Mental Health In Children And Young People
Mental health in childrenand young peopleAn RCN toolkit for nurses who are not mentalhealth specialists
AcknowledgementsWe would like to thank Sue Sylvester, Independent NurseConsultant, for revising this publication in conjunction withthe following people who have assisted in the developmentand review of this document by sharing their knowledge andexpertise:Sarah Day, School Nurse Manager, St Mary’s School andSixth Form College, BexhillOrla McAlinden, Lecturer in Children and Young People’sNursing, University of BelfastMervyn Townley, Consultant Nurse, Specialist Child andAdolescent Mental Health, Aneurin Bevan Health BoardProfessor Steven Pryjmachuk, Professor of Mental HealthNursing Education, University of ManchesterRachael Matthews, Children’s Nurse, Chesterfield RoyalHospital NHS Foundation TrustFiona Hardy, RN, Bsc(Hons) Lecturer (Adult Nursing),Institute of Health and Social Care Studies, PrincessElizabeth Hospital, GuernseyDr Gemma Trainor, Consultant Nurse, Greater ManchesterMental Health Foundation TrustFiona Smith, Adviser in Children and Young People’sNursing, Royal College of Nursing(Original contributors to 2009 document):Lesley Higgins, Designated Nurse for Children and YoungPeople in Care, Torbay Care TrustElsa Chadaway, Team Leader, School Nursing, CoventryPrimary Care TrustBev Kirwan, Nurse Specialist Vulnerable Children, WestSussex Primary Care TrustClare Mayo, Policy Adviser, Royal College of Nursing,ScotlandJan Maxwell, Transition Facilitator, CommunityRehabilitation, Astley Ainslie Hospital, EdinburghKaren Phillips, Ward Manager, Child Health Directorate,Royal Preston Hospital, Lancashire Teaching Hospital NHSFoundation TrustTim Stokes, Community Psychiatric Nurse, South SeftonChild and Family ServicesLisa Turnbull, Policy Adviser, Royal College of Nursing,WalesDawn Warwick, Lead Nurse for Adolescent Care andTransition, Lancashire Teaching Hospital NHS FoundationTrustMervyn Townley, Consultant Nurse for Child and AdolescentMental Health Services, Gwent NHS Healthcare TrustFiona Smith, Adviser in Children and Young People’sNursing, Royal College of NursingDocument prepared by Sally Ramsay, Independent NursingAdviserThis publication is due for review in September 2016. To provide feedback on its contents or on your experience of usingthe publication, please email publications.feedback@rcn.org.ukRCN Legal DisclaimerThis publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised thatpractices may vary in each country and outside the UK.The information in this publication has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made toensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used.Accordingly, to the extent permitted by law, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to becaused directly or indirectly by what is contained in or left out of this information and guidance.Published by the Royal College of Nursing, 20 Cavendish Square, London W1G 0RN 2014 Royal College of Nursing. All rights reserved. Other than as permitted by law no part of this publication may be reproduced, stored in a retrievalsystem, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of thePublishers or a licence permitting restricted copying issued by the Copyright Licensing Agency, Saffron House, 6-10 Kirby Street, London EC1N 8TS.This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it ispublished, without the prior consent of the Publishers.
Royal colleGe of nursingMental health in children andyoung peopleAn RCN toolkit for nurses who are not mental health specialistsContentsIntroduction4When to involve a specialist17Our aims5What this document includes5What this document does not include6What nurses should know6Issues for practiceChild and young person nCulture18181819192021Good mental healthRisk and protective factors78Summary21References22Useful websites24Further reading27Promoting good mental healthParents and carers99What is mental ill health?General assessment1010Some core themesBullying including digital (cyber) bullyingAbuseLong-term conditionsRestrictive physical interventionand therapeutic holding11111112Specific mental health disordersAnxietyDepressionSelf-harmSubstance misuseConduct disordersEating disordersPsychosis1212131314151616123
Mental health in children and young peopleIntroductionImproving the social and emotionalwelfare of the whole population isenshrined in the documents andpolicies of all four countries of theUnited Kingdom and theresponsibility of interagency andinterdisciplinary working ishighlighted in these documents.Nurses have both an ethical, as well as legal duty of care toreport concerns they may have about mental health issues ofthe children and young people they come into contact withand should be cognisant of Article 24 of the United NationsConvention on the Rights of the Child: “ children have theright to good quality health care – the best health carepossible ”. One in 10 children aged between five and 16years has a clinically diagnosable mental health problem.Just over half of these children and young people (5.8 percent) have a conduct disorder; 3.7 per cent an emotionaldisorder (anxiety, depression) and one to two per cent havesevere attention deficit hyperactivity disorder (ADHD) (ONS,2004). Twice as many boys aged between five and 10 yearsare diagnosed, in comparison to girls (ONS, 2004). Half ofthose with lifetime mental illness (excluding dementia) firstexperience symptoms by the age of 14, and three quartersbefore their mid-20s.The prevalence of these problems increased between the1970s and the 1990s (Collishaw et al 2004) and there is ahigh degree of persistence of these problems into adult life(Rutter et al., 2006). Evidence already suggests that theseproblems have a serious impact on life chances (for example,Ferguson et al., 2005; Colman et al., 2009). To ensure thatprovision meets demand the Chief Medical Officer Report,states ‘the imperative that data are collected on theprevalence and incidence of mental health conditions and anannual audit of services and expenditure in the areaundertaken’ (DH, 2013).Return to contents 4Early recognition and referral can make a positive differenceto the child and family, in both the short and longer term(RCN, 2004). The period between pregnancy and three yearsis increasingly seen as a critical period in shaping lifechances, based on evidence of brain formation,communication and language development and the impactof relationships formed during that period on mental health.The case for early intervention including perinatal andinfant mental health is well recognised in relation topromoting a foundation of resilience and thus improvingmental health outcomes (Allen, 2011).However, identifying mental health problems andresponding appropriately can prove challenging for nursesworking with children and young people.Most children with mental health problems are managedoutside specialised mental health services. Consequently, allhealth care staff should have an understanding of how toassess and address the emotional wellbeing of children andyoung people. They should be able to recognise if a child oryoung person may be suffering from a mental healthproblem and liaise with the appropriate services (DH, 2007).Mental health promotion should be an underpinningprinciple for all who come in contact with children andyoung people, whether they are well or unwell (Public HealthInstitute of Scotland, 2003).“Nurses, health visitors and midwives work across a range ofsettings, and are one of the largest groups of health careprofessionals who come into contact with children andyoung people. They are in the right place to promote thepsychological and emotional well being of children andfamilies and to prevent the development of mental healthproblems by being aware of the factors that can put childrenand young people at risk” (DH, 2003; DfES, 2003).
Royal colleGe of nursingOur aimsThis document aims to assist those nurses who are notmental health specialists who work with children and youngpeople in community, hospital and other settings. It will helpthem in identifying the skills and knowledge they need torecognise and, if necessary, refer children who haveproblems affecting their mental health. It will also help thosenurses who provide care in acute hospitals, while waiting forspecialist mental health practitioners to attend a particularchild or young person, by giving insight into the morecommon mental health problems and facilitating thedevelopment of local guidelines.In addition, this publication will be of use to those who arepreparing education and training programmes to assistnurses in their understanding, recognition and managementof mental health problems in children and young people.What thisdocument includesThe document gives brief outlines of the common mentalhealth problems that practitioners may identify in variouscommunity or hospital settings, including GP practices,school nursing services, looked after children, communitychildren’s nursing, accident and emergency departments,outpatient services, acute children’s wards and youthoffending services.It provides basic information on the knowledge and skillsnurses need in order to recognise and care for children andyoung people who present with possible mental healthproblems.Further, it includes references, organisations and websitesthat nurses may find useful for developing their knowledge.Some of these are specific to the four countries of the UK.It can be linked to the following NHS Knowledge and SkillsFramework dimensions: WB1 (promotion of health and wellbeing andHprevention of adverse effects on health and wellbeing) HWB3 (protection of health and wellbeing) WB4 (enablement to address health and wellbeingHneeds) HWB6 (assessment and treatment planning) HWB7 (interventions and treatments).Further information can be obtained fromwww.skillsforhealth.org.uk5 Return to contents
Mental health in children and young peopleWhat thisdocument doesnot includeThe document is not aimed at nurses working in child andadolescent mental health services (CAMHS) who havespecialist expertise. Nor does it replace the need for theinclusion of specific training in children and young people’smental health, in either pre- or post-registration educationprogrammes. However, it will assist nurse educators inpreparing programmes.What nursesshould knowThere is a raft of evidence relating to this topic anduseful background information, for example the NationalService Framework (England), Marker of good practice forStandard 9 states “All staff working directly with childrenand young people should have sufficient knowledge, trainingand support to promote psychological wellbeing of children,young people and their families.”Nurses at the frontline of service delivery for children andyoung people are often best placed to recognise when thechild or young person is experiencing difficulties. Theyshould be able to offer general advice and treatment for lesssevere problems; contribute towards mental healthpromotion; identify problems early in their development;and refer to more specialist services. (Every Child Matters,DfES, 2004a). Nurses will need to ensure that they are awareof local referral protocols to services as services will vary inlocalities. With support and training, they will be able toprovide screening and some simple interventions with youngpeople and their families.It is generally regarded as important for all children’s healthcare staff to undergo education and training in how torecognise and respond appropriately to the mental healthneeds of children, and to be able to support their families. Todo this effectively, nurses need to ensure they have goodknowledge of how children and young people developsocially, emotionally and psychologically, and the riskfactors that can lead to mental health problems.MindEd, an e-learning portal is being developed to supportyoung healthy minds and will be available from spring 2014.This programme aims to provide a single source ofe-learning materials, including content that covers thebreadth of children and young people’s mental health. TheRCN along with a number of other Royal Colleges, is one ofthe member organisations supporting this development(www.minded.org.uk).Return to contents 6
Royal colleGe of nursingThe skills and knowledge necessary for identifying potentialmental health problems are described in document MH14 ofcompetences developed by Skills for Health, the healthsector’s skills council (www.skillsforhealth.org.uk). Inparticular, they include the need for a working knowledge of: h ow to assess and manage the risks (for example,physical harm, but risks such as risk to a young person’seducational prospects or their peer relationships shouldnot be overlooked), to individuals, self and otherst he range of different mental health needs andtheir effects.Good mentalhealthMental health is everyone’s business. As No health withoutmental health states, “good mental health and resilience arefundamental to our physical health, our relationships, oureducation, our training, our work and to achieving ourpotential” (DH, 2011). The mental health of the child, youngperson and their family should be an integral part of allchildren’s services, not overlooked when a physical healthdisorder takes priority (DH, 2004).In children and young people, good mental health can beindicated by being able to: d evelop emotionally, creatively, intellectually andspiritually i nitiate, develop and sustain mutually satisfyingpersonal relationships f ace problems, resolve them and learn from them inways appropriate for the child’s age develop a sense of right and wrong be confident and assertive be aware of others and empathise with them enjoy solitude play and learn.(Mental Health Foundation, 2002)Following the Children’s Health Outcomes Forum Report in2012 in England the DH response included a commitment to:“Improve the mental health of our children and youngpeople by promoting resilience and mental wellbeing andproviding early and effective evidence based treatments forthose people who need it” (DH, 2013).7 Return to contents
Mental health in children and young peopleRisk and protective factorsFamily risk factors include: learning disabilityAny child can experience mental health problems, but somechildren and young people are at greater risk of developingmental health problems than others, whereas certain factorscan act as protection. abuse domestic violence prematurity or low birth weight difficult temperamentThese risks and protective factors can be related to thechild’s personality, family, socio-economic status andenvironment. physical illness lack of boundaries looked-after children lack of attachment to carer academic failure low self-esteem shy, anxious or difficult temperament young offenders chronic illness.Children and young people in special circumstances or thosewith learning difficulties and/or disabilities can be at greaterrisk. For these children and their parents or carers, theprovision of early intervention may make a significantdifference (National Service Framework, DH, 2004).Knowledge of the factors that increase the risk of problemsdeveloping or being sustained is important whenconsidering how to improve the mental health of childrenand young people (Townley, 2002).Child risk factors include:(Department of Health, 2004a).External risk factors include: s chool: unclear discipline, failure to recognise childrenas individuals poverty bullying – including cyber bullying family breakdown peer rejection/peer pressure single parent family school exclusion including school refusal. parental mental ill health parental criminality, alcoholism, or substance abuse overt parental conflict a good start in life and positive parenting lack of boundaries being loved and feeling secure frequent family moves/being homeless living in a stable home environment over protection parental employment hostile and rejecting relationships good parental mental health failure to adapt to the child’s developmental needs activities and interests death and loss, including loss of friendships positive peer relationships caring for a disabled parent emotional resilience and positive thinking school non-attendance. sense of humour full engagement with education.Return to contents 8Protective factors include:
Royal colleGe of nursingPromoting goodmental health“Social and emotional wellbeing creates the foundations forhealthy behaviours and educational attainment. It also helpsprevent behavioural problems (including substance misuse)and mental health problems. That’s why it is important tofocus on the social and emotional wellbeing of children andyoung people” (NICE, 2013).All children and young people, their parents or carers,require access to information and supportive environmentsto ensure that the child or young person’s mental health ispromoted.“Two key skills are necessary for positive mental health –learning to cope and even prosper in the face of adversityand the ability to create feelings of happiness throughhealthy, positive means If children and young people havepleasure, engagement and meaning in life, they are likely toexperience happiness, life satisfaction, wellbeing and leadmore flourishing lives” (Ward, 2008).Good practice towards achieving this includes: t he ability of frontline staff to access support and advicefrom specialist child and adolescent mental healthservices (CAMHS) and other children’s services to aidthe early identification and support of those with mentalhealth difficulties. These include social workers,behaviour specialists, educational psychologists andspecialist support staff local protocols for referral e nsuring that local needs’ assessments identify childrenin special circumstances – including those who arehomeless, seeking asylum, misusing substances, livingin young offender settings and those ‘looked after’, notattending school – and that services are in place to meettheir needs a n emphasis on children and young people who arevulnerable to mental health problems and on providingfocused, structured, proactive programmes which targetrisk factors, using a common assessment framework asappropriate s pecific activities such as tackling bullying (includingcyber bullying) and increasing awareness of mentalhealth issues p romoting lifestyles that protect children and youngpeople from mental health problems.“School nurses have an important role in the earlyassessment and increasingly in delivering effective earlyinterventions for children and young people with mentalhealth problems” (DfES, 2001). Examples of interventions byschool nurses are given in this document.Parents and carersParents whose children have never experienced worries,fears, bullying, sadness, problems with friendships andbereavement are in the minority.Parents whose child has mental health difficulties are oftenmade to feel it is their fault, and as a result they do not tellanyone. It is common for parents and carers to feel isolatedand alone in trying to deal with their child’s problems.In some instances, issues such as family breakdown, povertyand parenting difficulties may have contributed to the childor young person’s problems. However, practitioners shouldremain non-judgmental in their approach to parents andcarers, aiming to support and assist them. Several charitiesoffer specific help to parents and carers and knowledge ofthese organisation
children’s nursing, accident and emergency departments, outpatient services, acute children’s wards and youth offending services. It provides basic information on the knowledge and skills nurses need in order to recognise and care for children and young people who present with possible mental health problems. Further, it includes references, organisations and websites that nurses may find .
Mental Health, Mental Health Europe NGO and the UK Royal College of Psychiatrists7. "No health without mental health" has also been adopted by the Irish organisation Mental Health Ireland, Supporting Positive Mental Health. Burden of Mental Disorders Mental disorders have been found to be common, with over a third of people worldwide
3.2 european Policy 12 3.4 Happiness and wellbeing debates 14 4.0 Concepts and definitions: what is mental health? 15 4.1 Dual continuum model of mental health 16 4.2 Measuring mental health 17 5.0 Benefits of mental health promotion 19 5.1 Benefits of preventing mental illness 19 5.2 Benefits of promoting positive mental health 22
Children's Mental Health As a part of Children's Mental Health Awareness Week, addressing the mental health needs of children, youth and families is fundamental to the future of Fort Bend County. COVID-19 has had a significant impact on our communities and we must not overlook the psychological impact on our children's mental health.
3.1 Prevalence of mental ill health 9 3.2 Mental health service need 9 3.3 Mental health service provision gap 10 3.4 Housing system and homelessness 10 3.5 Entries into homelessness 11 3.6 Mental health and housing system capacity 12. 4 Links between housing and mental health 13 5 Housing for people with lived experience of mental ill health 16
A mental health policy (1996) and plan (2007-2011) existed. Emergency and disaster plans for mental health did not exist. Legislation A new Mental Health Act 846 2012 was passed in 2012 and was awaiting Government to establish the Mental Health Board. Financing of mental health services Mental health had a ring-fenced budget of 1.4% of
mental health is about much more than mental illness, and that there are significant benefits to be gained by approaching mental health from a public health perspective. Positive mental health, mental wellness and mental health promotion have emerged as the missing pieces in a system that has traditionally been
No Health Without Mental Health: A Cross Governmental Strategy (2011). 1. Why is the emotional and mental health of children and young people important? Good mental and emotional health is essential to enable children and young people to fulfil their potential. Emotional and mental health problems are a common group of disorders affecting about 1
of mental health conditions and, just as importantly, what promotes good mental health in children. National policy Given this concerning trend of worsening mental health among children, what is the government doing in response? At the end of 2017, the government published 114 Chapter 8: Mental Health Promotion in Primary Schools
