Draft and Confidential
Royal Greenwich Child and
Adolescent Mental Health Needs
Assessment 2014
DRAFT CAMHS NEEDS ASSESSMENT 2014
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Stacie Fennell
Performance Analysis and Systems Service
020 8921 2765
[email protected]
With thanks to:
Helen Crystal, Catherine Kane and Julia Chappell
DRAFT CAMHS NEEDS ASSESSMENT 2014
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Contents
Introduction.................................................................................................. 5
Aim and purpose of the needs assessment ..................................................... 6
Key messages ............................................................................................... 7
Section 1: Profile of young people with mental health needs in Royal Greenwich
.................................................................................................................... 8
Section 2: Children and young people at risk of poor outcomes get timely early
help ........................................................................................................... 10
a: Looked after children and children who are the subject of a CPP ................ 20
b: Children with disabilities or special educational needs............................... 25
c: Young offenders ...................................................................................... 27
d: Children who go missing from home or care ............................................. 28
e: Young people not in education, employment and training .......................... 30
f: Teenage mothers ..................................................................................... 31
g: Young people using alcohol and drugs ..................................................... 32
Section 3: Services are shaped by the views and wishes of children, young
people and their families ............................................................................. 34
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Introduction
A child with good mental and emotional health is much more likely to have
good mental health as an adult, be more able to take on adult responsibilities
and fulfil their potential. Some disorders begin in childhood and can affect
people for their whole life, but early intervention can enable them to manage
their condition better and ensure they have better long term outcomes.
Half (50%) of lifetime mental illness (excluding dementia) starts by the age of
141 and three-quarters by mid-20s2. Tackling mental health problems early in
life will improve educational attainment, employment opportunities and
physical health, and reduce the levels of substance misuse, self-harm and
suicide, as well as family conflict and social deprivation2.
In February 2011 the government launched a mental health outcomes strategy
for people of all ages called ‘No health without mental health’ and subsequently
published an implementation framework in July 2012. The framework includes
actions to bring about measurable improvements including that:

Mental health has parity of esteem with physical health within the health and
care system

People with mental health problems, their families and carers, are involved
in all aspects of service design and delivery

Public services improve equality and tackle inequality

More people have access to evidence-based treatments

Public services intervene early
In January 2014, the Department of Health (DoH) published “Closing the gap:
priorities for essential change in mental health”. This document set out 25
priorities for immediate action. One of the key priorities outlined by this policy
is that ‘Schools will be supported to identify mental health problems sooner’.
The DoH is funding a new online service3 to provide guidance and training on
child mental health for teachers, police, health professionals and other people
working with children. This service launched in spring 2014.
1
Source: Kim-Cohen et al, 2003; Kessler et al 2005; Kessler et al, 2007
2
Royal College of Psychiatrists: No Health without Public Mental Health 2010
3
www.minded.org.uk
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Aim and purpose of the needs assessment
The aim of this needs assessment is to identify emotional well-being and
mental health needs of children and young people in the Royal Borough of
Greenwich (RBG) including, where appropriate, recommendations for both
social care and health commissioners on gaps in meeting needs and issues
relating to service design or delivery. This document provides the evidence
relating to mental health needs that underpins the ambitions for children and
young people set out in the Children and Young People Plan, 2014-17.
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Key messages
1.
Only around a fifth of those estimated to have a mental health need
currently meet thresholds to receive a service. This suggests a need to
build greater capacity at lower levels of mental health support services
including early intervention for young people at risk of mental health
problems.
2.
Local evidence supports the need for intervention at a younger age to
prevent mental health issues escalating into early adulthood. In the last
three years, only 38% of young people seen by CAMHS were aged under
11.
3.
Despite a more representative uptake of services from the Targeted
Mental Health in schools (TaMHS), young people from Black and Minority
Ethnic (BME) backgrounds, particularly Black and Asian, are significantly
under-represented in referrals to CAMHS.
4.
It is estimated that between 6% and 14% of the RBG population aged 1116 are self-harming. Further information is needed to confirm the scale
and nature of the problem within RBG.
5.
The level of non-attendance at CAMHS appointments (‘DNAs’) has
consistently been at 13% or higher over the last four years suggesting
further improvements are needed to engage hard to reach young people,
particularly those where DNAs have been persistent.
6.
Inpatient admissions, primarily among those aged 16 to 19 years old,
have doubled over the last two years suggesting that the prevalence of
young people with more complex mental health needs has increased or
that risk thresholds have lowered. It also provides further support for the
key message around earlier intervention with support for younger age
groups.
7.
Over a quarter (26%) of looked after children who scored above the
average range for emotional wellbeing in their strength and difficulty
questionnaire did not receive a service from specialist CAMHS suggesting
that there could be unmet mental health needs for looked after children.
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8.
Over half of children missing from care (52%) had some known mental
health need which supports the need for targeted mental health support
services for these children.
9.
Other vulnerable groups of children and young people that are at higher
risk of mental health problems and/or more likely to attend CAMHS
include:
a. children at risk of sexual exploitation
b. children in treatment for substance misuse
c. children and young people with learning difficulties or
Behavioural, Emotional and Social Difficulties (BESD)
d. children known to the Youth Offending Service
e. children known to social care particularly when domestic violence
is a contributing factor
f. children and young people who are homeless
g. teenage mothers
h. young people who are Not in Education, Employment or Training
(NEET)
Section 1: Profile of young people with mental health needs in Royal
Greenwich (RBG)
Nationally one in ten young people (10%) aged 5-16 years old are estimated to
have a clinically diagnosed mental disorder4; 4% have an emotional disorder (3%
anxiety and 1% depression), 6% have a conduct disorder, 2% have a hyperkinetic
disorder (ADHD), and 1% have a less common disorder (including autism, tics,
eating disorders and mutism). Of these, around one in five have multiple
disorders.
Recent local prevalence estimates based on deprivation levels (Campion & Fitch,
2012) suggest that RBG has a higher proportion of children and young people
with clinically diagnosed mental disorders. RBG has the 8th highest estimated
prevalence of child and adolescent mental disorder in London out of 33
boroughs.
4
ONS 2004 survey
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Table 1: Estimated local prevalence of child and adolescent mental disorder
(some children have more than one disorder and are double/tripled counted
across categories)5
London
IMD Rank
% Conduct
% Emotional
% ADHD
Borough
(high =
Disorder
Disorder
(aged 5-
most
(aged 5-
(aged 5 -
15)
depr.)
16)
16)
Other
Hackney
2
9.0%
6.0%
3.0%
1.0%
Newham
3
8.9%
6.0%
3.0%
1.0%
Tower Hamlets
7
8.9%
5.9%
3.0%
1.0%
Haringey
13
8.8%
5.8%
2.9%
1.0%
Islington
14
8.7%
5.8%
2.9%
1.0%
Waltham Forest
15
8.7%
5.8%
2.9%
1.0%
B & D6
22
8.6%
5.7%
2.9%
1.0%
Greenwich
28
8.5%
5.7%
2.9%
1.0%
-
5.8%
3.7%
1.5%
1.0%
England
Source: Campion & Fitch, 2012
Based on one in five children having more than one type of disorder, we
estimate that 14.5% of RBG children and young people have a clinically
diagnosable mental disorder (0.8 x 18.17). In 2014, there are an estimated
5,858 young people aged 5-16 years old requiring professional support (tier 2
services or above) in RBG8.
This estimate of 5,858 is broadly in line with 2012 ONS estimates for RBG
mental health disorders, based on Kurtz’s methodology (1996). The Kurtz
methodology estimates that as at 2012, there were an estimated 5,590 young
people in RBG with mental health disorders (4,380 at Tier 2, 1,160 at Tier 3 and
50 at Tier 4).
5
Campion and Fitch, 2012
6
Barking & Dagenham
7
18.1% is the total percentage across all the categories in RBG.
8
Based on GLA population projections
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Table 2: Estimated numbers of 5-16 year olds with a clinically diagnosed
mental disorder
% increase in popn
14.5% of the total
from prev year
popn
40,400
2.5%
5,858
2015
41,550
2.8%
6,025
2016
42,750
2.8%
6,199
2017
44,000
2.8%
6,380
2018
45,400
3.1%
6,583
Year
Total 5-16 popn
2014
Source: GLA population projections
The current provider is currently seeing around a fifth of those in need (1,156
children in 2012/13), which will be young people with higher level needs
(mainly Tiers 3 and 4). Therefore there is a need to build capacity in lower level
mental health support, at Tiers 1 and 2, to deliver early intervention for young
people at risk of mental health problems.
Table 3: Number of young people seen by CAMHS between 2010/11 and
2012/13
2010/11
2011/12
2012/13
1,297
1,290
1,156
Source: CAMHS
Table 4: Population projections for 5-16 year olds in RBG by ward (sorted by
size of current 2014 population)
% change
Population projections
2014
2015
2016
2017
2018
Thamesmead Moorings
4,200
4,400
4,550
4,750
4,900
17%
Woolwich Common
3,450
3,600
3,650
3,800
3,900
13%
Woolwich Riverside
3,200
3,350
3,550
3,750
3,950
23%
Abbey Wood
3,000
3,050
3,100
3,100
3,150
5%
Glyndon
2,850
2,850
2,950
3,000
3,050
7%
Plumstead
2,700
2,700
2,750
2,750
2,800
4%
Peninsula
2,300
2,650
2,950
3,350
3,750
63%
Charlton
2,150
2,200
2,250
2,300
2,350
9%
Middle Park and Sutcliffe
2,150
2,150
2,150
2,200
2,200
2%
Greenwich West
2,100
2,200
2,300
2,400
2,500
19%
Kidbrooke with Hornfair
2,050
2,050
2,100
2,100
2,100
2%
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Shooters Hill
2,000
2,000
2,000
2,050
2,000
0%
Eltham West
1,900
1,950
2,000
2,050
2,150
13%
Coldharbour and New
1,800
1,750
1,750
1,750
1,750
-3%
Eltham North
1,750
1,700
1,700
1,700
1,700
-3%
Blackheath Westcombe
1,500
1,550
1,600
1,600
1,650
10%
Eltham South
1,400
1,450
1,450
1,450
1,500
7%
Eltham
Total
40,400 41,550 42,750
44,000 45,400
12%
Source: GLA population projections
The number of children aged 5-16 is increasing and there is a particular
pressure in the north of the borough, where there is the most deprivation. Over
the next five years there is going to be an ongoing, significant increase in the
number of young people living in the North West of the borough, particularly in
the Peninsula ward.
Map 5: RBG neighbourhoods within the 30% most deprived in England (IDACI
2010)
Linked to this, the Peninsula ward is particularly deprived so there is likely to be
an increased need for provision in this area. Research findings suggest that
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there is a strong link between deprivation and mental health disorders.
Nationally, children from the poorest 20% of households are at a three-fold
greater risk of mental health problems than children from the richest 20% of
households9. Woolwich Riverside, Woolwich Common, Glyndon, Thamesmead
Moorings, Abbey Wood, Charlton, Peninsula, Greenwich West, Eltham West and
Eltham South all have areas within the 0-5% most deprived LSOAs in England.
Therefore, mental health disorders are more likely to be prevalent within these
wards.
Around two thirds of young people who have been involved with RBG CAMHS
(68%) live in households categorised as ‘urban adversity’ or ‘financially
stretched’.
The ‘urban adversity’ category includes the most deprived areas of large and
small towns and cities across the UK. Characteristics of ‘urban adversity’ are
that household incomes are low, the level of people having difficulties with debt
or having been refused credit is double the national average and the numbers
claiming Jobseeker’s Allowance and other benefits is well above the national
average. Levels of qualifications are low and those in work are likely to be
employed in semi-skilled or unskilled occupations.
Table 6: ACORN category of those seen by CAMHS
Category
%
Urban Adversity
55%
Financially Stretched
13%
Comfortable
Communities
16%
Rising Prosperity
12%
Affluent Achievers
4%
Not Private Households
1%
Grand Total
100%
Source: CACI & Greenwich CAMHS
Age
9
Royal College of Psychiatrists: No Health without Public Mental Health 2010
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The population of RBG has grown faster than the London and national rates
since 2001, with the greatest increase in the 0-4 population (+35% between the
2001 and 2011 censuses). Furthermore, the 0-4 population is projected to rise
by 20% in the next ten years, which will add to pressure on services.
Almost two thirds of the young people seen by CAMHS services in RBG in the
last three years (62%) have been aged 11-18. There is a need to intervene
earlier than this, where possible, to prevent negative impact on a young
person’s outcomes.
Table 7: Age and gender as at first referral of those seen by CAMHS in the last
3 years
Age
Under 5
Age 5 to 10
% Female
% Male
Total %
3%
5%
8%
11%
19%
30%
24%
22%
9%
7%
47%
53%
Age 11 to
15
Age 16 to
18
Grand Total
46%
16%
100%
Source: CAMHS
The quality of early attachment relationships is fundamental to preventing later
development of emotional and conduct disorder problems. This is particularly
important pre-birth and in early years where there can be the most impact on
children’s early brain development. Influential parental factors, such as
smoking or alcohol consumption during pregnancy or other poor health
behaviours, the failure to develop secure attachment, poor quality of parenting
styles, parental conflict leading to divorce or separation, are all key risk factors
leading to poor mental health in children and increased risk for later life mental
disorders, which impact negatively across the life span.
Ethnicity
Evidence shows that the rates of mental health problems tend to be higher
among people from BME groups, as they are more likely to experience risk
factors associated with poor mental health, such as deprivation, discrimination
and poor educational and employment opportunities.
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Breakdowns from the 2004 ONS cohort (Green et al, 2005)10 indicate that rates
of mental illness are higher among black young people (just over 14%) and
lower among young Indian people (just under 3%). People from different
cultures may have different understandings of what mental health is. For
example, the survey found that the stigma of mental health problems is
particularly strong among people from certain backgrounds. Such attitudes can
impact on how children seek and access treatment.
As at the 2011 Census, 56% of young people aged 0-18 were from black and
minority ethnic (BME) backgrounds. RBG’s school population is even more
diverse with 62% of young people from BME backgrounds.
However, as is the case nationally, young people from BME backgrounds are
significantly under-represented in referrals to CAMHS. Of those with a known
ethnicity11, only 34% of referrals are for young people from BME backgrounds.
Young people from Black and Asian backgrounds are particularly underrepresented.
Table 8: Ethnicity of young people referred to CAMHS (those with a known
ethnicity)
Ethnicity
% referred to
% in RBG resident
CAMHS
popn
66%
44%
+22%
Other
4%
2%
+2%
Mixed
11%
10%
+1%
White Other
4%
6%
-2%
Asian
3%
10%
-7%
Black
11%
27%
-16%
White British/Irish
% Difference
Source: CAMHS
Between November 2008 and February 2010, 28 RBG schools took part in a
government funded Targeted Mental Health in Schools (TaMHS) project. The
aim of the project was to develop innovative models of therapeutic and holistic
mental health support in schools aimed at children and families, for those
children and young people aged 5 - 13 who were at risk of or experiencing
10
Explored further by Coleman and colleagues in the report Key Data on Adolescence 2011
(Coleman et al 2011)
11
245 young people out of a total of 943 referrals did not have an ethnic group recorded (26%
of all referrals).
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mental health problems. As part of this project, 27.5% young people from Black
backgrounds engaged with RBG school based interventions (reflecting the
proportion in the resident population). This suggests that there needs to be
more children’s centre/school based interventions available to ensure that all
young people with disorders can access support.
Feedback from a patient engagement event run by NHS Greenwich CCG in
November 2013 highlighted a need for more CAMHS treatment in young
people’s homes (outreach) and the need for more prevention work in schools.
Estimated prevalence of self harm in RBG
Prevalence of self harm is difficult to estimate reliably. Rates of between 6% and
14% have been found in community based surveys depending on the
parameters used;
 5.8% 11-15 year olds (Meltzer et al 2001)
 6.9% in last year 15-16 year olds (Hawton et al 2002 - school based
study)
 13.2% lifetime history in 15- 16year olds general population (Hawton et
al 2002)
 7% among 11-16 year olds (Green et al, 2005)
A sample of 2,161 young people aged 16 to 25 took part in an online poll12
between 30th October and 18th November 2013. The survey reported
particular concerns around the mental wellbeing of young people who are
NEET.
 Around one in 10 young people (nine per cent) believe they have nothing
to live for. This increases to more than one in five (21 per cent) amongst
the long-term unemployed
 One in three long-term unemployed young people (32 per cent) have felt
suicidal, compared to 26 per cent of their peers
 One in four long-term unemployed young people (24 per cent) have selfharmed. This compares to one in five (19 per cent) of their peers.
Table 9: Cases seen by the Deliberate Self Harm team at Queen Elizabeth
Hospital.
12
Poll conducted by YouGov on behalf of The Prince’s Trust
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2012/13 2013/14
130
203
Source: Greenwich CAMHS Performance Report Jan 2013
Table 10: Presentation of self-harm at local hospital A&E
Self Harm Emergencies 2012/13 2013- Present
Bexley
66
93
Bromley
98
129
Greenwich
150
183
Total
314
405
Source: Oxleas
Based on a 2002 study by Hawton et al only 12.6% of self-harm episodes
resulted in presentation to hospital (2002) therefore further information is
needed to confirm the scale and nature of the problem within RBG.
Referrals and attendance
Table 11: Number of referrals and inappropriate referrals
Financial Year
No. of referrals
Percentage of
inappropriate referrals
2009/10
1,536
34%
2010/11
1,734
36%
2011/12
1,537
29%
2012/13
1,520
17%*
2013/14
1,155
23%
* Based on 3 quarters only due to a system upgrade error in Q3
Source: Greenwich CAMHS Performance Report March 2014
In 2012/13, the largest referral source into specialist CAMHS were General
Practitioners (GPs) at 37% and the second largest was Local Authority Children's
Services at 15%. Of the referral sources, the largest proportion deemed
inappropriate by Oxleas CAMHS came from GPs with a rate of 21%. This has
decreased from 50% in 2010/11. This rate is expected to decrease further with
the introduction of a referral Management and Booking System to support GP
referrals into CAMHS.
Between 20 January 2013 and 20 June 2013, 87 young people aged under 18
were referred to CAMHS by the local Accident and Emergency department.
Table 12: Percentage of non attendance (DNA)
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2009/10 2010/11 2011/12 2012/13 2013/14
19%
18%
18%
15%
13%
Source: Greenwich CAMHS Performance Report March 2014
Non-attendance for treatment is a problem at a national level, however rates
have improved in RBG. Engagement of the child or young person and the family
by the end of the referral process is essential to ensure take up of assessment
and treatment.
Characteristics of those who do not attend for treatment
Over the last 8 months there were 1,336 appointments that were not attended
by 508 children.
Gender
No. Children
%
Female
270
53%
Male
238
47%
508
100%
Total
Age
No. Children
%
0-5
27
5%
6-10
93
18%
11-12
52
10%
13-14
102
20%
15-16
130
26%
17-18
104
20%
Total
508
100%
Ethnicity
No. Children
%
11
2%
54
11%
Mixed
59
12%
Not recorded
74
15%
Other
21
4%
White British
272
54%
White Other
17
3%
508
100%
Asian
Black or Black
British
Total
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Just under a third (32%) of children missed 3 or more appointments of which 3%
had missed 10 or more appointments suggesting that further improvements
are needed to engage hard to reach young people. An analysis of those that
persistently DNA showed an over-representation of females (65%) and of those
aged 17-18 (32%).
In 2009/10, Greenwich Oxleas CAMHS had 162 referrals for emergency
assessment13, of whom 157 came from Accident and Emergency at Queen
Elizabeth Hospital. The majority of referrals were for females (134 female and
27 male). Of the 162 cases, 83 had been admitted to hospital for an overdose,
32 for self-harm, 23 were suicidal, and 10 for aggression. The Royal College of
Psychiatrists guidelines state that young people under 16 who self harm should
always be admitted for CAMHS assessment the next working day.
Table 13: Tier 4 Admissions
Year
Number
2010/11
13
2011/12
15
2012/13
32
2013/14
22
Source: Greenwich CAMHS - March 2014
Table 14:Admissions to psychiatric hospital
Admissions
Bed days
NHS
Private Units
20
21
1,139
1,329
Source: Greenwich CAMHS
Please note this covers a 17 month period from January 2012
Admissions to psychiatric hospital of young people in RBG were analysed over a
17 month period from January 2012. There were 27 patients admitted 41 times
13
In 2012 there were 130 emergency referrals to CAMHS from Queen Elizabeth Hospital
through the Accident & Emergency and Paediatrics departments but no further breakdown of
the data is available.
DRAFT CAMHS NEEDS ASSESSMENT 2014
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with a total number of bed days of 2,468. Of these 8 patients accounted for
55% of the bed days.
Attainment and persistent absence
Nationally, poor mental health has been linked with poor attainment and the
increased likelihood of being “not in education, employment or training”
(NEET)14.
As is the case nationally, young people with poor mental health are less likely
to reach expected levels of attainment at each Key Stage in RBG. Outcomes get
progressively worse as young people progress through the Key Stages and only
around a quarter of young people involved with CAMHS in the last 3 years
achieved the headline 5+ A* - C Incl. English and maths measure at Key Stage 4
(26% compared to the 65% RBG average).
Research suggests that inconsistent school attendance is an early sign of
emerging or existing mental health problems during childhood and
adolescence15.
Persistent absence is particularly high among young people with Behavioural,
Emotional and Social Difficulties (BESD). BESD is directly linked with conduct
and emotional disorders. Therefore, it is crucial that intervention is provided at
the earliest stage to ensure better long term outcomes.
14
Centre for the Economics of Education: Mental Health and Education Decisions 2012
15
NCBI (National Center for Biotechnology Information): Children's mental health and school
success.
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Section 2: Children and young people at risk of poor outcomes get
timely early help
This section includes a profile of target groups where there is a greater
prevalence of clinically diagnosed mental disorders:

Looked After Children and those subject to CPP

Children with disabilities or SEN

Young offenders

Children who go missing from home or care

Young people who are not in education, employment and training

Teenage mothers

Young people using alcohol and drugs
a: Looked after children and children who are the subject of a CPP
Looked After Children
Nationally the prevalence of mental health difficulties is highest among looked
after children. Around 60% of looked after children and 72% of those in
residential care have some level of emotional and mental health problem16. A
high proportion experience poor health, educational and social outcomes after
leaving care. Looked after children and care leavers are between four and five
times more likely to attempt suicide in adulthood.
Looked after children need to be seen as a priority to prevent escalation of
need. Providing services to looked after children to address their emotional and
behavioural health will help to increase feelings of well-being and reduce
behaviour patterns which could be destructive to themselves and others.
RBG has a high rate of looked after children compared to national rates; 84.6
per 10,000 young people aged 0-18 compared to 60.1 per 10,000 nationally.
As at December 2013, there were 520 looked after children in RBG. Most
looked after children are in the care system as a result of abuse or neglect (55%
in RBG).
Table 15: Looked after children by placement as at December 2013
Placement
16
Number
%
NICE: Promoting the quality of life of looked after children. NICE public health guidance 2010
DRAFT CAMHS NEEDS ASSESSMENT 2014
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Placement with foster carer (not a relative or a friend)
377
73%
Foster placement with a relative or a friend
44
8%
Children’s home
43
8%
Independent living
28
5%
Placed for adoption
15
3%
4
1%
3
1%
Secure unit
3
1%
Residential care home
2
0.4%
Unknown
1
0.2%
520
100%
Young offender institution or prison
Placed with own parents or other person with parental
responsibility
Total
Source: Framework-i
The majority of RBG looked after children are in foster placements which is
considered to be the best option for children in care as it replicates as far as
possible a normal family unit. Most RBG looked after children are placed with
carers outside of the borough (70% as at 31 March 2013). Of those placed out
of borough, around two in five are placed in neighbouring boroughs (Bexley,
Lewisham and Bromley), around a quarter are placed in Kent, around one in
eight in other London Boroughs and the remainder across the rest of the
country.
Emotional and behavioural health of looked after children
All LAs in England are required to provide information on the emotional and
behavioural health of the children they look after. Data is collected by LAs
through a strengths and difficulties questionnaire (SDQ) which is completed for
each looked after child aged between 4 and 16. The questionnaire is completed
by the main carer, usually at the time of the child’s statutory annual health
assessment.
The SDQ is a short behavioural screening questionnaire. It has five sections that
cover details of emotional difficulties; conduct problems; hyperactivity or
inattention; friendships and peer groups; and also positive behaviour, plus an
“impact supplement” to assist in the prediction of emotional health problems.
The local authority calculates the child’s Total Difficulties Score which ranges
from 0 to 40. On an individual basis a score of 13 or below is normal, between
14-16 is borderline and 17 and above is a cause of concern.
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Table 16: Average SDQ score of looked after children
2010/11 2011/12 2012/13
13.1
12.0
12.9
Source: Greenwich CAMHS
* Good performance is indicated by a low number
Positively, the average score for the SDQ has been decreasing and fewer
children are scoring in the abnormal range. The abnormal range is a score
between 17-40.
Table 17: Percentage of looked after children scoring in the abnormal range
(SDQ)
2010
2011
2012
RBG
32%
31%
30%
National
38%
37%
36%
Source: DfE SFR Outcomes for children looked after by local authorities
During 2012/13, 107 Royal Greenwich looked after children and young people
met the threshold for referral into CAMHS services based on the score from
their SDQ. Further referrals were made based on behaviour apparent at health
assessments or documented by carers.
Table 18: Looked after children seen by CAMHS
Total
Year
Seen by
looked
CAMHS
after
%
children
2011/12
102
565
18%
2012/13
79
575
14%
Source: Greenwich CAMHS
Table 19: Placement stability – Number of children with 3+ placements
2010/11
2011/12
2012/13
RBG
15.8%
11.7%
8.7%
National
10.7%
11.0%
11.1%
10.8%
11.1%
11.7%
Statistical
Neighbours
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Source: DfE SFR Children Looked After by LA’s (incl. adoption and care leavers) and DfE SFR
Children in Care and Adoption Performance 2011/12
Placement stability is improving for children who stay looked after. Fewer
children have three or more placements in a year in RBG than nationally. One of
RBG’s key priorities is improving permanence for looked after children to
improve their outcomes. RBG performance for length of placements and
children returning home from care is also better than national averages.
Domestic Violence
Domestic violence is often associated with parental mental health and alcohol
and substance misuse, which may result in a child becoming looked after.
A UK survey examining the impact of domestic violence on the mental health of
school-age children and young people (Meltzer et al 2009) found that
witnessing domestic violence was significantly associated with conduct
disorders in children.
The impact of exposure to domestic violence may account for some of the
emotional and behavioural difficulties of children in the looked after system. A
UK study of 68 looked after children and young people (Farmer 2006) found
that 52% of the sample had a history of experiencing domestic violence in their
birth families.
Table 20: Domestic violence rates over the past five years as the total number
of recorded offences in RBG
Total offences
% Domestic
Violence
2007/08
2008/09
2009/10
2010/11
2011/12
33,086
31,302
28,460
27,490
25,751
15%
15%
16%
17%
18%
Source: RBG Safer Communities
In 2011/12, there were 4,632 domestic violence incidents in RBG (including
offences and other crimes not counted as offences), making up 18% of all
recorded crime. Incidents between parents, or where children are present are
not separately identified in these statistics, but it is assumed that in areas
where there are higher rates of domestic violence incidents, more children are
likely to be affected. In 2012/13, Woolwich Riverside, Abbey Wood and
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Woolwich Common had the highest rate of domestic violence incidents.
Domestic violence was a contributing factor to a child being made subject to a
child protection plan in around two fifths (42%) of cases in 2012/13.
Children subject to a Child Protection Plan (CPP)
Child abuse is associated with a several fold increased risk of mental disorder,
suicide and self-harm. Child Protection Plans, parenting programmes and
school based interventions are important to prevent child abuse because
adverse child experiences are the single largest risk factor for mental health
disorder (30%).
There has been a significant decrease in the number of RBG children who are
subject to a CPP. As at December 2013, 268 children were subject to a CPP
compared to 412 in the 2012/13 financial year. However, RBG’s CPP rate is still
higher than the national rate (43.6 per 10,000 young people aged under 18
compared with 37.9 per 10,000 nationally).
Table 21: Children subject to a Child Protection Plan in December 2013 by
category of need
Registration category of need
Number
%
166
62%
91
34%
Neglect and sexual abuse
6
2%
Sexual abuse
5
2%
268
100%
Emotional abuse
Neglect
Total
Source: Framework-i
Emotional abuse can hold back a child's mental development, such as their
intelligence and memory. It can also increase the risk of a child developing
mental health problems, such as eating disorders and self-harming.
Sexual Exploitation
Childhood sexual abuse has been associated with both short and long-term
mental health
problems such as anxiety, phobic reactions, guilt, substance abuse, difficulty
trusting others,
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low self-esteem, and dissociation (Walker, 1988), depression, and even suicide
(Briere and
Runtz, 1987)17
In 2012/13 there were 75 children and young people identified as at risk of
sexual exploitation, of which 29 children (39%) have been referred to CAMHS on
one or more occasion in the last 3 years.
A patient engagement feedback event run by NHS Greenwich CCG in November
2013 highlighted a need for counselling for sexually abused children with
appropriate therapy for younger children.
b: Children with disabilities or special educational needs
Using DfE prevalence modelling it is estimated there are between 2,630 and
3,850 disabled children living in Royal Greenwich (RBG), or 3% to 5% of the 024 year old population.
As at January 2013, the most common primary SEN need among young people
with statements in RBG is Autistic Spectrum Disorder (ASD) - 31% compared to
22% nationally. The proportion of young people with statements for ASD is
particularly high at the primary phase (40% of all statements in 2013).
There is a strong link between ASD and mental health difficulties. Nationally, it
is estimated that as many as 70% of children with autism have mental
health problems, such as anxiety disorders, depression, and obsessive
compulsive disorder (OCD), and 40% have two or more (National Autistic Society
2011). Therefore, this is a key group for early mental health intervention in
schools.
Table 22: SEN Primary Need for statemented young people attending RBG
schools
SEN Primary Need (All Phases)
RBG Stmd.
NAT Stmd.
Autistic Spectrum Disorder
31%
22%
Severe Learning Difficulty
16%
13%
17
Sexual abuse and therapeutic services for children and young people executive summary
(NSPCC)
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Speech, Language and
Communication Needs
12%
14%
Difficulties
8%
14%
Other Difficulty / Disability
6%
2%
Difficulty
6%
5%
Moderate Learning Difficulty
6%
16%
Hearing Impairment
5%
3%
Physical Disability
4%
6%
Specific Learning Difficulty
4%
5%
Visual Impairment
2%
2%
0.1%
0.2%
Behaviour, Emotional and Social
Profound and Multiple Learning
Multi-Sensory Impairment
Source: January 2013 School Census
Nationally, young people with Speech, Language and Communication Needs
(SLCN) are four times more likely to have a mental health disorder. In RBG, the
majority of young people at School Action Plus have SLCN as their Primary SEN
need (42% of those at School Action Plus). This is another key group for
targeted early mental health intervention in schools.
Young people with learning difficulties are estimated to be 2-3 times more
likely to have a mental health disorder. There is a link between young people
having learning difficulties or SLCN as their primary SEN need being recorded
with ASD or BESD as their secondary SEN need.
Table 23: RBG young people with ASD or BESD as a secondary SEN type
Primary SEN Type
No. with ASD or BESD as a secondary
SEN type
Learning Difficulties (any)
164
Speech, Language and
124
Communication Needs
BESD if ASD the secondary SEN type
or ASD if BESD the secondary SEN
28
type
Physical Disability (any)
12
Other Disability (not specified)
11
Total
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Source: January 2013 School Census
c: Young offenders
There are a number of studies which provide insight to the mental health of
young people who have had contact with the criminal justice system. Young
offenders are at high risk of suffering mental health problems and 40% have a
diagnosable disorder (Green et al, 2003).
National research18 suggests that prevalence of mental health problems for
young people in contact with the criminal justice system range from 25% to
81%, being highest for those in custody. Early interventions for young people
with mental health needs, particularly those with conduct disorders, will help to
keep an increased proportion of this vulnerable group out of the youth
offending system.
Research conducted by the Mental Health Foundation suggests the detection of
mental health problems in young offender populations is imprecise, and tends
towards underestimation, particularly of internalising disorders.
Table 24: Young offenders who were screened by YOS for mental health
problems
2010/11 2011/12 2012/13
Total YOS cases
564
395
372
154
151
129
% Screened by YOS
27%
38%
35%
No. seen by CAMHS
48
42
47
% seen by CAMHS
9%
11%
13%
21
22
23
4%
6%
6%
No. screened by YOS for mental
health
No. screened by YOS & seen by
CAMHS
% screened by YOS and seen by
CAMHS
Source: Youth Offending Service & Greenwich CAMHS
18
The Mental Health Foundation
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In 2012/13, Youth Offending Service (YOS) screened around a third of young
offenders (35%) for mental health problems. YOS professionals are being
supported to manage their own cases rather than refer to specialist CAMHS.
Only those with high level needs will be referred to CAMHS.
Young people involved with the YOS will be assessed through an ASSET and will
be subject to a range of interventions or diversionary activities. One of the
available interventions is Multisystemic Therapy (MST). MST is an intensive
family and community based treatment program that focuses on addressing all
environmental systems that impact chronic and violent young offenders.
There were 54 referrals for MST between December 2012 and 2013. Around
three in five referrals (59%) were from the YOS, including the Youth Crime
Prevention Panel lead by YOS. Of 35 post-trial MST families treated between
September 2011 and December 2013, no new offences were committed in
82.8% of cases which is better than the 79.7% United States (US) average and
88.9% of the young people were still living at home compared to the 84.1% US
average. However, there is a need to improve the percentage of young people
education, training or work at the end of treatment (60% compared to the 83%
US average).
d: Children who go missing from home or care
Children who go missing are vulnerable to considerable associated risks,
including drug and alcohol abuse linked to gang activity, becoming the victim
or perpetrator of crime and sexual exploitation.
Recent data shows that there has been an increase in the number of RBG
children going missing from home and care. In the first three quarters of
2013/14, 64 children had gone missing from home compared to 54 for
2012/13 and 55 children had gone missing from care compared to 46 for
2012/13.
The mental health of looked after children who go missing is a particular
concern. Between October and December 2013, 28 out of the 54 children
missing from care (52%) had known mental health needs. Furthermore, 61% had
substance misuse issues, 46% were known to youth offending, 28% were at risk
of sexual exploitation and 20% were known to be involved with gangs.
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Table 25: Number of children missing from care between Oct-Dec 2013 by age
Age (Yrs)
Number
%
12
5
9%
13
9
17%
14
8
15%
15
8
15%
16
14
26%
17
10
19%
Total
54
100%
The majority of children who go missing from care were in out of borough
placements between October and December 2013 (35 out of 54 – 65%). Of
those who go missing from care in the borough, most are semi-independent
living.
Table 26: Number of looked after children who have had 3 or more placements
between April 2012 and March 2013 and have gone missing from care (seen by
CAMHS)
Looked after
Missing more than
Missing more than
24 hours on one or
24 hours on two or
more occasion
more occasions
50
21
15
32
13
10
children who have
had 3 or more
placements
RBG Number
Seen by
CAMHS
Source: CAMHS
Looked after children who have had more than three placements are at risk of
going missing. Around two in five (42%) of those with 3+ placements have gone
missing from care one or more times, and several (30%) have gone missing on
two or more occasions.
Homelessness
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According to national research19 it can be suggested that one out of every 100
young people aged 16–24 experiences some form of homelessness annually.
A CLG20 survey revealed that the proportion of homeless 16–17 year olds with
(current) mental health problems could be nearly three times that of their peers
in the general population (Pleace et al., 2008)
In a London based study of young people experiencing homelessness in which
psychiatric diagnostic criteria were used, two thirds met the threshold for a
mental disorder (Craig et al 1996). In the same study 70% of those with a
diagnosable mental illness had experienced their first symptoms before their
first episode of homelessness.21
Based on a local cohort study, nearly half of young people who disclosed
homelessness had been seen by CAMHS within the year.
In 2012/13 there were 108 young people aged between 16 and 25 accessing
The Point for a targeted service, who needed help with housing. Of these, 86
(80%) also presented with an Emotional & Mental Health need. Within this
cohort, 25 young people (23%) had a high level of need for housing as well as a
high level Emotional & Mental Health need.
e: Young people not in education, employment and training
Young people aged 16-18 years old who are not in education, employment or
training (NEET) are more likely to have poor health and die an early death. They
are also more likely to have a poor diet, smoke, drink alcohol and suffer from
mental health problems.22
As at Q4 2013/14, 7.0% of RBG resident young people aged 16 - 18 (academic
year 12-14) were NEET. This is higher than the national average (5.3%) and the
statistical neighbour average (5.5%).
19
Youth homelessness in the UK - Joseph Rowntree Foundation
20
Communities and Local Government
21
Making the link between mental health and youth homelessness - A pan-London study
22
North East Public Health Observatory (NEPHO)/Public Health England
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As at January 2014, the majority of the RBG NEET cohort were from White
British backgrounds (71%), male (56%) and in Year 14/aged 18 (56%). There has
been an increase in the number of teen parents and those with learning
difficulties in the NEET cohort between January 2013 and 2014.
A local analysis of the primary need of RBG NEET in December 2012 found that
of those with school action plus or statement, 60% had Behaviour, Emotional
and Social Difficulties (BESD) compared to 22% in RBG secondary schools.
Therefore there is a significant over-representation of young people with BESD
in the NEET cohort. Children and young people with BESD often have complex
conditions or identified mental health difficulties. The term BESD can include
mental health conditions such as conduct disorders, Attention Deficit
Hyperactivity Disorder (ADHD), school phobia, self-harm and depression.
A Risk of NEET project is currently being piloted with schools to monitor and
provide interventions for particularly vulnerable groups of children such as
those with BESD to prevent them from becoming NEET.
The Feel Good Greenwich initiative should also help to get young people into
education, employment and training. This initiative is run by Greenwich Mind in
partnership with RBG, Volunteer Centre Greenwich, Greenwich Co-operative
Development agency, Oxleas NHS Foundation Trust, Age UK Greenwich and Big
White Wall. Feel Good Greenwich want to help local people feel better and
happier through trying new things and meeting new people. The main aim is to
connect people to opportunities and services which are right for them.
f: Teenage mothers
It is widely acknowledged that teenage pregnancy is a cause of health
inequalities and child poverty. It is broadly recognised that teenage pregnancy
can contribute to long term poor health outcomes for teenage parents and their
children23.
Teenage mothers specifically are three times more likely to get post-natal
depression than older mothers, face a higher risk of poor mental health for
three years after the birth, are more likely to smoke during pregnancy and are
23
Teenage Pregnancy Next Steps, DCSF 2007
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one third less likely to breastfeed. Babies of teenage mothers are more likely to
be born prematurely or at a low birth-weight and are twice as likely to be
admitted to hospital as a result of an accident24. Children of teenage mothers
have a greater risk of developing conduct, emotional or hyperactivity
problems25.
Table 27: Teenage pregnancy rates per 1,000
Statistical
Year
RBG
National
2009
58.6
37.1
52.3
2010
58.2
34.2
46.9
2011
38.1
30.7
38.7
Neighbours
Source: Conception Statistics, England and Wales, 2011
Teenage pregnancy rates had remained at a high level in Greenwich over many
years. However, rates have dropped significantly in recent years. The latest
available teenage conception rate, as at December 2012, is 34.9 per 1,000 girls
aged 15-17. Therefore RBG is closing the gap with the national average (28.5
per 1,000 as at December 2012).
As at Q3 2013/14, 4 out of 68 female looked after children aged 15-17 were
parents (5.9%) which is an increase on 2012/13 performance (2 out of 75 –
2.7%).
A patient engagement feedback event run by the NHS Greenwich CCG in
November 2013, highlighted a need to improve the experience of women
during labour to reduce the numbers needing counselling for Posttraumatic
Stress Disorder.
g: Young people using alcohol and drugs
Based on Schools Health Education Unit (SHEU) survey findings, there has been
an increase in the percentage of Year 8 and 10 pupils trying drugs (9.1% in
2006, 10.5% in 2008, 14.6% in 2010 and 15.4% in 2012). Linked to this, more
young people are being treated for substance misuse.
24
Teenage Pregnancy Advisory Group Briefing, 2011
25
National Teenage Pregnancy Unit presentation
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Table 28: Number of young people accessing treatment services in RBG
between 2008/09 and 2012/13
Treatment Services
2008/09
2009/10
2010/11
2011/12
2012/13
86
73
106
79
143
87
80
112
84
152
Young people in
treatment
Episodes of treatment
Source: National Treatment
Agency
The majority of young people being treated for substance misuse are male
(97/152 episodes – 64%), aged 15-16 years old (90/152 – 59%) and from a
White background (106/152 – 70%). Most of the young people are being treated
for cannabis misuse (115/152 – 76%).
Research suggests that there is a strong link between cannabis misuse and
schizophrenia. The use of cannabis in adolescence has been reported to
increase the risk of developing symptoms of schizophrenia in adulthood
(Tsapakis et al, 2003).
Young people aged 11-16 years old with an emotional and/or conduct disorder
are more likely to smoke, drink and use drugs, based on national research by
Green et al in 2005.
Table 29: Link between disorders and use of alcohol or drugs
Risk behaviour
Smoke regularly (age 11-16)
Drink at least twice a week (age
11-16)
Ever Used Hard Drugs (age 1116)
Emotional
Conduct
No
Disorder
Disorder
Disorder
19%
30%
5%
5%
12%
3%
6%
12%
1%
Source: Green et al, 2005
Table 30: Inpatient stays at Queen Elizabeth Hospital for mental & behavioural
disorder due to use of drugs
Year
Number
2008/09
11
2009/10
11
2010/11
13
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2011/12
16
2012/13
5*
Source: NHS information on hospital admissions
*Please note this is for Q1 and Q2 only
More young people are accessing substance misuse treatment, yet the number
of inpatient Queen Elizabeth Hospital stays for mental and behavioural disorder
due to use of drugs has risen slightly in the last few years.
In 2012/13, there were 22 dual diagnoses of mental health needs and
substance misuse problems. A CAMHS worker works jointly with the
commissioned drug treatment specialist to deliver interventions to these young
people.
In the first half of 2012/13 there were 92 young people in Tier 3 substance
misuse treatment at KCA with 42 (46%) identified as having a mental health
problem.
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Section 3: Services are shaped by the views and wishes of children,
young people and their families
The 2014-17 CYPP includes an ambition that services are shaped by the views
and wishes of children, young people and their families.
Since 2006, RBG has conducted a Schools Health Education Unit (SHEU) survey
every other year. The SHEU survey includes questions around emotional health
and well-being to primary school pupils (Years 4 and 6) and secondary school
pupils (Years 8 and 10).
The emotional health and wellbeing of pupils has an impact on all aspects of
school life, including their motivation, concentration, aspiration, satisfaction,
contribution, relationships with peers and adults, happiness, achievement and
attainment.
Table 31: The percentage of primary school children who agreed with each of
the following statements:
Statement
The school cares whether I am happy or
% 2010
% 2012
% 2012
RBG
RBG
All SHEU
67%
69%
73%
62%
59%
67%
63%
59%
64%
not
My achievements in and out of school are
recognised
The school teaches me how to manage my
feelings
Source: SHEU survey
Table 32: The percentage of secondary school children who agreed with each of
the following statements:
Statement
The school cares whether I am happy or
% 2010
% 2012
% 2012
RBG
RBG
All SHEU
24%
32%
39%
38%
40%
39%
17%
21%
25%
not
My achievements in and out of school are
recognised
The school teaches me how to manage my
feelings
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Source: SHEU survey
RBG is below all the national SHEU survey averages for the emotional health and
wellbeing of pupils, with the exception of achievements being recognised for
secondary school pupils.
Bullying
Research26 shows that children and young people who are bullied are at
increased risk for mental health problems including depression and anxiety.
Those who are bullies are at increased risk for substance misuse, academic
problems, and violence compared to others later in life. Individuals who are
both bullies and victims suffer the most serious effects of bullying and are at
greater risk for mental and behavioral problems than those who are only bullied
or are only bullies.
Anyone involved with bullying (those who bully others, those who are bullied,
and those who bully and are bullied) are at increased risk for depression27 and
unlike traditional forms of bullying, those who are bullied electronically are at
higher risk for depression28. Bullying can also cause long-term damage to selfesteem.29
Based on 2012 SHEU survey findings, 27% of RBG Year 4 and 6 pupils have been
bullied at least once in the last year and 14% of RBG Year 8 and 10 pupils.
Linked to positive mental health and well-being and education, it is important
to address bullying as it puts children and young people at significant risk of
developing mental health problems.
Include consultation information from sessions with service users.
Feedback to be added here.
26
Smokowski P. R., & Kopasz K. H. (2005). Bullying in school: An overview of types, effects,
family characteristics, and intervention strategies. Children and Schools, 27, 101–109.
27
Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2010).
Taking a stand against bullying.
28
Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2012).
Focus on children's mental health research at the NICHD.
29
Reece, T. (2008). Bullies beat down self esteem.
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