but still they lost the battle of hearts.
There’s obviously no single reason for this, and no doubt books are already being written to explain it, but the one phrase that keeps coming back to me is ‘faceless bureaucrats’. Remain seemed to have let this trope into the conversation unchallenged, and I can’t help wondering why.
If someone is faceless, they lose their individuality, and become part of a process, humanity subjugated to the needs of the organisation they serve. There’s also a suggestion in the phrase that they are hiding, unwilling to be accountable and ‘face’ the people whose lives are affected by their decisions.
As far as I am aware, no representative of the EU ever publicly faced questions from the British public. Why didn’t Remain arrange this? Possibly, of the several thousand people employed by the EU, none of them had sufficient communication skills to face a hostile audience? Seems unlikely. Perhaps Remain were terrified of allowing a ‘foreigner’ to participate in ‘our’ debate, but isn’t that just playing into the narrow agenda of Leave?
There would have been risks, but if they had found someone fresh, persuasive and optimistic about Britain’s place in Europe, who is also a ‘bureaucrat’, it may, just, have challenged the damaging, dehumanising rhetoric of facelessness.
We’re all guilty of it, at times. When I get an email from management that annoys me, I chunter at the ‘bloody management’. But the email wasn’t written by management. It was written by a person, as I discover when I get off my high horse and bother to talk to them.
Of course, there are far more damaging forms of dehumanisation, and you only need to glance at social media to see both sides vigorously peddling stereotypes about the other.
But when campaigning for a cause, often the first thing we reach for is a human face- the most striking recent example of this being the refugee crisis. The Remain campaign’s failure to give the EU a human face played into the hands of its opponents, and was therefore a political, as well as moral, failure.
Quick one this, I’m rushing out and this just appeared:
Too much folate in pregnant women increases risk for autism, study suggests
Researchers say that while folate deficiency is bad for developing fetus, excessive amounts could also be harmful
JOHNS HOPKINS UNIVERSITY BLOOMBERG SCHOOL OF PUBLIC HEALTH
Women who plan on becoming pregnant are told they need enough of the nutrient folate to ensure proper neurodevelopment of their babies, but new research from the Johns Hopkins Bloomberg School of Public Health suggests there could be serious risks in having far too much of the same nutrient.
The researchers found that if a new mother has a very high level of folate right after giving birth – more than four times what is considered adequate – the risk that her child will develop an autism spectrum disorder doubles. Very high vitamin B12 levels in new moms are also potentially harmful, tripling the risk that her offspring will develop an autism spectrum disorder. If both levels are extremely high, the risk that a child develops the disorder increases 17.6 times. Folate, a B vitamin, is found naturally in fruits and vegetables, while the synthetic version, folic acid, is used to fortify cereals and breads in the United States and in vitamin supplements.
The findings will be presented May 13 at the 2016 International Meeting for Autism Research in Baltimore. A press conference is scheduled for 10 a.m. on May 11 at the at the Baltimore Convention Center, Room 302-303.
“Adequate supplementation is protective: That’s still the story with folic acid,” says one of the study’s senior authors M. Daniele Fallin, PhD, director of the Bloomberg School’s Wendy Klag Center for Autism and Developmental Disabilities. “We have long known that a folate deficiency in pregnant mothers is detrimental to her child’s development. But what this tells us is that excessive amounts may also cause harm. We must aim for optimal levels of this important nutrient.”
Folate is essential in cell growth and promotes neurodevelopmental growth. Deficiencies early in pregnancy have been linked to birth defects and to an increased risk of developing an autism spectrum disorder. And despite this push to ensure women get adequate folate, some women still don’t get enough or their bodies aren’t properly absorbing it, leading to deficiencies. The Centers for Disease Control and Prevention says that one in four women of reproductive age in the U.S. have insufficient folate levels. Levels are not routinely monitored during pregnancy.
Autism spectrum disorder is a neurodevelopmental condition characterized by social impairment, abnormal communication and repetitive or unusual behavior. One in 68 children in the U.S. have the disorder, with boys five times more likely than girls to have it. The causes remain unclear but research suggests the factors are a combination of genes and the environment.
For the study, researchers analyzed data from 1,391 mother-child pairs in the Boston Birth Cohort, a predominantly low-income minority population.
The mothers were recruited at the time of their child’s birth between 1998 and 2013 and followed for several years, with the mother’s blood folate levels checked once within the first one to three days of delivery. The researchers found that one in 10 of the women had what is considered an excess amount of folate (more than 59 nanomoles per liter) and six percent had an excess amount of vitamin B12 (more than 600 picomoles per liter).
The World Health Organization says that between 13.5 and 45.3 nanomoles per liter is an adequate amount of folate for a woman in her first trimester of pregnancy. Unlike with folate, there are not well-established thresholds for adequate vitamin B12 levels.
A large majority of the mothers in the study reported having taken multivitamins – which would include folic acid and vitamin B12 – throughout pregnancy. But the researchers say they don’t know exactly why some of the women had such high levels in their blood. It could be that they consumed too many folic acid-fortified foods or took too many supplements. Or, they say, it could be that some women are genetically predisposed to absorbing greater quantities of folate or metabolizing it slower, leading to the excess. Or it could be a combination of the two.
More research is needed, the scientists say, in order to determine just how much folic acid a woman should consume during pregnancy to have the best chance that she will have optimal blood folate levels to ensure her offspring’s health.
With many types of vitamin supplements, the conventional wisdom has been that too much is not harmful, that the body will flush out the excess. That may not be the case with folic acid and vitamin B12.
“This research suggests that this could be the case of too much of a good thing,” says study lead author Ramkripa Raghavan, MPH, MSc, a DrPH candidate in the Department of Population, Family and Reproductive Health at the Bloomberg School. “We tell women to be sure to get folate early in pregnancy. What we need to figure out now is whether there should be additional recommendations about just what an optimal dose is throughout pregnancy.”
In summary: FFS
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.