Joint Strategic Needs Assessment (JSNA)
Child and Adolescent Mental Health
The Royal Borough of Windsor and Maidenhead work in close partnership with
Berkshire Healthcare NHS Foundation Trust, GPs, schools and voluntary sector
organisations to commission services for the local population.
The Foundation Trust provides specialist mental health and community health
services to a population of around 900,000 within Berkshire. The Trust has over 210
mental health beds and on any one day has over 20,000 people in its care for mental
health. It works with six local unitary authorities including West Berkshire, Reading,
Windsor and Maidenhead, Slough, Bracknell Forest and Wokingham.
During 2014/15 the Trust continued to provide mental health and community health
services under its contracts with Berkshire Clinical Commissioning Groups (CCG’s)
and other commissioning bodies. The CCGs have committed to increasing resources
into Tier 3 CAMHS in 2015/16. This additional resource will initially be targeted at
on-going risk mitigation and the reduction of waiting lists. With regard to Tier 4, NHS
England have been working closely with the CCG who following a review of Tier 4
CAMHS services identified the need to develop Tier 4 provision in Berkshire
(increasing the number of inpatient beds and raising its service specification to meet
the Tier 4 NHS England standards).
Effective mental health commissioning will need to ensure interventions and services
work to reach young people at a level that is appropriate to their need. The range of
services on offer varies from mental health promotion and primary prevention to
specialist care for those with more complex and severe psychiatric needs. It is
recognised that within this there are some gaps in service provision at present.
Information about the definition and classification of mental health conditions in
children and young people can be found on the Child and Adolescent Mental Health
website.
What do we know?
Mental health problems in children and young people are common. They account for
a large proportion of the total burden of ill health in this age group (Department of
Health and NHS England, 2014). 1 in 10 children aged 5 to 16 has a mental health
problem with some experiencing more than one mental health problem (1 in 5
children with a mental health problems is estimated to have more than one problem)
(ONS, 2004).
Boys are generally more likely to have a diagnosable mental illness than girls but this
may be due to boys being more likely to display externalising disorders such as
conduct disorders which are more easily identified than internalising disorders such
as anxiety and depression.
1
Joint Strategic Needs Assessment (JSNA)
Common mental health issues affecting children and young people include conduct
disorders (5.8%); anxiety (3.3%); depression (0.9%); and hyperkinetic disorder
(1.5%) (Department of Health and NHS England, 2015).
Adolescence is a peak age for the onset of mental illness with mental health needs
intensifying from the age of 14 years. Common mental health problems in this age
group are depression and anxiety but eating disorders and psychosis can also
emerge during this life stage (Pona, Royston, Bracey, & Gibbs, 2015).
CAMH services are provided through a network of services currently described as:




Universal services such as early year services and primary care (Tier 1)
Targeted services such as YOT, primary mental health workers (Tier 2)
Specialist community CMAHS (Tier 3)
Highly specialist service such as inpatient services (Tier 4).
Recent reviews has emphasised a need to move away from this tiered system
(Wolpert, et al., 2014) as they represent a barrier to treatment.
One in ten children will need support or treatment for a mental health condition yet
only a quarter of children and young people with a diagnosable mental health
problem receive treatment (Department of Health and NHS England, 2014).
An independent review of Tier 4 CAMHS service (NHS England, 2014) along with
evidence from the Health Select Committee (Health Select Committee, 2014) show
that a large proportion of children with poor mental health or emotional difficulties are
not receiving timely, high quality, evidence-based support.
30% of people of all ages who have a long term physical health problem also have a
mental health problem. Equally 46% of people of all ages with a mental health
problem also have a long term physical illness (The King's Fund).
One study estimates that 70% of children with ASD will have at least one mental
health problem with common diagnoses being social anxiety, ADHD, and
oppositional defiant disorder (Simonoff, Pickles, Charman, Loucas, & Baird, 2008).
Children who are looked after (LAC) are around four times more likely to have a
mental disorder than other children. These mental health needs are often unmet
leading to placement instability and poor educational attainment. The high
proportions of children with a behavioural disorder are at a particularly high risk of
placement breakdown (Bazalgette, Rahilly, & Trevelyan, 2015).
25% of 18 to 24 year olds and 19% of 11 to 17 years olds are severely maltreated
and suffering abuse or neglect during childhood accounts for almost one third of all
poor mental health. (Joint Commissioning Panel for Mental Health, 2013). Common
2
Joint Strategic Needs Assessment (JSNA)
mental health problems occurring amongst children who have been abused or
neglected include depression, posttraumatic stress disorder and risky sexual
behaviour and substance misuse.
A review of the literature into the mental health needs of young people in contact
with the youth justice system (The Mental Health Foundation, 2002) found that
mental health problems are at least three times as high amongst this group of young
people when compared to the general population with rates highest amongst those
children detained in custody. Common problems are similar to that of the general
population with substance misuse being a particular concern amongst those in
contact with the youth justice system.
Many children will have a parent who will, at some point, have a mental illness –
68% of women and 57% of men with a mental health problem are parents (Royal
College of Psychiatrists, 2015). Between 50 and 66% of parents with severe and
enduring mental health problems live with one or more child age under 18 (Mental
Health Foundation). Having a parent with a mental health problem can increase the
likelihood of a child also having a mental health problem. For example, children of
mothers with depression are five-times more likely to have a conduct disorder; 51%
of parents of children with a conduct disorder have an emotional disorder and 18%
have a severe emotional disorder; 48% of parents with a child with an emotional
disorder also have an emotional disorder themselves (Joint Commissioning Panel for
Mental Health, 2013).
There is a large body of evidence which show a small but significant association
between perinatal mental illness and an increased risk of poor child psychological
and developmental outcomes (Stein, et al., 2014).
20% of children with no working parent are estimated to have a mental illness. 20%
of 11 to 16 year olds from household with a weekly income of less than £200 are
also estimated to have a mental illness (Joint Commissioning Panel for Mental
Health, 2013).
The time in transition from child to adult services can be particularly problematic in
ensuring that the social and emotional wellbeing needs of older teenagers are met
with 16 to 17 year olds including the most vulnerable being particularly likely to be let
down by services (Pona, Royston, Bracey, & Gibbs, 2015). The transition between
CAMHS and adult mental health services is often where support disappears. The
needs of 16 to 17 year olds are often not taken into account when CAMHS are
commissioned with data around 16 to 17 year olds been patchy with a lack of clarity
whether this groups should be part of CMAHS or AMHS (Pona, Royston, Bracey, &
Gibbs, 2015).
Statistics about mental health are published by Young Minds
www.youngminds.org.uk/, a charity committed to improving the emotional wellbeing
3
Joint Strategic Needs Assessment (JSNA)
and mental health of children and young people. These illustrate why ensuring early
support is essential.
Facts, Figures, Trends
The Child and Maternal Health Intelligence Network (ChiMat)
publishes estimates of the numbers of children with different mental health
conditions in Local Authority areas. These are calculated by applying estimated
prevalence to local population size and therefore acknowledged to be
approximations only. The latest figures for 2014 indicated that 1,730 children aged 516 living in the Royal Borough were estimated to have a mental health disorder
(7.7% as compared to 9.3% across England). In addition, 3.0% of children and
young people (aged 5-16) as compared to 3.6% for England were estimated to have
an emotional disorder. The prevalence of conduct disorders was estimated to be
4.5% as compared to 5.6% and the prevalence of hyperkinetic and eating disorders
were 1.3% and 1,703 as compared to 1.5% (England) and 126,533 (South East)
respectively.
In 2014/15 the Windsor and Maidenhead Child and Adolescent Mental Health
Service received 504 referrals for children with complex or severe mental health
needs.
The total number of children and young people being treated by Berkshire Health
Care Foundation Trust for a mental health disorder is presented below:



In 2013/14 the number of 5 to 19 year olds in treatment with mental health
disorder in Berkshire increased by 17.5% to 4,214
In 2013/14 the total number of Deliberate self harm cases (DSH) increased by
52% to 76
In June 2013 there were:
- 1,340 open cases of Attention Deficit Hyperactivity Disorder (ADHD)
- 1,387 open cases of Anxiety and Depression
- 663 open cases of Autism
- 26 young people admitted to the Berkshire Adolescent Unit with mental ill
health, which is an increase on 16 in 2011/12.
National & Local Strategies (current best practices)
The Health Select Committee, following the report from the Chief Medical Officer in
2013, held an enquiry into CAMHS services.
It focused on improving children’s mental health outcomes at national level. The
report highlighted major problems with children waiting for a hospital bed, cuts to
early intervention services and waiting times for CAMHS. The Chief Medical Officer
stated that promoting children’s physical and mental health development in schools
4
Joint Strategic Needs Assessment (JSNA)
creates a positive cycle reinforcing children’s attainment and achievement that in
turn improves wellbeing enabling children to thrive and achieve their potential.
In February 2014, twenty-two national bodies involved in health, policing, social care,
housing, local government and the third sector came together and signed the Crisis
Care Concordat. http://www.crisiscareconcordat.org.uk/about/ A national agreement
between services and agencies involved in the care and support of people in crisis. It
sets out how organisations will work together better to make sure that people get the
help they need when they are having a mental health crisis. The use of police cells to
detain Children under section 136 of the Mental Health act due to lack of available
place of safety has been a particular area of focus and concern.
In July 2014, the NHS England review of inpatient CAMHS provision was published.
This revealed major difficulties with children and young people being placed on a
regular basis in beds hundreds of miles away from home and children being placed
inappropriately on adult wards.
In August 2014, Care Minister Norman Lamb announced a Taskforce
https://www.gov.uk/government/groups/children-and-young-peoples-mental-healthand-well-being-taskforce to ascertain how CAMHS services could be improved. The
taskforce considered how to improve the way children’s mental health services are
organised, commissioned and provided and how to make it easier for young people
to access help and support, including in schools, through voluntary organisations
and online. The Taskforce (DOH) published its report Future in Mind: Promoting,
protecting and improving our children and young people’s mental health and
wellbeing, in March 2015. The report made key recommendations to schools,
commissioners, and early years staff. It emphasised the need to improve services for
children and young people from vulnerable backgrounds, to improve access to
services and to improve data and standards.
More information about the Children and Young People’s Mental Health and
Wellbeing Taskforce, including a link to the report:
https://www.gov.uk/government/groups/children-and-young-peoples-mental-healthand-well-being-taskforce
In November 2014 Public Health England looked at the link between pupil health and
wellbeing and attainment and found there was a strong correlation.
Mental Health and Behaviour in Schools published in March 2016 provided nonstatutory advice relating to the powers and the duties for school staff and the
approaches they can adopt to manage behaviour in their schools. The advice
clarifies the responsibility of the school, outlines what they can do and how to
support a child or young person whose behaviour – whether it is disruptive anxious,
depressed or otherwise – may be related to unmet mental health needs.
5
Joint Strategic Needs Assessment (JSNA)
In order to put mental health services on a par with physical health services an
introduction of new standards and commissioning processes are being developed.
Access and waiting times for mental health are being introduced (e.g. Early
Intervention in Psychosis; and Access and Waiting Time Standard for Children and
Young People with and Eating Disorder (NHS England, 2015).
This introduction of new standards and commissioning processes will additionally
drive a much richer data set for quality and performance management of all service
for all ages. The maternity and children’s dataset (Health and social care information
centre, 2015) will allow commissioners and providers of services to design and plan
to best meet the needs of children and young people in the local area.
Local Strategies
A Common Point of Entry for Berkshire Healthcare trust was set up in 2013 and this
includes specialist pathways for Autistic Spectrum Disorder (ASD), Attention Deficit
Hyperactivity Disorder (ADHD) and Anxiety and Depression (A&D). There is a 20%
increase in referrals and the waiting time for the specialist clinics is increasing.
Targeted provision in the Royal Borough has continued to support schools to
increase their awareness and understanding around social and emotional well-being.
The THRIVE Model for the Royal Borough aims to promote the joint decision making
with children, young people and their families to ensure they get the best intervention
for their needs.
(http://www3.rbwm.gov.uk/downloads/file/1407/mental_health_an_emotional_wellbei
ng
In addition:



The youth counselling service (voluntary sector) has a base in Windsor (Youth
Talk) and Maidenhead (No.22) and works with children and young people aged
11 years and above.
An Early Help Hub was formed in January 2016 in order to coordinate all the
Early Help services across Windsor, Ascot and Maidenhead to ensure the most
appropriate plan and support is offered for children and families. There is a
single point of access for all requests for early help and safeguarding. The
function of the Early Help Hub is to identify what help and child and family require
to prevent needs escalating.
The Psychology and Wellbeing Service offers a range of services that use
psychology, therapeutic interventions and current educational and psychological
research to develop and strengthen school practice. The aim is to promote and
improve the learning, emotional wellbeing, resilience, development and inclusion
of all children, especially vulnerable children and young people. The service
ensures that all schools have a named link Educational Psychologist. The
service provides both generic and bespoke training for schools and parents in
6
Joint Strategic Needs Assessment (JSNA)









relation to specific needs and difficulties and a range of evidenced based
strategies e.g. to build resilience and to reduce anxiety. Training and supervision
is provided to all Teaching Assistants who have also trained as ELSA’s
(Emotional Literacy Support Assistants). Group interventions are also offered
e.g. the co-facilitation of evidenced based programmes such as Friends for Life
and Circle of Friends.
The Wellbeing service is a three year programme commissioned by RBWM
schools to raise awareness regarding mental health and emotional wellbeing
(working with children aged 5-18 years and their families).
The Behaviour Support Outreach Team work in partnership with Educational
Psychology, forming the Psychology and Wellbeing service. This freely
accessible service to maintained primary schools (and traded service for middle,
secondary and academy schools) can provide support for individual pupils in
school for 6-8 sessions (e.g. self esteem, social skills, managing anger) and can
provide a weekly Friends for Life Programme focusing on building resilience and
reducing anxiety. In addition a transition programme/group can be offered to
vulnerable pupils in the summer term with follow up monitoring at the pupil’s next
school. Centrally and school based Nurture groups are offered across the
borough for KS1 and KS2.
The Youth Support Service works with young people aged 8-19 years who need
to be supported with making informed decisions around risk taking behaviour and
engaging in positive activities both in and outside of school. One off awareness
raising sessions are provided to students on subjects such as cyberbullying,
positive thinking and staying safe online. Targeted group workshops are also
provided with a focus on self esteem and managing anger. Targeted individual
intervention is also offered to young people who have attended a group workshop
on a referral basis (eight individual sessions).
Specialist services such as Intensive Family Support Service, Directions and
Youth Intervention Support Programme may also work with children, young
people and their families around emotional and behavioural needs. Some schools
provide their own counselling/therapeutic service directly to their school.
The Psychological Perspectives in Education and Primary Care (PPEP) project
aims to help staff in primary care and education to (i) better recognise and
understand mental health difficulties in children and young people and (ii) better
support these children, young people and their families by providing psychoeducation and drawing on relevant psychological techniques (using a cognitive
behavioural framework).
Children and their families are also being supported through work in Children's
Centres, Youth and Community Service, voluntary sector (for example Family
Friends) and the Borough's Parenting Service.
www.kooth.com provides free on-line counselling for 11-18 year olds. It is a
commissioned service providing live forums, information, advice and guidance on
a range of mental health issues that are affecting young people.
Nurture groups for primary aged children.
Counselling service offered to all middle and secondary schools.
7
Joint Strategic Needs Assessment (JSNA)


Attachment work for adoptive parents and carers.
Parenting group for parents of children with ADHD being developed
What are the key inequalities?


Support for parents of children with mental health problems is limited depending
on diagnosis. For example, children with a diagnosis of anxiety are supported
through the anxiety clinic (CAMHS), but if a diagnosis of Autistic Spectrum
Disorder is given after the child is 8 years old or a diagnosis of Attention deficit
hyperactivity disorder (ADHD) there is currently no evidence-based support
available.
Some schools are better able to understand, identify and meet the needs of
pupils with emotional health and well-being needs.
Recommendations









Support for both children and their parents with a diagnosis of Autistic Spectrum
Disorder (ASD) and Attention deficit hyperactivity disorder (ADHD)
Support for young adults moving from Child and Adolescent Mental Health
Services (CAMHS) to the adult services with significant mental health issues,
including enduring special educational needs
Longer term therapeutic input for children with enduring mental health or
attachment issues who don't meet the criteria for more specialist medical support
Training for all schools around understanding and identifying emotional health
and well-being issues, covering areas such as attachment difficulties, bullying,
self-harm.
Waiting times for appointments.
Post diagnostic support and support for those not eligible for treatment.
Engaging parents/carers and families in genuine participation particularly those of
children and young people who may feel blamed or stigmatised.
Engaging pupils through pupil voice, decision-making and peer led approaches.
It is key that all levels of interventions in schools meet the needs of CYP and their
families, that they are properly implemented and evaluated to ensure the best
outcomes and further inform future outcomes or any gaps in provision.
Also see


Adult mental health
Autism in children
8