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We’re all mental

Identifying and treating the significant minority of children and young people with a mental health disorder is a vital step in tackling anti-social behaviours argues Dinah Morley.

In the UK today 9.6% of 5-16 year old children and young people have a mental disorder (ONS 2004). This means a condition that affects daily living and which does not get better in a few weeks. A disorder will not usually remit without professional help and can seriously affect both the child and the family. It is more prevalent in boys than girls. Girls tend to catch up in the higher ages groups, but more boys find their way into the justice system, where over 90% have mental health problems (ONS 2000). Looked after children i.e. those in public care, are also at greater risk with studies showing between half to 80% with a mental disorder.

The scandal of children’s mental health problems is two-fold. If such vast numbers of children as this had a serious and lengthy physical illness there would be a public outcry. This has not happened for these children. Secondly many adults with mental illness display symptoms in childhood but do not access treatment. Studies show that teachers and GPs did not recognise the presentation. Children’s mental health is everybody’s business, from those who directly work in mental health services, through all those working with children in any setting, to all of us who have any contact at all with the young. The bulk of mental health support for children and young people is delivered through the family and through schools. The way in which these early years and education services take up their responsibilities in relation to children’s mental health is critical for us all.

Increasingly it is accepted that the essential building blocks for mental health are put in place at the earliest stages of life – there is some evidence to suggest that what goes on in the womb is also highly relevant. Children are not all born with equally easy temperaments and from the start require sensitive parenting that attunes to their differing needs and meets them appropriately. Where this does not happen, or is not ‘good enough’ things begin to look bleak for the child’s mental health.

It is reasonable to assume that all parents want the best for their children but parents who do not develop a consistent approach to parenting, who cannot provide a stable and loving home, who are pre-occupied with their own difficulties and cannot slowly and appropriately encourage their child to independence are likely to be putting their children at risk of poor mental health. Factors such as poverty and bereavement are significant risk factors. This is not to say that poverty per se engenders poor mental health but that, where families are struggling with extreme poverty and all that follows, they cannot always effectively meet the child’s need for attention, closeness and love. Similarly it is not the loss of a parent that destroys the mental health of the child so much as the fact that good parenting and a secure home environment are often removed. It is this security, consistency and unconditional love which are the essential ingredients of mental health.

The mental health of children and young people is one of the greatest health concerns in the western world. Not all mental disorders are on the increase, but instances of depression and conduct disorder are rising. Conduct disordered behaviour is probably the least well understood of all mental disorders and illnesses. It is dismissed by many – professionals included, as bad behaviour and naughtiness, when in fact the behaviours that these young people present are outward signs of inward damage, usually at a much younger age. There are links with adult personality disorder. The evidence base for treatments is growing rapidly, but there are some treatments which have a very slim research base, but which are known to be effective through case studies for some severely damaged young people, such as psychodynamic psychotherapy. Because this treatment is lengthy and requires a highly trained and skilled practitioner to provide it, it is expensive and scarce. Behavioural therapy – which takes place over a much shorter time span, is seen to be more cost effective. For children, young people and families who are the most challenging and vulnerable the evidence suggests that a multi-faceted, multi-skilled approach is necessary if real change is to be seen. These multi-modal approaches are also expensive, requiring the input of several practitioners with diverse skills and roles. It is likely that support will be needed over a sustained period, with the child and family needing to come back for further support from time to time – much as with a physical condition such as asthma.

Through the Government’s Change for Children Programme (Every Child Matters and the National Service Framework for Children, Young People and Maternity Services) things are improving. Significant investment has been made in Child and Adolescent Mental Health Services (CAMHS) over the last 6 years. Government targets – to be met this year – expect PCTs to ensure that they have primary mental health workers in place, i.e. practitioners working in the community to pick up and support young people at the earlier stages, 24-hour on-call support and services which target those young people with dual diagnosis, particularly learning disability and mental disorder. The recent progress report shows that many PCTs have significantly improved but that there are others that fall well short of meeting these standards.

Concurrently there is recognition in policy documents on children, parenting and youth that mental health is an important ingredient of total wellbeing. But we are all wary of using the word ‘mental’ for fear of stigmatising and driving people away from the best supports and services. Whilst there will always be a need to use terminology that pulls the person into help rather than away, we need to rehabilitate the word ‘mental’ to take its place beside its partner ‘physical’. It is only by so doing that we will ensure that the stigma is defeated and that those whose mental health is bad feel able to ask for and receive speedy, effective treatment.