Integrated Strategic
Needs Assessment
Children and Young
People - Emotional Health
and Wellbeing
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Children and Young People’s Emotional Health and Wellbeing
Contents
Acknowledgements ............................................................................................................................................. 4
1.0
Introduction to the ISNA ......................................................................................................................... 5
1.1 Background ...................................................................................................................................................... 5
1.2 Introduction ..................................................................................................................................................... 5
1.2 Integrated Strategic Needs Assessment (ISNA) ................................................................................................ 6
2.0 Methods & Project Management ................................................................................................................... 7
2.1 Accountability .................................................................................................................................................. 7
2.2 Scope ................................................................................................................................................................ 7
2.3 Literature Review ............................................................................................................................................. 8
2.4 Engagement ..................................................................................................................................................... 8
3.0 Defining the issue .......................................................................................................................................... 8
3.1 What is emotional health and wellbeing?........................................................................................................ 8
3.2 Mental illness and mental disorders ................................................................................................................ 9
4.0 Who is included in this ISNA? ...................................................................................................................... 10
5.0 Why is this issue highlighted? ..................................................................................................................... 10
5.1 National Context ............................................................................................................................................ 11
5.2 Local Context .................................................................................................................................................. 14
5.3 Clinical Guidelines and briefings .................................................................................................................... 14
5.4 Measuring emotional health and wellbeing .................................................................................................. 14
5.4.1 Measuring mental health........................................................................................................................ 15
5.4.2 Public Health Outcomes Framework ...................................................................................................... 15
5.4.3 Measuring wellbeing ............................................................................................................................... 15
6.0 Size of the problem ...................................................................................................................................... 16
6.1 Maternal mental/emotional health and wellbeing ........................................................................................ 16
6.1.1 Maternal mental health .......................................................................................................................... 16
6.1.2 Maternal Wellbeing ................................................................................................................................ 16
6.2 Early years 0-5 years mental/emotional health and wellbeing ...................................................................... 17
6.2.1 Early years mental health ....................................................................................................................... 17
6.2.2 Early years wellbeing .............................................................................................................................. 17
6.3 Primary and secondary school aged children (5-16 years) mental/emotional health and wellbeing ............ 18
6.3.1 Mental health ......................................................................................................................................... 18
6.3.2 Wellbeing in primary and secondary school aged children ................................................................... 19
6.4 Young people 16-24 years .............................................................................................................................. 21
6.4.1 Mental Heath .......................................................................................................................................... 21
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Children and Young People’s Emotional Health and Wellbeing
6.4.2 Transition issues ..................................................................................................................................... 21
6.4.3 Wellbeing ................................................................................................................................................ 22
6.5 Self-Harm ....................................................................................................................................................... 23
6.6 Inpatient Admissions for Mental Health Disorders ........................................................................................ 26
6.7 Suicide ............................................................................................................................................................ 27
6.7.1 Child suicides .......................................................................................................................................... 27
6.7.2 Young people aged 15 years + ................................................................................................................ 27
6.7.3 Suicidal behaviour and bullying .............................................................................................................. 27
6.7.2 Suicidal behaviour and parenting ........................................................................................................... 27
6.8 Cost ................................................................................................................................................................ 28
6.8.1 The costs of mental health problems ..................................................................................................... 28
6.8.2 A different approach ............................................................................................................................... 28
7.0 Who is at risk and why? ............................................................................................................................... 29
7.1 Risk and protective factors ............................................................................................................................. 29
7.2 Adverse Childhood Experiences ..................................................................................................................... 33
7.3 Social and Economic Factors .......................................................................................................................... 34
7.3.1 Ethnicity .................................................................................................................................................. 34
7.3.2 Deprivation ............................................................................................................................................. 34
7.3.3 Social relationships and social capital ..................................................................................................... 34
7.3.4 Loneliness and isolation ......................................................................................................................... 35
7.4 Children and young people at higher risk of emotional health health problems .......................................... 35
7.4.1 Looked After Children ............................................................................................................................. 36
7.4.2 Children with Special Educational Needs................................................................................................ 36
7.4.3 Young People Not in Education, Employment or Training (NEET) .......................................................... 36
7.4.4 Offending and young people .................................................................................................................. 37
7.4.5 Children and young people registered deaf or hard of hearing ............................................................. 37
8.0 Level of need in population ......................................................................................................................... 37
8.1 Population of children and young people ...................................................................................................... 37
8.2 Service demand .............................................................................................................................................. 38
8.2.1 Background ............................................................................................................................................. 38
8.2.2 Levels of service demand ........................................................................................................................ 40
9.0 Good Practice .............................................................................................................................................. 41
9.1 Preventative Approach................................................................................................................................... 41
9.1.1 Ante-natal and post-natal home visiting ................................................................................................ 41
9.1.2 School health promotion programmes ................................................................................................... 41
9.2 Assets-based approach .................................................................................................................................. 41
9.2.1 Social capital ........................................................................................................................................... 41
9.2.2 Five Ways to Wellbeing ........................................................................................................................... 42
9.3 REACH – Routine enquiry about adversity in Childhood ................................................................................ 43
9.4 Youth Mental Health First Aid (YMHFA) ......................................................................................................... 43
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Children and Young People’s Emotional Health and Wellbeing
10.0 Current Services/initiatives ........................................................................................................................ 44
10.1 Service provision ...................................................................................................................................... 44
11.0 Gaps........................................................................................................................................................... 45
11.1 Measurements of mental/emotional health and wellbeing ........................................................................ 45
11.2 Current investment in emotional health and wellbeing .............................................................................. 45
11.3 Transition to Adult Services ......................................................................................................................... 45
11.4 Opportunities ............................................................................................................................................... 46
12.0 Value for money ........................................................................................................................................ 46
13.0 Involvement............................................................................................................................................... 47
13.1 Engagement ................................................................................................................................................. 47
13.1.1 Health Watch Survey ............................................................................................................................ 47
13.1.2 Engagement work with children and young people on early intervention service provision .............. 47
13.2 What Young People Told Us ......................................................................................................................... 48
13.2.1 Background ........................................................................................................................................... 48
13.2.2 Objectives ............................................................................................................................................. 48
13.2.3 Methodology ........................................................................................................................................ 48
............................................................................................................................................................................. 49
13.2.4 Commissioned Projects......................................................................................................................... 49
13.2.5 Engagement Activities .......................................................................................................................... 53
13.2.6 Analysis ................................................................................................................................................. 54
13.2.7 What children, young people and parents say about emotional health and wellbeing – findings from
the engagement activities ............................................................................................................................... 56
14.0 Discussion and Recommendations ............................................................................................................. 68
14.1 Discussion ..................................................................................................................................................... 68
14.2 Recommendations ....................................................................................................................................... 72
15.0 Existing strategies plans and policies ......................................................................................................... 75
Where to find out more ..................................................................................................................................... 81
References......................................................................................................................................................... 82
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Children and Young People’s Emotional Health and Wellbeing
Acknowledgements
Many thanks to all those who contributed to this document including the following:
Home Start
Children’s Centres
Primary & Secondary Schools across Blackburn with Darwen
Blackburn College
Inter Madrassah Organisation
James Street Project
Night Safe
Blackburn Youth Zone
Blackburn Central High School with Crosshills
Educational Psychologists-Blackburn with Darwen Borough Council
Young Carers – Child Action North West
T.H.O.M.A.S.
Lifeline
Care Leavers
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Children and Young People’s Emotional Health and Wellbeing
1.0 Introduction to the ISNA
1.1 Background
This Integrated Strategic Needs Assessment (ISNA) is intended to capture the key issues and challenges
for the emotional health and wellbeing of children and young people 0-25 years living in Blackburn
with Darwen. The purpose of the ISNA is to articulate current and future health and social care needs
and develop a shared understanding that will contribute to local health and wellbeing strategies,
programmes and commissioning approaches.
The ISNA document is available in two formats - this full version and a summary ‘ISNA lite’ version
which may be accessed here.
1.2 Introduction
Children and young people’s emotional health and wellbeing is an important public health issue.
Around 10% of all children between ages of 5 and 16 years living in Blackburn with Darwen will have a
diagnosable mental health disorder. This equates to 1 in 10 for all school aged children, or
approximately three children in every average sized classroom. Many more children and young people
will have low level mental health problems that will never come to the attention of specialist services.
In addition there are emerging new trends such as self harm, legal highs, excessive gaming and cyber
bullying that threaten young people’s emotional wellbeing as well at those already known, such as
alcohol and drug misuse.
The recent economic downturn means that many families are facing daily challenges of
unemployment, and food poverty. Having a parent with low mental wellbeing is one of the biggest risk
factors for children’s emotional health. Outcomes are bleakest for those in the most deprived
communities. For many children and young people, problems associated with poor social, emotional
and psychological health will continue into adulthood. A recent study has shown that children exposed
to four or more adverse childhood experiences (ACE’s) including household dysfunction such as
parental substance abuse, divorce/separation, and physical, emotional or sexual abuse are significantly
more likely to have lower life satisfaction and mental wellbeing than individuals not exposed to such
experiences in childhood.1 The longer term social and economic burden associated with poor mental
health is significant, with associated costs in providing mental health services, loss of productivity and
reduced quality of life of those affected. There is robust evidence that early help in childhood can
prevent later physical and mental health problems and prevent inter-generational transmission of
social and emotional problems.
The government’s strategy No Health without Mental Health (2011)2 focuses on the importance of
‘parity of esteem.’ This values good mental health alongside good physical health from early childhood
upwards, thereby setting the foundations for healthy behaviours that extend well into adulthood. The
case for more preventative and early help for children and young people is also set out in the Annual
Report of the Chief Medical Officer (CMO, 2012) ‘Our Children Deserve Better: Prevention Pays’3. A
central theme of the report is supporting children to develop emotional resilience to deal with life’s
adversities, and taking a life course perspective to improve their health and wellbeing outcomes.
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Children and Young People’s Emotional Health and Wellbeing
In Blackburn with Darwen we know that improving children and young people’s emotional health and
wellbeing requires more than just focussing on poor mental health. An important question for this
Integrated Strategic Needs Assessment (ISNA) is how can we offer ‘proportionate universalism’ - that is
improving the lives of all with proportionately greater resources targeted at more disadvantaged
groups4. The Children’s Partnership Board has prioritised four areas: (i) Adverse Childhood Experiences
(ACE); (ii) Emotional Health and Wellbeing; (iii) Early Help and (iv) Parenting Skills. Furthermore the
Early Intervention Foundation (EIF) is supporting the Early Help priority and the whole approach
recognises the need to offer ‘upstream’ prevention activities to improve the emotional health and
wellbeing of all our children and young people.
The current national and local focus on ‘wellbeing’ also offers a fresh perspective emphasising the
value of positive emotional health. Good self-reported wellbeing such as happiness or life satisfaction
is one of the strongest predictors of healthier lifestyles, participation in social activities, reduced risk
taking behaviours, good family relationships and positive social networks.5 The New Economics
Foundation (2008) developed the ‘Five ways to wellbeing’ as a set of evidence-based messages to
promote positive mental health and wellbeing.6 The 5 ways is an assets-based approach that values
local strengths, resilience, knowledge and the social capital held within communities.
Partners across Blackburn with Darwen through the Health and Wellbeing Board are well placed to
work collaboratively to improve wellbeing of our children and young people. This can be achieved by
working together to influence the wider determinants of emotional and mental health including
education, housing, the environment and ensuring fairness for all. Improving mental health and
wellbeing is a key principle underpinning our Health and Wellbeing Strategy. We have set out to
understand further the emotional health and wellbeing needs of children and young people through
this Integrated Strategic Needs Asessment. The following section describes the approach we have
taken in Blackburn with Darwen.
1.2 Integrated Strategic Needs Assessment (ISNA)
Under the Health and Social Care Act (2012) local authorities and clinical commissioning groups (CCGs)
are required through their Health and Wellbeing Boards to undertake a Joint Strategic Needs
Assessment (JSNA).7 The purpose of the JSNA is to articulate current and future health and social care
needs and assets and plan how these will be met. In Blackburn with Darwen this process is known as
an Integrated Strategic Needs Assessment (ISNA). The commissioning of this ISNA is a clear
commitment to understanding the emotional and mental health needs of children and young people
living in the borough. The approach will balance identifying levels of local need while recognising the
resilience and strengths present in local communities.
The promotion of mental health and wellbeing is a principle underpinning the borough’s Health and
Wellbeing Strategy (2012-15).8 This ISNA will further develop the shared understanding of children
and young people’s emotional health and wellbeing issues and will contribute to relevant local
strategies, programmes and commissioning approaches.
The ISNA begins by setting out the scope and methodological approach taken. This is followed by a
definition of children and young people’s emotional health and wellbeing with a description of the
various terminologies in common use around mental health issues. National and local datasets are
presented for different stages of childhood and adolescence together with a discussion around the
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Children and Young People’s Emotional Health and Wellbeing
limitations of the available information. This is followed by an overview of what young people have
told us is important to them in terms of their emotional health and growing up in Blackburn with
Darwen.
Listening to the voices of children and young people both to validate their views and to shape services,
is an important theme set out in the CMO’s Report (2012) and has been central to the development of
this work.3 A number of local engagement activities were organised and to date over 250
conversations have taken place with children and young people living in Blackburn and Darwen. This
has ranged from focus groups with parents in local children’s centres right through to discussions with
some of our most vulnerable young people such as the homeless and those living with addictions.
What is clear is that regardless of their personal circumstances all children and young people value the
opportunity to feed back on issues that are important to them. It is essential that we commit to listen
and talk to young people and report back to them on what has changed. The engagement section of
this document summarises the results of those discussions with links to commissioned reports and
activities.
Finally concluding remarks are presented with key recommendations for health and wellbeing
partners.
2.0 Methods & Project Management
2.1 Accountability
A project steering group was established to oversee the development of the ISNA. The group chaired
by the Director of Children’s Services of Blackburn Council established the scope of the ISNA detailed
below. The recommendations will be developed in consultation with members of the Children’s
Partnership Board reporting to the Health and Wellbeing Board.
2.2 Scope
The project steering group determined the scope for the ISNA. The aim of the ISNA was to identify key
issues relating to the emotional health and wellbeing of children and young people aged 0-24 years
living in Blackburn with Darwen. This age-range is recommended in the CMO Report (2012) and by the
World Health Organisation3. The age range was further sub divided into age strata including 0-5 years,
primary school age children, secondary school age children, 16-18 years and 19 -24 years. The
steering group also agreed that a key part of the ISNA would be to engage with children and young
people from specific socio-demographic groups of interest and vulnerable or ‘hard to reach groups’
including looked after children, homeless young people and those known to drug and alcohol services.
Consideration was also given to the nine protected groups under the Equality Act (2010). The
protected groups include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Age
Disability
Gender reassignment
Marriage and civil partnership
Pregnancy and maternity
Race
Religion and belief
Sex/Gender
Sexual Orientation
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Children and Young People’s Emotional Health and Wellbeing
2.3 Literature Review
A literature review was carried out using a search of electronic databases, including Google Scholar,
Medline and NHS Evidence using the following terms:

Terms relating to children and young people:
(child* OR young person OR young people OR youth OR adolescent OR teen*)

Terms relating to emotional health and wellbeing:
(emotional adj. health OR mental health OR mental health disorder OR wellbeing)
Criteria for inclusion were information sources written in English published from 2004 onwards. Other
relevant material was located using websites of national bodies and charities including: Public Health
England, Department of Health, National Institute of Health and Clinical Excellence (NICE),
YoungMinds, Mental Health Foundation.
Relevant literature from the various sources were used to inform different subsections of the ISNA.
2.4 Engagement
Engaging with children and young people was fundamental in developing this ISNA. Full details of the
engagement methodology and activities are set out in section 13.2 ‘What young people told us’.
3.0 Defining the issue
The focus of this ISNA is on emotional health and wellbeing for children and young people. There are
many different concepts and definitions of emotional health and wellbeing. Many of these offer
slightly different perspectives often relating to specific disciplines or professions such as psychology,
social policy and sociology. In the wider literature the term emotional health is often used
interchangeably with mental health.
For the purposes of this ISNA the term emotional health and wellbeing will be used to refer generally
to all aspects of mental health. The document will also make reference to mental illness and mental
health disorders amongst children and young people, which relate to specific conditions and
classifications of mental health diagnoses and are discussed in more detail below.
This ISNA
recognises the importance of covering a wide scope - from prevention and early intervention activities
right through to specialist treatment provision. Commonly used definitions and concepts for emotional
and mental health are discussed below:
3.1 What is emotional health and wellbeing?
Emotional health and wellbeing can be described as:
“A positive sense of wellbeing which enables an individual to be able to function in society and meet
demands of everyday life; people in good mental health have the ability to recover effectively from
illness, change or misfortune.”
‘Being able to develop psychologically, emotionally, intellectually and spiritually; initiate, develop and
sustain mutually satisfying personal relationships; use and enjoy solitude; become aware of others
and empathise with them; play and learn; develop a sense of right and wrong; resolve (face)
problems and setbacks and learn from them.’
Mental Health Foundation, 19999
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Children and Young People’s Emotional Health and Wellbeing
These definitions emphasise the importance of positive regard for good mental health with resilience
to deal with life’s ups and downs. For some time social research and policy has focused on identifying
mental ill health or deficits and responding to those needs with expensive public services. More
recently attention has turned to asset based approaches recognising that individuals and communities
have strengths, knowledge and social connections that can be mobilised for improved mental health
outcomes.
Attributes or characteristics of emotional health and wellbeing typically include good self-esteem,
being in control, being healthy and secure.10 As part of the engagement work for this ISNA, children
and young people living in Blackburn with Darwen were asked what emotional health and wellbeing
means to them:
‘Emotional health and wellbeing means being safe, having good physical health, being active, having
close bonds with family and pets and strong social connections with friends and community. It also
includes having positive behaviours and emotions, having confidence, attaining personal goals and
having a faith.’
Report of primary and secondary school aged children
The views of local children and young people highlight that emotional health is more than just the
absence of mental illness, supporting the definitions as set out by the Mental Health Foundation
(1999)4. It encompasses aspects of health, friends, family and community. The burgeoning field of
public mental health recognises the importance of influencing the wider social determinants such as
housing, education, and the environment in promoting good mental health across the life course. This
means that giving children the right platform to develop sound emotional, physical and social skills will
enhance their life chances and help avoid the human and economic costs associated with adverse
childhood and adult experiences.
Children’s wellbeing is central to that of society as a whole. Promoting children’s wellbeing is not
only important in order for children to have a good childhood, but also as a solid foundation for their
future wellbeing as adults. In order to achieve this goal it is vital that we understand the key factors
that affect children’s lives.
Children’s Society 2012
3.2 Mental illness and mental disorders
Mental illness ranges from day-to-day worries to serious long term conditions. Mental illness is a
prominent cause of disability, is often linked to other chronic diseases and unhealthy lifestyles with
significant costs to health and welfare services. Most mental health problems start in childhood and
adolescence. Estimates predict that around 50% of mental illness in adult life starts before the age of
15 years, and 75% before before age 25 years11, making a strong case for efforts to be directed at
early years support for vulnerable children and their families:
“Most mental illness begins before adulthood and often continues through life. Improving mental
health early in life will reduce inequalities, improve physical health, reduce health-risk behaviour and
increase life expectancy, economic productivity, social functioning and quality of life. The benefits of
protecting and promoting mental health are felt across generations and accrue over many years.”
No health without public mental health2
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Children and Young People’s Emotional Health and Wellbeing
The diagnosis and classification of mental health disorders is important to deliver appropriate clinical
services and is an important issue for affected individuals. Common mental disorders in children and
young people include: conduct disorder depression, eating disorders (anorexia nervosa/bulimia
nervosa), anxiety disorders and hyperkinetic disorders. Other mental health issues such as self
harmmay be symptoms or expressions of underlying emotional or mental distress.
4.0 Who is included in this ISNA?
There are various arbitrary age-groups used to define significant life stages for children and young
people. Evidence states that emotional development continues well into the early twenties. As such
this ISNA will adopt the age range of 0 to 24 years which is in line with recommendations set out by
the CMO report (2012) and the World Health Organisation.3
Health and social care services are delivered predominantly on a person’s chronological age and not on
levels of their emotional development and intelligence. This can present significant challenges not
only for children who are not emotionally attuned to their chronological age but also for young people
transitioning to adulthood. Young people’s services may cease typically at 16 or 18 years of age.
However adult services are often either not available or are not appropriate to the emotional stage of
the young person’s development. It is very important for services to remain responsive during the
transitional stage and consider differing levels of emotional maturity for young people.
The ISNA will consider children and young people’s emotional health and wellbeing in terms of the
following chronological age bandings and significant transition points, but recognises that emotional
intelligence and maturation levels for children and young people may be different at different stages:




0-4 years (early years)
5-11 years (primary school aged children)
12-16 years (secondary school aged children)
16-24 years (further education, employment)
Maternal emotional health and wellbeing will also be considered within the document because this is
vital for babies and the early years agenda. The study also takes into account the needs of specific
vulnerable groups known to be at increased risk of poor emotional and mental health including lookedafter children and young offenders. These have been identified from the literature review and and
also with reference to the nine protected groups of the Equality Act (2010).
5.0 Why is this issue highlighted?
Children and young people who are emotionally well will have stronger social networks, engage in
fewer risk taking behaviours, are more active, have better educational achievement and cope with
adversities better. Good social relationships at home and at school are important predictors of
wellbeing and help build resilience and positive health behaviours that extend well into adulthood.
Conversely we know that poor emotional health and wellbeing is linked with a range of personal social
and economic costs. Many mental health problems start early in life with half of those with lifetime
mental health problems first experiencing symptoms by the age of 14 years and three quarters by their
mid-20’s.11
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Children and Young People’s Emotional Health and Wellbeing
It is therefore vital to understand emotional health and wellbeing issues amongst children and young
people and we need to understand what resilience children and young people need to flourish and
what support we need to give when a mental health diagnosis is made.
Over recent years improving positive mental health has become increasingly important for national
and local mental health and social care policies. The following sets out some of the national and local
policies and strategies driving this agenda, along with current clinical guidelines and a brief overview
of issues relating to measuring emotional health and wellbeing.
5.1 National Context
The Marmot Review ‘Fair Society, Healthy Lives’ (2010)4 outlines the importance of ‘giving every child
the best start in life’ to reduce health inequalities across the life course and recognises that early child
development has life-long health and social consequences and therefore support is most important in
the early years.
The foundations of virtually every aspect of human development - physical, intellectual and
emotional - are laid in early childhood. What happens during those early years, starting in the
womb, has lifelong effects on many aspects of health and wellbeing, from obesity, heart disease and
mental health, to educational achievement and economic status. …….. Later interventions, although
important, are considerably less effective if they have not had good early foundations.
The Marmot Review (2010) –Fair Society, Healthy Lives4
The government’s strategy ‘No Health without Mental Health’ (2011) recommends taking a ‘cradle to
grave’ approach to promote mental health and wellbeing.2 In practice, this means supporting
wellbeing across the life course and also ensuring people with mental illness are identified and have
access to high quality services. A core theme of the strategy is the importance of early intervention
centreing on preventing and addressing mental illness in children and young people. The strategy also
emphasises the need for ‘parity of esteem’ which means mental health is valued as importantly as
physical health. There is robust evidence to show that physical and mental health are interdependent. Poor physical health is often associated with poorer mental health and vice versa. Good
wellbeing can be supported by physical exercise and other esteem-building activities.
In her 2012 annual report Our Children Deserve Better: Prevention Pays the Chief Medical Officer made
a strong case to advocate for more preventative and early help support for children and young
people.3 The report emphasises helping children to build emotional resilience to deal with life’s
adversities, and taking a life course approach to improve their health and wellbeing outcomes.
Listening to the voices of children and young people is a key theme of the report and an important
aspect guiding this ISNA.
The concept of ‘proportionate universalism’ - improving the lives of all with greater resources targeted
at more disadvantaged groups - has been highlighted (Marmot Review 2010; CMO, 2012).4,3 This
means that finite resources are targeted at groups identified as being most in need whilst at the same
time encouraging preventative approaches to support emotional health and wellbeing at the wider
population level.
More emphasis has also started to be placed on the importance of involving individuals, groups and
communities to improve wellbeing. Using an approach that values assets, identifies local strengths,
resilience, knowledge and social capital of communities can provide a solution-focused story of
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Children and Young People’s Emotional Health and Wellbeing
wellbeing. In 2008 the Government Office for Science published findings from the Foresight project on
Mental Capital and Wellbeing.12 As part of this project the New Economics Foundation (NEF)
developed the 5 ways to wellbeing as a set of evidence-based activities or messages that promote
positive mental health and wellbeing.6 Since then the ‘5 ways’ have been used by many organisations
and groups to frame their approaches around wellbeing.
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Children and Young People’s Emotional Health and Wellbeing
Figure 5.1 The Five Ways to Wellbeing
Connect…
With the people around you. With family, friends, colleagues and neighbours. At home, work,
school or in your local community. Think of these as the cornerstones of your life and invest
time in developing them. Building these connections will support and enrich you every day.
Be Active…
Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance.Exercising makes you feel
good. Most importantly, discover a physical activity you enjoy and that suits your level of
mobility and fitness.
Take Notice…
Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons.
Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be
aware of the world around you and what you are feeling. Reflecting on your experiences will
help you appreciate what matters to you.
Keep Learning…
Try something new. Rediscover an old interest. Sign up for that course. Take on a different
responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food.
Set a challenge you will enjoy achieving. Learning new things will make you more confident as
well as being fun.
Give…
Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a
community group. Look out, as well as in. Seeing yourself, and your happiness, linked to the
wider community can be incredibly rewarding and creates connections with the people around
you.
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Children and Young People’s Emotional Health and Wellbeing
5.2 Local Context
There are several key local strategies and policies that consider the emotional health and wellbeing of
children and young people living in Blackburn and Darwen. These are considered in more detail below.
Blackburn with Darwen Health and Wellbeing Strategy (2012-2015) sets out a 3-year vision for
improving health and wellbeing for people living in the Borough.13 In developing the strategy the
Health and Wellbeing Board adopted ‘no health without mental health’ as one of the underpinning
principles. This recognises that good mental health sets the foundations for all aspects of health and
wellbeing. Another defining principle is that an assets-based approach should be taken utilising the
local strengths, skills and knowledge indigenous to local people and communities.
The Health and Wellbeing Strategy takes the Marmot lifecourse approach incorporating ‘Best Start for
Children’. A key outcome of Programme Area 1 of the Strategy is ‘to improve the emotional and
psychological wellbeing of children and young people’. There is also a commitment to integrating the
Five Ways to Wellbeing (figure 5.1) through out the planning and commissioning of community health
and wellbeing programmes.
The Early Help Strategy has been developed by the Children’s Partnership Board to support the Health
and Wellbeing Board achieve its ambitions for children and young people set out in Programme Area
1.14
Children and families are key to the strategy, and multi agency work will ensure earlier
identification and support for unmet needs and low level problems, as well as ensuring services are
targeted at families most at risk.
5.3 Clinical Guidelines and briefings
The National Institute of Health and Clinical Excellence (NICE) published a local government briefing on
‘Social and emotional wellbeing for children and young people’ (2013) which describes how children
and young people’s emotional health and wellbeing skills are enhanced through building self-esteem
and self-efficacy, emphasises the importance of early help and includes ante-natal and post natal
home visiting particularly for vulnerable children and their families.15 This is particularly pertinent as
responsibilities for health visiting and the 0-5 years element of the Healthy Child Programme transfer
to local authorities in 2015. In addition the briefing also recommends that ‘whole school approaches’
are adopted for developing emotional health and wellbeing across primary and secondary school
establishments.
NICE have produced a number of guidelines to support various aspects of children and young people’s
emotional health and wellbeing. These are outlined in more detail in Existing strategies plans and
policies.
5.4 Measuring emotional health and wellbeing
In general there is a lack of data that can be used to describe patterns of emotional health and
wellbeing for children and young people. Measurements tend to focus on high end needs for example
emergency admissions for self-harm. This is why significant engagement work was undertaken with
various groups of children and young people living in Blackburn with Darwen. For more information on
the engagement work see: What Young People Told Us.
The following section outlines some of the key issues around measuring mental health and emotional
wellbeing.
14
Children and Young People’s Emotional Health and Wellbeing
5.4.1 Measuring mental health
The last comprehensive national survey of mental health issues amongst children and young people
was undertaken in 2004.16 In the report ‘Overlooked and Forgotten’ the Children and Young People’s
Mental Health Coalition raised concerns around this survey still being used to estimate current
prevalence of mental health illness.17 Since the survey was carried out there has been a significant
economic downturn and rise in use of social media, all of which may have positive and negative effects
on children and young people’s emotional health and wellbeing. The report recommends that new
data should be in place to inform commissioning for mental health needs for children and young
people. In the absence of more up- to- date data the 2004 survey has been used to estimate
prevalence of mental health disorders in Blackburn with Darwen.
5.4.2 Public Health Outcomes Framework
The Public Health Outcomes Framework provides strategic direction and a range of indicators which
Health and Wellbeing Boards can use to benchmark progress. The framework has 4 domains:
improving the wider determinants of health; health improvement; health protection and health care
and preventing premature mortality. Under the health improvement domain there are several
indicators relating to subjective wellbeing, although these are restricted to individuals aged 16 years
and above and therefore provide only part of the overall picture. As part of the ONS Measuring
National Well-being (MNW) programme, a new set of measures of national wellbeing for children aged
0-15 years is currently being developed.
5.4.3 Measuring wellbeing
Wellbeing can be measured across two dimensions: subjective or objective wellbeing.18
Subjective wellbeing relates to how people think and feel about their own wellbeing and includes
life satisfaction (evaluation), positive emotions (hedonic) and whether life is meaningful
(eudemonic).
Objective wellbeing can be measured through self-report (e.g. asking about a specific health
condition) or through objective measures (e.g. mortality rates and life expectancy).
The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) is a validated tool used to assess positive
mental wellbeing for people aged 13 years and above. WEMWBS is a scale of 14 positively-worded
items with 5 possible responses covering hedonic and eudemonic aspects of wellbeing. The scale has
been incorporated in the North West Mental Wellbeing Survey 2012/2013 to provide estimates of
wellbeing at the regional and local level.19 In addition a number of services use the tool to track the
impact of interventions on individuals’ wellbeing. A number of commissioned services in Blackburn
with Darwen use WEMWBS as an outcome monitoring tool. However there is no overall consistent
approach to measuring wellbeing as other services use different methods or tools.
15
Children and Young People’s Emotional Health and Wellbeing
6.0 Size of the problem
Prevalence refers to the proportion of a disease or condition in a population at a given point in time.
The following section sets out key information relating to (1) mental health problems and (2)
wellbeing, for children and young children at the following life stages:




Maternal mental/emotional health and wellbeing
Early years (0-5 years)
Primary and secondary school aged children (5-16 years)
Young people (16-24 years)
6.1 Maternal mental/emotional health and wellbeing
The following sets out information relating to emotional and mental health during pregnancy:
KEY ISSUES MATERNAL MENTAL/EMOTIONAL HEALTH AND WELLBEING




10-15% women experience mental health problems during/ after pregnancy,mostly anxiety
and depression.20
Locally this equates to 230-345 women in Blackburn with Darwen (based on 2012 data).
Maternal mental health problems are associated with increasing risk of birth complications,
stillbirth and low birth weight babies along with longer term consequences for the child’s
emotional and mental health.21
Pregnant women tend to have higher rates of self-reported wellbeing compared with
mothers of very young children aged 0-2 years. Evidence indicates that wellbeing declines
for some women following birth, particularly for those who have difficulties adjusting
physically and emotionally to motherhood, and also women with few social connections.22
6.1.1 Maternal mental health
Pregnancy, birth and the postnatal period is a time of significant social and psychological change for
women as they adapt to their roles as mothers. Supporting emotional health and wellbeing during this
time is increasingly being recognised as being as important as looking after physical health.
Mental health problems are common in pregnancy as they there are at other times of life. The antenatal period is important as a time of ‘transition to parenthood’ as important psychological changes
occur during this time.23 Studies have found that there is increased risk of depressive symptoms and
interpersonal problems in the first five weeks following giving birth.21
Maternal mental health problems in the ante-natal or post-natal period can have significant long term
effects on children’s mental health and wellbeing in the early years and adolescence. Antenatal
depression and anxiety are linked to higher levels of emotional and behavioural problems in children at
ages 3-5 years.24 Fathers’ mental health also can influence children’s emotional health. Paternal
depression during pregnancy is linked to children’s emotional difficulties in the early years. [
6.1.2 Maternal Wellbeing
Measures of maternal emotional wellbeing tend to focus on mental health problems or deficits
assessed during antenatal and post natal visits. There is some data on subjective maternal wellbeing
from the Lifecourse Tracker Research Study - a large-scale survey of pregnant women and mothers of
0-2 years. Self-reported levels of wellbeing were found to be higher amongst pregnant women
16
Children and Young People’s Emotional Health and Wellbeing
compared with mothers of very young children aged 0-2 years (78% vs. 66% respectively).22 Factors
contributing to higher levels of wellbeing included: having a planned pregnancy, higher socio-economic
status and women having positive perceptions of their own health and wellbeing during pregnancy.
6.2 Early years 0-5 years mental/emotional health and wellbeing
KEY ISSUES 0-5 YEARS
 Approximately 19.6% of children in England aged 2-5 years have a mental health
disorder.25
 1,170 children aged 2-5 years living in Blackburn with Darwen have or are likely to have a
mental health disorder based on these prevalence estimates.
6.2.1 Early years mental health
There is relatively little data on prevalence rates for emotional and mental health issues in pre-school
age children. The estimated prevalence rate of mental health problems in children aged 2-5 years is
19.6% (Green et al 2004).16 By applying this estimate to the mid-year population estimates for 2012 it
can be can be predicted that approximately 1,770 children aged 2-5 years living in Blackburn with
Darwen will have a mental health disorder.
Mental health problems in early childhood can be predictive of mental health problems later in life.
Retrospective studies have found that some adult mental health disorders can be linked to problems
observed in children as early as three years of age.26 It is also important to observe that not all children
with difficulties early on have problems in adulthood. However evidence indicates that difficulties in
early childhood can be predictive of mental health problems later in life (these include anti-social
behaviour, alcohol, depression and suicide). Therefore early identification and support is beneficial.
6.2.2 Early years wellbeing
Conventionally concepts of wellbeing for very young children have been assessed through proxy
measures such as birth weight, mortality rates and levels of deprivation. However it can difficult to
equate such measures with an estimate of wellbeing. The Millenium Cohort Study found that in 7
year-olds, self-reported wellbeing was not adversely affected by living with one parent, having a
disabled parent or living in social housing.27
A number of factors known to affect wellbeing in very young children are outlined in section 7.1.
17
Children and Young People’s Emotional Health and Wellbeing
6.3 Primary and secondary school aged children (5-16 years) mental/emotional
health and wellbeing
KEY ISSUES 5-16 YEARS








10% of children have a clinically significant mental health disorder such as depression,
anxiety and conduct disorders.25
Boys aged 5-10 years are more than twice as likely as girls to have mental health disorder.
Emotional disorders are higher amongst girls particularly around in adolescence. Sub-clinical
emotional problems e.g. depression and anxiety, amongst teenage girls are higher than
boys.
Conduct disorders are the largest single group of psychiatric disorders in children and
adolescents, being the main reason for referral to child and adolescent mental health
services (CAMHS).
Around 20% of adolescents will experience a mental health problem, most commonly
depression or anxiety, but many will never come to the attention of professional services.28
Half of adults with a life-time mental illness experience symptoms by the age of 14 and three
quarters before the age of 25.29
National mental health charities are lobbying for a new national survey to establish more
reliable data on children and young people’s emotional and mental health.17
Adolescence is a critical period for emotional and physical development. Subjective
wellbeing declines in the mid-teenage years. In addition physical maturity often precedes
psychosocial maturity. Risk-taking behaviours including smoking and substance abuse often
begin in this period. Therefore special consideration needs to be given to supporting
teenagers at this vulnerable stage of life.
6.3.1 Mental health
There is a lack of prevalence data that can be used to estimate the size of the problem in primary and
secondary school aged children. Current estimates rely on national survey work undertaken a decade
ago (Green et al, 2004).16 The key findings from the 2004 national survey work are set out in Table 6.1.
The CMO Report (2012)3 recommends an annual survey to be commissioned on children and young
people’s mental health including comparisons with other developed countries. This will improve the
evidence base around children and young people’s assets and needs that can be used for the planning
and commissioning of interventions and/or services.
Table 6.1
In children and young people in England aged 5 to 16 years it is estimated that25:






Mental health problems are higher in boys (11.5%) than girls (7.8%).
Children aged 11- 16 years are more likely than those aged 5-10 years to experience mental
health problems
5.8% have clinically significant conduct disorders
3.7% have clinically significant emotional disorders
1.5% have clinically significant hyperkinetic disorders
Three quarters of adult mental health illness have occured by the mid teenage years.
18
Children and Young People’s Emotional Health and Wellbeing
Prevalence of mental health disorders amongst children and young people can be estimated by using
the 2012 mid-year population statistics for Blackburn with Darwen (see figure 6.1). It should be noted
that actual local prevalence rates for mental health disorders may vary due to local socio demographic
factors, as this estimate has not been standardised for deprivation. Therefore the actual prevalence is
likely to be much higher in Blackburn with Darwen. Furthermore these estimates only include
diagnosed cases, and do not include children and young people with sub-threshold symptoms or those
with low emotional wellbeing.
Figure 6.1
Estimated prevalence mental health disorders in children 5-16 years in
BwD 2012
3000
2500
2000
940
1500
490
1000
1475
500
530
970
330
100
250
Emotional
disorder
Hyperkinetic
disorder
Less common
disorder
0
Any mental health Conduct disorder
disorder
55
405
Boys aged 5-16 years
Girls aged 5-16 years
It can be noted from the the prevalence estimates that:



Conduct disorders represent the largest single group of psychiatric disorders in children and
adolescents and are the main reason for referral to CAMHS.
Males are at higher risk than females for conduct and hyperkinetic disorders.
Emotional disorders are higher amongst girls particularly around in adolescence. This is in line
with findings from national wellbeing studies that indicate sub clinical emotional problems
amongst teenage girls are also higher than in boys.
6.3.2 Wellbeing in primary and secondary school aged children
There are currently no national measurements which investigate the emotional wellbeing of children
under the age of 11 years. The Office for National Statistics (ONS) is proposing a new set of measures
of national wellbeing for children aged 0-15 years.30 This is part of the ONS Measuring National Wellbeing (MNW) programme. The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) has now been
validated for use with 13-15 year olds31
Evidence from the Children’s Society indicates that subjective wellbeing (how happy young people rate
themselves) declines in the teenage years, particularly around 14-15 years (see figure 6.2).32 The
decline can be observed across a range of items including family, health and choice. The trend also
19
Children and Young People’s Emotional Health and Wellbeing
seems to follow a U-shape in that wellbeing starts to recover again at around 17 years of age. The
increase is most significant for perceptions around ‘choice’, perhaps reflecting increasing
independence and freedoms as young people approach adulthood.
Figure 6.2 Age Differences for items in The Good Childhood Index: ages 8 to 17
Source: The Good Childhood Report 201332
The charity New Philanthropy Capital (NPC), has devised a multi-dimensional measure of wellbeing.
This has been tested on over 6000 young people and appears to confirm the general picture of
declining happiness as young people go through adolescence (figure 6.3).33 There is also evidence of
gender differences, with teenage girls having lower subjective wellbeing than boys. Teenage girls do
tend to report more sub-clinical emotional problems such as feeling down more frequently than boys.
Factors contributing to this include levels of autonomy and choice, family relationships and personal
appearance.
Figure 6.3 Drop in emotional wellbeing in early
teens, Male v. Female (Well-being Measure, NPC33
Ag
There is strong evidence highlighting the role of sleep
in adolescent development.
Sleep is critically
important for physical, cognitive, and psychological
functioning.
Chronic sleep alteration during
adolescence is associated with poor academic
achievement and psychological wellbeing.34
20
Children and Young People’s Emotional Health and Wellbeing
To inform policy and practice, more understanding is required around the decline in subjective
wellbeing and the important neurological changes that take place in in the teenage years. In the
second decade of life the adolescent brain is still developing and this continues into early adulthood.
Many risk-taking behaviours that have serious consequences for longer term health begin in this
period, including smoking, alcohol and drug use. In addition many of these health-related behaviours
that emerge during adolescence also tend to cluster in certain individuals. For example, young people
who use tobacco are more likely to drink alcohol as well, to be involved in bullying or fighting and to be
injured. Evidence also indicates that clustering is even more likely if the risk-taking behaviour occurs in
early adolescence, rather than after the age of 15 or 16 years. It is important to note that many
studies and surveys of adolescent health focus on older adolescents aged 14 years upwards. Focusing
on younger adolescents aged 10-12 years may help to identify earlier preventative approaches.
It is important therefore that support is reinforced during adolescence. The growing evidence base
indicates the importance of closer nurturing of teenagers through positive parenting and support
offered by schools and other services. Adolescence and the teenage years provide a second chance
for interventions and opportunities to undo damage done in earlier years. 35
6.4 Young people 16-24 years
6.4.1 Mental Heath
The transition from childhood to adulthood is a social construct and is often related more to how
services are configured and funded than chronological age. The pathway to adult is in reality more
dependent on the young person’s individual rate of physical, emotional and psychological maturation.
Neurological studies indicate the brain undergoes significant growth and change in the teenage years.
However, the frontal lobes of the brain, responsible for emotional maturity, impulse control, planning
and memory, are the last areas of the brain to mature - sometimes not until people are in their
twenties. Studies suggest that the combination of rapid brain development and delayed emotional
maturity in teenagers accounts for many behaviours associated with this time of life, including
impulsivity and risk-taking behaviours.36 This period is associated with increased risk of unintentional
injuries, suicide attempts, substance abuse, and many mental health problems. Research indicates
that for 75 % of adults with mental disorders the onset of mental ill health will have occurred by the
age of 24 years.11
6.4.2 Transition issues
For individuals already known to services there is often a gap between service provision aimed at
children and young people and those aimed at the adult population. The transition between children
and adult services is often an imperfect handover. In the first study to follow an identified cohort of
young people crossing the boundary from child to adult mental health services, Singh et al (2010)
reported that a third were not referred on to adult services and a fifth of those referred on were never
seen. Fewer than four per cent were reported to have experienced optimal transition. The study was
relatively small but suggests the need for more data on this topic.37
The transitional stage for young people known to services is important as this stage often coincides
with the time many teenagers are more likely to participate in risk-taking or offending behaviour and
are at greatest risk of mental health problems and low wellbeing.38 Section 7.4 considers groups at
higher risk of mental health problems and low wellbeing in more detail.
21
Children and Young People’s Emotional Health and Wellbeing
6.4.3 Wellbeing
The North West Mental Wellbeing Survey 2012/1319 provides a snapshot of wellbeing for individuals in
the region over the age of 16 years.19 The survey uses a questionnaire format including the seven-item
Warwick Edinburgh Mental Wellbeing Scale (WEMWBS).
The most recent survey undertaken for 2012/13 indicates that Blackburn with Darwen has the lowest
scores for wellbeing compared with other areas in the North West. However it should be noted that
statistical tests were not calculated to infer whether these differences were statistically significant.
The survey also indicates that individuals in the 16-24 age group (for all NW localities) have higher
levels of mental wellbeing than all other age groups. Scores for this age group were significantly higher
than the North West average (see figure 6.4).
Overall evidence suggests that the middle teenage years and adolescence are identified as a risk point
where wellbeing declines and risk-taking behaviours increase. Data from the NW Mental Wellbeing
Survey indicates that wellbeing continues to fluctuate across the lifecourse with higher rates of
wellbeing in the late teens and early 20’s which starts to decline again in middle age.
Figure 6.4 Mean WEMWBS scores by gender and age group 2012/13
Source: North West Mental Wellbeing Survey 2012-13
22
Children and Young People’s Emotional Health and Wellbeing
6.5 Self-Harm
KEY ISSUES

Self-harm is an important public health issue affecting significant numbers of children and
young people. 10-13% of 15-16 year olds have self-harmed but only a fraction of cases are
seen in hospital settings.39

Nationally hospital admissions for self-harm in children have increased in recent years, with
admissions for young females being much higher than admissions for young males. With
links to other mental health conditions such as depression, the emotional causes of selfharm may require psychological assessment and treatment.

A study by Hawton et al (2012) found that rates were higher for females than males,
particularly females aged 15-18 years. Self-poisoning was the most common method with
paracetamol implicated in 58.2% of those cases.

Increases in rates of self-harm have become a worrying trend over recent years. The
national charity ChildLine reported a 41 per cent increase in contacts about self-harm in
2012 - particularly amongst 12 year-olds, which represented the highest increase of all
ages.40

Only one in three teachers reported they were comfortable covering the topic of self-harm
in lessons despite that 97% of young people said self-harm should be addressed in schools.
Self-harm is when an individual intentionally injures or damages their body. It is a way of coping with
or expressing overwhelming emotional or psychological distress. Sometimes the person does intend to
die when they self-harm but more often the intention is a form of punishment to express distress or
relieve tension. There are many ways people can intentionally harm themselves including cutting their
skin, self-poisoning with tablets, substance abuse or deliberate starvation41.
A survey of 15-16 year olds found that just over 13% reported having self-harmed ever and 6.9% had
self harmed within the past year. The survey also indicated gender differences with approximately
10% of girls and 3% of boys self-harming in the previous year.42 Self-harm is thus a serious public
mental health issue.
In 2012/13 the hospital admission rate for self-harm in Blackburn with Darwen for 10-24 year olds was
526/100,000 equating to 156 admissions that year. * This was significantly higher than the average
rate for local authorities in England of 346.3/100, 000 and for the North West 433/100,000.
Hospital admission rates for self-harm in Blackburn with Darwen have been amongst the highest for
local authorities across England between 2010/11 to 2012/13 (figure 6.5). Admission rates in Blackburn
*
It should be noted that the data refer to episodes of admission and not persons. Any indicator based on hospital
admissions may be influenced by local variation in referral and admission practices as well as variation in
incidence or prevalence. Does not include attendance at A&E.
23
Children and Young People’s Emotional Health and Wellbeing
with Darwen have remained fairly stable over the last few years (figure 6.6). It should be noted that
only a fraction of cases are ever seen in hospital settings. 39 Childline has reported a 41% rise in
contacts about self-harm in a single year (2011/12-2012/13).
Rates (DSR) self harm per 100 000
Hospital admission rates for England- self-harm (10-24 years) -2010/11 2012/13 (pooled data)
1000
800
600
Blackburn with Darwen
561.9/100 000
Figure 6.5
400
200
0
Average rate - England
Figure 6.6
Directly Standardised
Rate/100 000
Hospital admissions rates - self harm 10-24 years BwD 2007/08-2012/13
580
573.7
570
566.1
561.9
560
550
544.3
540
2007/08-2009/10
2008/09-2010/11
2009/10-2011/12
2010/11-2012/13
24
Children and Young People’s Emotional Health and Wellbeing
Hospital Episode Statistics (HES) data also indicates that nationally, A & E attendances for self harm are
greatest around midnight, and highest of all on Friday and Saturday nights (Figure 6.7)43
Figure 6.7 Hospital Episode Statistics NHS Accident and Emergency Statistics (England) 2011-1243
A&E attendances by day and hour of arrival (Self-harm), 2010-11 and 2011-12
Percentage of attendances (per day)
1.4%
2010-11
2011-12
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
00:00
03:00
06:00
09:00
12:00
15:00
18:00
21:00
0.0%
Monday
Tuesday
Wednesday
Thursday
Friday
Day and hour of arrival
Saturday
Sunday
It is also interesting to note that in Blackburn with Darwen, there are more A&E attendances for selfharm in August than in any other month. (Figure 6.8)
Percentage of all
attendances
Figure 6.8 Percentage of attendances by month at Blackburn A&E for self-harm October 2009 to
14
12
10
8
6
4
2
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
September 2013 Source:- TIIG44
25
Children and Young People’s Emotional Health and Wellbeing
6.6 Inpatient Admissions for Mental Health Disorders
In 2012/13 the inpatient admission rate for mental health disorders amongst children and young
people in Blackburn with Darwen was 129.4 per 100,000 population.* This rate was significantly worse
than the England average (87.6/100,000), and was amongst the highest admission rates for any local
authorities that year (figure 6.9).
Figure 6.9
Blackburn with
Darwen 129.4/100
000
Inpatient admission rate for mental health disorders per 100,000
population age 0-17 years 2012/13
450
350
250
150
50
-50
Average rate-England
Average Rate-NW
Table 6.2 below shows annual rates for inpatient admissions for mental health disorders for children
and young people. Admissions are for children and young people with a primary diagnosis of mental
health disorder based on strict clinical criteria. The data shows that there is year-to-year variation for
inpatient admissions.
It is important to reiterate that 1 in 10 children have a clinically diagnosable mental health problem
with around half experiencing symptoms by the age of 14 years.
Self-harming and substance misuse are more common in children with a mental health disorder, with
over 10% of 15-16 year olds self-harming.
Table 6.2
Year
No. of admissions in
Blackburn with
Darwen
2010/11
38
Rate per 100,000
population in
Blackburn with
Darwen
99.2
Rate per 100,000
population-England
average
2011/12
29
75.0
91.3
2012/13
50
129.4
87.6
93.7
Source: Public Health England
*
This equates to 50 admissions for that year.Note that the data refers to admissions not individuals.
26
Children and Young People’s Emotional Health and Wellbeing
6.7 Suicide
6.7.1 Child suicides
When analysing suicide statistics for those aged 15 years or over, it is usual to include deaths by injury
or serious poisoning where the person’s intent to kill themselves is less than certain (‘undetermined’).
However it is considered inappropriate to make any such assumptions in the case of a child under 15
years, so the suicide figure for this age-group only include those cases where intent has been firmly
established.45,46 According to this strict definition, there were only six such deaths in children under 15
years in 2012 in the whole of England and Wales, and figures for individual local authorities are not in
the public domain.
6.7.2 Young people aged 15 years +
The youngest age-group for which suicide statistics are routinely published at the local authority level
is 15-34 years, which goes beyond our definition of ‘young people’. The rules on disclosure have
recently been relaxed, and annual counts at the local authority level can now be found in the public
version of the HSCIC Indicator Portal (https://indicators.ic.nhs.uk/webview/). By either definition,
there was one (male) suicide in the 15-34 year age-group in Blackburn with Darwen in 2012.
For 2010-2012 as a whole, the rate of suicide or injury undetermined in Blackburn with Darwen was
9.0 per 100,000 persons aged 15-34 years, which compares with an England average of 7.8 per
100,000. However, the local rate is clearly based on very small numbers, and this difference is not
statistically significant.
6.7.3 Suicidal behaviour and bullying
Recent US research indicates that there is a strong association between bullying and suicidal
behaviours47. One study found that in secondary school-aged children, suicidal ideation and attempts
were three to five times higher for bully victims and perpetrators compared with non-involved youth48.
Another study found that children and young people involved in bullying either as victims or
perpetrators were also more likely to have a history of self-harm within the previous year and greater
emotional distress49. Factors which seem to protect young people from suicidal behaviour include
good relationships with parents, caring friendships, physical activity and neighbourhood safety. The US
Centers for Disease Control and Prevention (CDC) has outlined a number of evidence-based
approaches to prevent suicidal behaviour amongst young people. These include promoting individual
coping strategies, support for parents, and whole school approaches to providing positive climates for
emotional health27.
6.7.2 Suicidal behaviour and parenting
A large German study involving 44,610 young people examined the link between parenting style in
childhood and suicidal behaviour in adolescence. Young people exposed to ‘authoritative’ parenting
styles in childhood which are high in warmth and control were less likely to report suicidal behaviour.
Individuals exposed to ‘rejecting –neglecting’ parenting styles which is low for both warmth and
control are more likely to report suicidal behaviours. Other significant factors associated with suicidal
behaviour were ADHD, female gender, smoking, binge drinking, absenteeism, and parental separation.
The study highlights the importance of parenting styles and subsequent mental health outcomes in
teenagers. These findings not only apply to suicidal behaviour but also to other risk-taking behaviours.
27
Children and Young People’s Emotional Health and Wellbeing
There are therefore important implications for population-based parenting and early intervention
programmes.50
6.8 Cost
6.8.1 The costs of mental health problems
Emotional and mental health problems are common in children and young people. Moreover they can
be long-lasting with costs to both society and the individual.
The total cost to society of mental health problems has been estimated at £105 billion per year, and
treatment costs are expected to double over the next 20 years. Strikingly the annual UK cost of
obesity is £15.8 billion and the annual UK cost of cardiovascular disease is £30.7 billion. However only
11.1% of the NHS budget- or £11.9 billion - was spent on NHS services to treat mental health problems
during 2011/12. 51
For children and young people with mental health problems, estimated costs of treatment are
between £11,030- £59,130 annually per child. These costs include service provision (education, social
services and youth justice) and direct costs to the family in terms of the child’s illness.3
“The annual cost of severe antisocial behaviour in childhood in the UK is substantial and widespread,
involving several agencies, but the burden falls most heavily on the family. Wider uptake of evidencebased interventions is likely to lead to considerable economic benefits in the short term, and probably
even more in the long term.” British Journal of Psychiatry52
A study of ten-year-old children who had been diagnosed with oppositional defiant disorder or
conduct disorder found that by the age of 27, each had cost the public £200,000. This was 10 times
the cost of children with no mental health problem. 53
A recent report by the Royal College of Psychiatrists (2010) has highlighted how CAMHs is grossly
under-funded relative to need, and that this represents a missed opportunity to prevent considerable
suffering and expense in the future. Given that three quarters of enduring mental health problems are
diagnosed during adolescence the lifetime costs associated with failing to offer appropriate services
are immense.
6.8.2 A different approach
The economic downturn has placed pressures on mental health spending with a number of services
being reduced or cut altogether. There is growing evidence that shifting the focus to public mental
health offers opportunities to deliver upstream, preventative approaches which will improve societal
outcomes and are cost effective. The Health and Wellbeing Board is well placed to ensure public
mental health remains a priority, and can contribute to the social and emotional health of children
through strategies that promote proportionate universalism.
28
Children and Young People’s Emotional Health and Wellbeing
7.0 Who is at risk and why?
This section describes some of the key risk and protective factors that influence children and young
people’s emotional health and wellbeing. The next part of the section looks at groups that are at
higher risk of mental health problems and poor wellbeing.
7.1 Risk and protective factors
It can be suggested that risk factors operate at three levels: individual, social and environmental:
Individual attributes or behaviours: relate to individual characteristics and behaviours and may be
influenced by biological and genetic factors.
Social and economic circumstances: the immediate social environment such as relationships with
friends, family and community has an impact on the individual sense of wellbeing. Economic factors
such as opportunities for gainful employment are also important.
Environmental factors: relate to the wider societal and geographical infrastructure within which
people live their lives, including access to basic needs –food, water and shelter - along with ethnic and
cultural beliefs and practices. Macro politics and economics are also wider determinants of wellbeing.
Figure 7.1 sets out risk and protective factors for emotional health and wellbeing in children and young
people. These determinants interact in a dynamic way and can work for or against an individual’s
emotional health and wellbeing. These factors are considered in more detail in the section below.
29
Children and Young People’s Emotional Health and Wellbeing
Figure 7.1 Risk and protective factors for emotional health and wellbeing in children and young
people.
*
Risk factors
Low birth weight
Excessive computer gaming, social
networking
Substance misuse (particularly high
levels of cannabis use in adolescence)
Television viewing for more than three
hours a day
Protective factors
Participation in sport and physical
actvity
Choice and autonomy
Good self-reported health
Having many friends
Intelligence
Parental/family factors
Ante natal depression and anxiety
Poor health and wellbeing of mother
during pregnancy
Maternal smoking
Substance misuse during pregnancy
Negative parenting practice
Four or more adverse experiences
Child abuse (physical, emotional and/or
sexual abuse and/or neglect)
Feeling unsafe at home
Family conflict or breakdown
Parental imprisonment
Unemployed parent
Parent with mental health problem
Breastfeeding
Good family relationships
Good parenting skills
Spending leisure time together as a
family
School
School absenteeism
Exclusion
Bullying others and being bullied
Positive school environment
Having friends at school
Homes and
neighbourhoods/social and
environmental
Poverty, inequalities and deprivation
Living in the 20% most deprived areas
Lower household income
Poor housing quality
Living in social housing
Damp conditions
Neighbourhood violence and crime
Access to green space
Encouraging play
Child
Factors
/Individual
attributes and behaviours
*
Risk factors do not indicate causation. Some may be indicators of other circumstances that increase the risk of
poor mental health and wellbeing
30
↑
Child behavioural problems
↑
Common mental disorders
x 4.25 x 3
x 6.5
x8
x 4-5 x 2-3
Emotional/conduct disorder
x3
x5
x2
x 4-5
Conduct disorder
x3
x 6-7
x3
Anti-social / delinquent outcomes
Depression
x 15.5
x4
Anxiety
x 8.1
x4
x 7 (F)
x 18 (M)
Attempted suicide (as young person)
x 4-5
Attempted suicide (as adult)
x 18 (M)
x 40 (F)
Suicide
Multiple poor outcomes
Children of prisoners
Looked-after children
Young people in
custody
Young offenders
Young LGBT
Homeless young people
(in B&B or hostel)
Children with physical
illness
Children with Special
Educational Needs
Children with learning
disability
Child abuse
Deprivation (highest v.
lowest group)
Parents with no
qualifications
Poor parenting skills
Unemployed parent
Low birthweight
OUTCOME…………………………………
Maternal stress during
pregnancy
RISK GROUP
OR FACTOR
Use of alcohol/ drugs/
tobacco in pregnancy
Miscellaneous risk factors
Children and young people exposed to certain risk factors are more likely than average to experience
negative emotional health and wellbeing outcomes (Figure 7.2 ).
Figure 7.2- Risk groups and factors for emotional wellbeing in children and young people e.g. x3= 3
fold increased risk,  =increased risk (unquantified)
↑
↑
31
Maternal health is particularly important, and poor environmental conditions, poor health and
nutrition, smoking, alcohol and drug misuse can have a negative impact on the developing foetus and
later life outcomes.
A report by the World Health Organisation (2012) sets out vulnerabilities and risk factors for poor
emotional and mental health using a life course perspective.54 This recognises that different risks
occur at different age stages. Figure 7.3 derived from the WHO report presents a schematic overview
of some of the individual, societal and environmental risks over the life course.
Figure 7.3 Schematic overview of risk factors for poor emotional/mental health across the life
course
32
Children and Young People’s Emotional Health and Wellbeing
7.2 Adverse Childhood Experiences
Some experiences early in childhood can have a profound effect on wellbeing several years or even
decades later. A large retrospective study involved 1500 adults in Blackburn with Darwen being asked
to complete a questionnaire to identify any adverse childhood experiences (ACE’s) in their personal
histories.1 ACE’s included exposure to parental substance abuse, divorce/separation, and physical or
sexual abuse. Increasing ACE’s were associated with poorer health and social outcomes. Individuals
who had 4 or more ACEs were likely to have significantly lower mental wellbeing and life satisfaction
compared with individuals who had not experienced any adverse experiences in childhood. These
results were still apparent even when other factors including deprivation, ethnicity, gender and age
were accounted for. Earlier studies have found that lower perceptions of life satisfaction and mental
wellbeing are linked with increased risk taking behaviours. This evidence provides a rationale for
programmes that can offer early help to parents bringing up children particularly in difficult
circumstances.
Figure 7.4 ACE’s and risks of developing health harming behaviours
33
Children and Young People’s Emotional Health and Wellbeing
7.3 Social and Economic Factors
7.3.1 Ethnicity
Blackburn with Darwen has a population with a high proportion from Black and Minority Ethnic groups.
For children and young people 0-19 years the ethnic composition is 57% white, 39% Asian and 4%
other minority groups.
Higher rates of mental health problems amongst BME groups have been linked to poverty and
deprivation. Recent needs assessment work has indicated that in Blackburn with Darwen some of the
disadvantaged and deprived wards are predominantly where the South Asian communities reside, for
example Audley and Bastwell. Research indicates that these groups are traditionally underrepresented in CAMHS services.55
7.3.2 Deprivation
There is established evidence of the links between living in deprived circumstances and mental health
problems in children and young people. Children who grow up in poverty are at increased risk of
poorer educational achievement and worklessness in adult life. Worklessness contributes to poorer
health, unhappiness and depression. For many the cycle of socio economic disadvantage is passed
from one generation to the next. Individuals who move from worklessness into work report
substantial improvements in mental health and wellbeing.
The prevalence of psychiatric disorders among children aged 5-15 in families who have never worked
is almost double that of children with parents in low skill jobs, and around five times greater than
children with parents in professional occupations.
Working for a Healthier Tomorrow. Dame Carol Black (2008)56
The following are some key statistics for deprivation in Blackburn with Darwen:





Blackburn with Darwen is ranked 17th most deprived authority out of 149 top tier authorities
with 1 indicating the most deprived.
More than half of the small neighbourhoods known as Lower Super Output Areas (LSOA) in
Blackburn with Darwen fall within the most deprived 20% LSOA’s in England.
The Index of Child Wellbeing (2009) indicates that Blackburn with Darwen was ranked 49th
worst out of 152 top tier authorities for wellbeing (with the area ranked 1 having the highest
levels of overall wellbeing).57
In 2011 the percentage of children living in poverty was 25.3% compared with 22.5% in the
North West and 20.6% for England58.
Children who live in a household where no adult household member works 24.3% - North
West 18.1% and England 14.9%.
7.3.3 Social relationships and social capital
Social relationships and having friends are important predictors of children and young people’s
emotional health and wellbeing. There is strong evidence to demonstrate that children who have lots
of friends tend to have higher subjective wellbeing than children with few or no friends. Bullying or
being bullied by other children are strong predictors of low wellbeing.59
34
Children and Young People’s Emotional Health and Wellbeing
1 in 4 children under the age of 11 years who contacted Childline were reporting bullying or on-line
bullying.
Childline Report 201340
Good relationships at home are also important. Children who get along with siblings and have fun at
the weekend with their families also report higher subjective wellbeing.60
Over recent years attention has turned to the concept of social capital. This relates to people’s
participation and belonging within their communities. There is strong evidence that higher levels of
social capital are associated with lower risk of mental illness. However it is noteworthy that in some
cases high levels of social capital can be associated with an increase in risk-taking behaviours. 20
7.3.4 Loneliness and isolation
A report by the charity Childline found that a significant proportion of telephone counselling episodes
related to loneliness and isolation amongst children and young people. Contributing factors included
family relationship problems, issues linked to school and bullying. 61 Young people who are lonely are
more likely to participate in risk-taking behaviours such as drug taking and be suffering with increased
anxiety and paranoia.30
7.4 Children and young people at higher risk of emotional health health problems
Emerging evidence indicates that there are groups of children and young people who are at increased
risk of poor emotional and mental health. Examples of these groups are set out in table 7.1
Table 7.1 Groups of children at risk of poor emotional health and wellbeing
Children with a learning disability
Children with long term conditions e.g. epilepsy
Children with a disability
Children with learning difficulties
Homeless young people
Young lesbian, gay, bisexual and transgender (LGBT) people
Young offenders
Children of prisoners
Children with parents with a mental health issue
Children living in poverty
Young carers
Children subjected to abuse (physical, sexual or emotional) or neglect
Looked after children
Children absent from school more than 15 days in previous term
Children from households with no working parent
Unaccompanied asylum-seeking children
The next section provides further information on some specific groups considered to be at higher risk
of mental health problems.
35
Children and Young People’s Emotional Health and Wellbeing
7.4.1 Looked After Children
In 2013 there were 345 looked after children in Blackburn with Darwen This equates to a rate of 89
per 10,000 children under 18 years and is higher than rates for England (60/10000) and the North West
region (79/10000).62
Children and young people within the care system often have complex health needs. This is partly due
to the impact of their personal histories which often includes family breakdown, parental abuse or
neglect that may have contributed to them being placed in care. Many may have been exposed to
adverse or traumatic experiences such as bereavement, violence or sexual abuse. It is estimated that
around 60% of looked after children in England, and 72% of those in residential care, have emotional
and/or mental health needs. Furthermore, a high proportion experience poor health and poor
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.39
All local authorities in England are required to provide data on the emotional and behavioural health of
children in their care. This is gathered by teachers or carers using the Strengths and Difficulties
Questionnaire (SDQ), a brief behavioural screening tool for 3-16 year olds. Items are scored on the
questionnaire and relate to aspects of emotional problems; conduct/behaviour problems;
inattention/hyperactivity; relationship with peers and pro-social behaviour. Each completed SDQ
produces an overall score which provides an assessment of the individual child and can also be used
for evaluation purposes using the SDQ before and after scores.
For 2013-14, 49% of looked-after Children in Blackburn with Darwen had SDQ scores of 17 or above.
Scores of 17 or above prompts action to be taken by the child’s social worker and the child brought to
the attention of the principal CAMHS practitioner.
7.4.2 Children with Special Educational Needs
It is estimated that 44% of children with special educational needs (SEN) are affected by a mental
health disorder63. In 2013 there were 27,587 school pupils overall and 523 (1.9%) children and young
people with SEN statements in Blackburn.64
Pupils with SEN are more likely to be eligible for and claiming free school meals than pupils with no
SEN, indicating that many are from disadvantaged families. Mental health and wellbeing problems are
prevalent amongst this group. In secondary schools the most frequently assessed primary need for
pupils at school action plus or with a statement of special educational needs is for ‘behavioural,
emotional and social diffculties’ (27.7%) followed by moderate learning difficulty (21.6%).65
7.4.3 Young People Not in Education, Employment or Training (NEET)
Blackburn with Darwen has a relatively high number of 16-18 year olds who are not in education,
employment or training (NEET). This group is more prone to mental health problems compared to their
peers who are working or continuing their training and education.66 In 2013 there were 5982 young
people aged 16-18 years known to the local authority. Of those, 370 (6.2%) were NEET and this was
higher than the proportion for the North West region (5.6%).67 A recent report by the Children and
Young People’s Mental Health Coalition has estimated that the lifetime cost of each new NEET entrant
is £97,000. Childhood mental health disorders are associated with poorer educational attainment and
36
Children and Young People’s Emotional Health and Wellbeing
poorer employment prospects and increase the likelihood of not being in education, employment or
training
7.4.4 Offending and young people
In 2012-2013 there were 177 children and young people aged 10-17 years in Blackburn with Darwen
known to the Youth Justice System.68 Young offenders are at higher risk of having mental health
problems. This may be due to having a risk factors that lead to offending behaviour, such as poor
parenting or risk-taking behaviours. The offending behaviour and subsequent consequences may lead
to further detachment and increasing risk of homelessness. Prevalence estimates of mental health
problems for young people involved in the criminal justice system range from 25% to 81%, with rates
highest for young people in custody.69
7.4.5 Children and young people registered deaf or hard of hearing
In 2010 there were 630 people registered as deaf or hard of hearing living in Blackburn with Darwen.
Numbers for children 0-17 years are not published to protect confidentiality as numbers are small (less
than 5). There is high prevalence of depression and anxiety amongst deaf people and many face
significant barriers in accessing services. A recent survey has indicated that a third of British Sign
Language users avoid seeing their GP because of communication issues.70
8.0 Level of need in population
8.1 Population of children and young people
The ONS mid-2012 population estimate for Blackburn with Darwen is 147,713 people.71 The borough
has a younger than average age profile with 28.7% of the population aged under 20 years (n = 42,434).
This compares with an England average of 23.9%, and is the fifth highest proportion of any local
authority in England (after Barking & Dagenham, Slough, Bradford and Birmingham). Table 8.1 below
shows the 2012 mid-year population estimates for children and young people aged under 24 years,
with estimates for each 5 year age banding by gender.
Table 8.1 Mid-year population estimates (2012) for children and young people 0-24 years
Blackburn with Darwen
Age-group
Male population
Female population
Total
0-4
5751
5581
11332
5-9
5382
5246
10628
10-14
5221
4906
10127
15-19
5407
4940
10347
20-24
4618
4733
9351
Total
26379
25406
51785
37
Children and Young People’s Emotional Health and Wellbeing
8.2 Service demand
8.2.1 Background
Estimating the demand for services required to meet children and young people’s emotional health
and wellbeing needs is challenging. In previous chapters it is noted that 10% of individuals aged
between 5 and 16 years will have a clinically diagnosable mental health problem, equating to 2415
individuals in Blackburn with Darwen. Furthermore Blackburn with Darwen has a large population of
children and young people - a trend set to continue for years to come. The social and economic
burden associated with providing mental health services for children and young people is significant.
Population-based approaches to promote wellbeing and prevent mental health problems are
becoming increasingly relevant within the current climate of budget constraints. Table 8.2 sets out
estimates of children and young people at risk and likely to be affected by mental illness.
38
Children and Young People’s Emotional Health and Wellbeing
Table 8.2 Estimates of children and young people likely to be affected by mental illness
Population
denominator
Primary School Aged
Children (5-10 years)
Early years 0-5
Pregnancy
2293
maternities
(2012)
10-15%
9012 children
aged 2-5
(mid-2012)
Any mental health
condition
19.6%
1770 (2-5
years)
6433 M,
6269 F,
12702 M+F
Aged 5-10
(mid-2012)
Any mental health
disorder
Conduct Disorder
10.2%
5.1%
6.9%
2.8%
2.2%
2.5%
2.7%
0.4%
2.2%
0.4%
12.6%
10.3%
8.1%
5.1%
4.0%
6.1%
2.4%
0.4%
1.6%
1.1%
2.2%
980
1435
Emotional Disorder
Less Common Disorder
6446 M,
5989 F,
12435 M+F
Aged 11-16
(mid-2012)
Secondary School Aged
Children (11-16 years)
% affected
Mostly anxiety and/or
depression
Hyperkinetic disorder
Any mental health
disorder
Conduct Disorder
Emotional Disorder
Hyperkinetic disorder
Less Common Disorder
8895 M,
8635 F,
17530 M+F
Aged 16-24
(mid-2012)
Young adults 16-24 years
Risk Groups
Condition
Estimated
number of
individuals
affected
230-345
Looked After
Children
SEND
360
NEET
370
Young Offenders
177
523
Depressive Disorder
625
305
205
170
825
625
175
175
M/F
breakdown
(where
available)
660
320
445
180
145
160
175
30
145
30
815
620
525
310
260
370
155
25
105
70
385
Post traumatic stress
disorder
Anxiety disorder
4.7%
825
16.4%
2875
Personality Disorder
1.9%
335
Psychotic Disorder
0.2%
35
Any mental health
condition
Any mental health
condition
Any mental health
condition
Any mental health
condition
60%
216
44%
230
25% - 81%
44-143
39
Children and Young People’s Emotional Health and Wellbeing
8.2.2 Levels of service demand
The Mental Health Foundation report “Treating Children Well” (1996) provides an estimate of the
number of children and young people requiring interventions at the different levels of service provided
by CAMHS.72 Figure 8.1 shows the estimated number of children and young people in Blackburn with
Darwen that could require a service intervention. It should be noted that the estimates are based on
national rates applied to the mid-2012 under-18 population of Blackburn with Darwen, on the
assumption that CAMHS services cater for young people up to the age of 17 years.
Figure 8.1 Estimated service demand at CAMHS Tiers 1-4 (Blackburn with Darwen, age 0-17 years,
mid 2012)
Tier
Description of Tier
73
Estimated Estimated
Prevalence numbers
Tier 4
Highly
specialist/
inpatient
0.075%
29
Tier 3
Require involvement
of specialist support
1.85%
715
Tier 2
Require consultation, targeted
or individual support
7%
2704
Tier 1
Universally encountered and can be
addressed in everyday settings
15%
5795
40
Children and Young People’s Emotional Health and Wellbeing
9.0 Good Practice
9.1 Preventative Approach
Amid the pressures on mental health spending, there is growing evidence that shifting the focus
towards early intervention can improve societal outcomes and be cost-effective. NICE has issued a
local government briefing on Social and emotional wellbeing for children and young people, which
stresses the importance of building self-esteem and self-efficacy, reducing bullying behaviour, reducing
risk-taking behaviours and supporting the development of social and emotional skills.74 The ChiMat
‘Resource Directory’ for commissioners of children’s mental health and wellbeing services presents a
strong case for prevention and early intervention on both moral and economic grounds, and devotes a
full chapter to the evidence, issues and challenges surrounding this approach.
Key elements of the NICE guidance include:
9.1.1 Ante-natal and post-natal home visiting
NICE advises that health visitors or midwives should offer a series of intensive home visits by an
appropriately trained nurse to parents assessed to be in need of additional support. 74 This initiative
aims to assist vulnerable families and children with issues such as the mother-child relationship, home
learning and parenting skills and practice, and is particularly pertinent as responsibilities for health
visiting will transfer to local authorities in 2015.
9.1.2 School health promotion programmes
NICE advocates taking a ‘whole school’ approach to pupils’ social and emotional wellbeing, which
means embedding the appropriate support and values into the ethos of the school.74 The Faculty of
Public Health endorses the view that school-based programmes to promote mental health can be
among the most effective of all school health promotion programmes.75 Both organisations agree that
the optimum approach is to combine universal programmes with specific help for those children most
at risk.
9.2 Assets-based approach
9.2.1 Social capital
More emphasis is also now being placed on the importance of involving individuals, groups and
communities in promoting wellbeing, and acknowledging the strengths, resilience, knowledge and
social capital of the local community. A systematic review of the research literature has found
evidence of a strong link between family and community social capital and the health and wellbeing of
children and adolescents.76 The elements most closely associated with mental health and problem
behaviours are illustrated in Figure 9.1:
41
Children and Young People’s Emotional Health and Wellbeing
Figure 9.1 Elements of family and community social capital having the strongest association with
mental health and problem behaviours
Source: Glasgow Centre for Population Heatlh
9.2.2 Five Ways to Wellbeing
The five ways to wellbeing were developed by nef (the New Economics Foundation) based on evidence
from the government’s 2008 Foresight project on Mental Capital and Wellbeing. They have since been
used by schools, local councils, health organisations and community projects across the UK and beyond
to help people take action to improve their wellbeing.
Figure 9.2 - Five ways to wellbeing logo devised by Tameside Council
The Children’s Society has been working with nef to find out whether the five ways to wellbeing are
beneficial to children as well as adults.77 They have found good evidence that the first four ways –
Connect, Be active, Take notice and Keep learning – do work for children. The evidence for the fifth
way – Give – was more mixed, although many children may help others without perhaps realising it.
The Society favours replacing it with a fifth concept related to creativity, imagination and play. They
are about to publish their findings in a joint report with nef, along with a guide for professionals.
42
Children and Young People’s Emotional Health and Wellbeing
9.3 REACH – Routine enquiry about adversity in Childhood
Routine enquiry about adversities in childhood is the process of routinely asking individuals about
traumatic/adverse experiences during contact with services, with the intent to respond appropriately
and plan interventions which in the longer term will reduce the impact of the experiences on their
later health and wellbeing.
A recent study carried out in Blackburn involved asking 1500 adults, and a further cohort of substance
misusers, to record any adverse childhood experiences (ACE) by completing a questionnaire.
Individuals who had 4 or more ACEs were likely to have poor behavioural, mental and physical
outcomes over the life course including smoking, heavy drinking and lower wellbeing. The REACH
project will embed routine enquiry within the working practices of frontline staff who regularly come
into contact with service users who have 4 or more ACEs. The purpose of the project is to support
individuals’ disclosure of adverse experiences in childhood, so that appropriate and earlier support can
be put in place in the client’s recovery journey.
9.4 Youth Mental Health First Aid (YMHFA)
This is an evidence-based training programme aimed at those working with young people age 11-18
years. The training provides information, tools and techniques to promote young people’s emotional
and mental health wellbeing. This includes information on the early signs of mental health problems in
young people and guiding individuals to the right support on a range of topics including: self-harm,
suicide, cyber-bullying and promoting protective factors such as positive parenting. To date the
YMHFA has been delivered to a number of individuals and organizations in Blackburn with Darwen.
43
Children and Young People’s Emotional Health and Wellbeing
10.0 Current Services/initiatives
10.1 Service provision
The following model (figure 10.1) illustrates a simple model of service provision for children and young
people. Universal services, for example, schools, are available to all children to promote their
development including emotional health and wellbeing. Targeted services may be focused on
individuals at increased risk of developing mental ill-health or those living in particular geographical
areas. Targeted services may also include ‘early interventions’ and ‘early help’. Specialist support
tends to be aimed at those children and young people who may already be experiencing harm or illhealth. It should be noted that the figure below may be differentiated from the CAMHS tiers of
intervention model displayed in figure 8 which is specific to mental health.
Figure 10.1 Service provision for children and young people
Specialist support
For children and young people
with complex needs or high risk
Targeted
For children/young people with
identified needs or who live in targeted
areas and neighbourhoods.
Universal
For all children/young people and families including Children's
Centres, schools, colleges
A directory of local services for children and young people can be accessed here.
44
Children and Young People’s Emotional Health and Wellbeing
11.0 Gaps
At the time of writing, the House of Commons Health Committee is conducting an inquiry into
children’s and adolescent mental health and CAMHS, prompted by “concerns that have been
expressed by the Chief Medical Officer and others about both the extent to which children and
adolescents are affected by mental health problems and difficulties with gaining access to
appropriate treatment”.78 Two of the main issues it is considering are the lack of data on children’s
and young people’s mental health (see 11.1), and the transition to adult mental health services.
11.1 Measurements of mental/emotional health and wellbeing
There is currently a lack of consistent data on wellbeing for children and young people nationally. The
Office for National Statistics (ONS) is proposing a new set of measures of national wellbeing for
children aged 0-15 years30 and another for young people aged 16-24 years.79 This is part of the ONS
Measuring National Well-being (MNW) programme. The Warwick Edinburgh Mental Wellbeing Scale
(WEMWBS) has now been validated for use with 13-15 year olds. Some local services do use
WEMWBS and other outcome measures to monitor the progress on wellbeing for service users.
However there is probably scope for existing and new commissioned services to use a validated and
consistent measure of wellbeing.
Similarly there is a lack of hard data on measures of mental health disorders amongst children and
young people. Much of the prevalence data in common use is based on survey work that was
undertaken over a decade ago. The reliability of these estimates is questionable in the current climate.
Since that time the economic downturn and other factors are likely to have influenced levels of
emotional and mental health and wellbeing in the population. The Chief Medical Officer draws
attention to the lack of up-to-date data, and calls for this to be remedied. She has recommended that a
regular survey should be commissioned to establish the prevalence of mental health problems in
children and young people, and that it should be extended to provide information on 0-5 year-olds,
ethnic minorities, those in the youth justice system, and children with underlying neurodevelopmental
issues.3
A key consideration locally is how measures of mental ill health and emotional wellbeing can be
developed at the local level.
11.2 Current investment in emotional health and wellbeing
Locally a number of interventions and programmes known to have been effective have now ceased,
many due to efficiency savings. Preventative programmes such as the Targeted Mental Health in
Schools (TaMHS) initiative offered early intervention support to primary and secondary schools.
Evidence from the national evaluation indicated that the effectiveness of the programme was largely
around primary school aged children. Support in school is variable with some investing more than
others in building emotional health and resilience within the school community.
11.3 Transition to Adult Services
Young people’s mental health services may typically cease at 16 or 18 years of age, but this means that
the transition to adult services takes place at a time of high risk to wellbeing and mental health, and
susceptibility to risk-taking and offending behaviour.80 In the first study to follow a cohort of young
people crossing the boundary from child to adult mental health services, a third were not referred on
to adult services, and a fifth of those who were referred were never seen. Fewer than 4% were
45
Children and Young People’s Emotional Health and Wellbeing
reported to have experienced an optimal transition.81According to ChiMat, the reason some teenagers
may not be referred to adult mental health services, or may be turned away, is that they have a
problem which is not catered for by adult services, or does not meet their thresholds. 11
11.4 Opportunities
There are opportunities for the Healthy Child Programme to address issues around emotional health
and wellbeing for school aged children and young people aged 5-19 years. School nursing teams are
able to support children and young people around emotional and mental health issues working
collaboratively with specialist teams including CAMHS, and working in partnership with families and
neighbourhoods utilising local community resources. Opportunistic interventions using principles of
Making Every Contact Count and the Five Ways to Wellbeing are also evidence-based approaches to
supporting emotional wellness and physical health in children and young people82. Recommendations
from this ISNA will include these approaches and will inform action plans to be developed by the
Children’s Partnership Board.
12.0 Value for money
A study by the London School of Economics (LSE) presents compelling evidence of the costeffectiveness of mental health promotion and mental illness prevention, including where children and
young people are concerned.83 Parenting interventions for parents of children with, or at risk of
developing, conduct disorders are a case in point. Such interventions cost about £1200 per child, but
produce savings of £9300 gross (i.e. £8100 net) over a 25-year period. This includes not only savings to
the public sector (principally NHS and criminal justice system), but the avoidance of costs incurred by
victims of crime and of lost output due to crime.
The LSE report also confirms that school-based social and emotional learning programmes are costsaving for the public sector, and that school-based anti-bullying initiatives offer good value for money
on a long-term perspective. NICE acknowledges that the upfront costs of preventative interventions
will sometimes not be recouped for a number of years, but states that they will often be far
outweighed by the future health benefits and long-term cost savings achieved.74
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Children and Young People’s Emotional Health and Wellbeing
13.0 Involvement
13.1 Engagement
The following section describes engagement activities with children and young people that have
recently taken place in Blackburn and Darwen.
13.1.1 Health Watch Survey
In 2014, Healthwatch developed a joint research project with Blackburn College to find out the social
and emotional issues affecting young people with the college/university campus. A total of 118
respondents were included in the study. 62 respondents (53%) reported experiencing stress. 84
respondents (71%) felt there was not enough information and support on emotional issues, and 77
respondents (65%) reported that they did not know who to speak to or where they should go if they
need help. Young people interviewed felt that more could be done to reduce stigma and raise
awareness around mental health issues. Tutors were also interviewed on their perspectives on
student emotional health and wellbeing. 29 out of 30 tutors (97%) felt that mental health training
would be helpful in the workplace and 23 out of 30 tutors (77%) interviewed have had to help a
student with mental health and wellbeing issues.
13.1.2 Engagement work with children and young people on early intervention service provision
In 2013 an engagement project was carried out with children and young people living in Blackburn
with Darwen aged 7-19 years. The engagement work involved focus groups and workshops carried out
in local primary and secondary schools, and Blackburn College. Key findings of the research included:








A lack of early intervention provision for children and young people experiencing mental
health issues as a result of traumatic or negative events.
A lack of awareness amongst children and young people of local service provision for
emotional and mental health issues.
Bullying was frequently cited amongst 7-10 year olds; self harm was more commonly reported
amongst older children 11-19 years.
Family and friends were commonly identified as primary sources of help and support.
Teachers and college tutors were also identified as key sources of support.
The therapeutic benefits of looking after pets and animals were common themes amongs
children and young people.
Suggestions for improvements to address gaps in provision included: self-defence classes,
alternative therapies and activities, counselling services/talking therapies.
There was generally a perception that there needed to be more awareness of local support
available for children and young people including through digital platforms and local children
and young people’s forums.
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Children and Young People’s Emotional Health and Wellbeing
13.2 What Young People Told Us
13.2.1 Background
It was agreed that engaging with and listening to local children and young people would be at
the heart of developing this ISNA. A series of engagement activities were carried out to
effectively engage local children and young people in conversations and gain insight into their
knowledge, attitudes and behaviours relating to emotional health and wellbeing. The purpose
was to understand children and young people’s assessment of their own lives and the issues that
influence these. Over 200 children and young people have been involved in conversations
around emotional health and wellbeing and what this means to them growing up and living in
Blackburn with Darwen.
Asking young people to evaluate their lives and experiences - is essential to fully understand the
factors that influence wellbeing. The importance of listening to the voices of children, young people
and their families to shape service provision is outlined by the Report of the Children and Young
People’s Health Outcomes Forum (2013). It is also underpinned by principles of the UN Convention on
the Rights of the Child which emphasises respecting the views of the child and involving them in
shared decision making. Public Services that take into account the views of children and young people
tend to have informed consumers, improved services and better value for money.
13.2.2 Objectives
The objectives of the engagement activities were:



To identify and engage with groups of local children and young people aged 0-25 years living
in Blackburn with Darwen
To meet children and young people in their communities and use a range of approaches for
effectively engaging and listening to their voices and opinions
To accurately document the shared views and opinions gathered during the engagement work
13.2.3 Methodology
The engagement work was carried out by two researchers from the Specialist Public Health Directorate
in Blackburn with Darwen Council between November 2013 and April 2014. In addition several
engagement projects were commissioned to inform the research. Details of these projects are given
under 13.2.4 Commissioned Projects.
The scope of the engagement work was to engage with children and young people aged 0-25 years.
The conventional upper limit for adulthood at 18 years was extended to include young adults up to the
age of 25 years as recommended by the latest report by the Chief Medical Officer 2013 . This
approach was used to capture the recent experiences of young people transitioning to adulthood and
their views on local service provision.
Children and young people were chosen to be representative of wider groups of views that reflect
significant age bandings and transition points across the life course including:
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Children and Young People’s Emotional Health and Wellbeing




Early years 0-5 years
Primary school aged children
Secondary school aged children
Young people aged 16-24 years
Figure 13.1 shows the groups involved in the engagement phase.
Figure 13.1
Children’s
Centres
Primary
Schools
Home Start
Young
Carers
Secondary
Schools
Inter
Madrassah
Organisatio
Blackburn
College
Leaving
Care
THOMAS
James
Street
Youthzone
Night
Shelter
Lifeline
13.2.4 Commissioned Projects
A series of commissioned engagement activities were carried out. Details of all the commissioned
activities are discussed below.
Early years 0-5 years
Children under 5 years were considered too young to participate in the engagement work. Therefore
49 parents/care-givers involved with the local voluntary organisation Home Start and also two local
Children’s Centres were asked about their experiences of pregnancy and child-care through focus
groups and semi-structured interviews.
The full report from Home Start can be accessed here
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Children and Young People’s Emotional Health and Wellbeing
Primary and Secondary School aged children
A team of Educational Psychologists employed by Blackburn with Darwen Borough Council were
commissioned to conduct specific engagement work with local primary and secondary aged school
children. In total 64 children and young people aged 6-15 years attending schools in the borough of
Blackburn with Darwen were involved in the
engagement activities.
The full report of engagement work with
primary and secondary aged school children can
be accessed here.
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Children and Young People’s Emotional Health and Wellbeing
Citizens Jury
Healthy Living Blackburn with Darwen was commissioned to undertake a Citizens Jury with twelve Year
10 children from Blackburn Central High School with Crosshills. The pupils worked intensively over
several weeks to develop and produce a film on emotional health and wellbeing.
The film ‘Our Emotions Matter’ produced by pupils from Blackburn Central High School and Healthy
Living Blackburn with Darwen can be accessed here
A copy of the interactive report providing the details of the film production and findings can be
accessed here.
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Children and Young People’s Emotional Health and Wellbeing
What Matters to Me?-Event at Blackburn Youth Zone
On Wednesday 26th March 2014 the showcase event ‘What Matters to Me?’ was
organised at Blackburn Youth Zone. The event premiered the short film ‘Emotions
Matter’ produced by Blackburn Central High School and Healthy Living Blackburn with
Darwen.
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Children and Young People’s Emotional Health and Wellbeing
16-24 years
Young people from a wide range of agencies and organisations were included in this age banding.
Students from Blackburn College were recruited to two focus groups or participated in one-to-one
interviews. Interviews were conducted by the college research co-ordinator.
A group of Asian heritage young people affiliated to the Inter Madrassah Organisation were trained as
engagement practitioners by the project team. They recruited and carried out face-to-face interviews
with 25 other young people from their community or social networks. The interviews were audiotaped and transcribed by the Inter Madrassah Organisation.
Specific groups of interest
Specific groups of interest and ‘at risk’ groups were identified for engagement work through
consultation with local key professional networks and with reference to the literature. These groups
included:




Young people aged 16-23 years not in education employment or training (NEET) leaving local
authority care.
Homeless young people - two face to face interviews at James Street Housing Project and
focus group at Night Safe
A focus group with 12 Young Carers (Child Action North West)
Young substance misusers - three face to face interviews with young people from Lifeline and
THOMAS)
13.2.5 Engagement Activities
A range of approaches were undertaken to consult with the various individuals and groups involved in
the engagement work. These approaches included:

Face to face interviews

Focus Groups

Participatory research

Open space technique

Citizens Jury
Each of the engagement activities lasted around 1 hour and consisted of open-ended discussions
exploring knowledge attitudes and beliefs around emotional health and wellbeing. The researchers
used a series of prompt questions to support the discussions including:
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Children and Young People’s Emotional Health and Wellbeing

What does emotional health and wellbeing mean to you?

What makes you feel better? What improves your emotional health and wellbeing?

What works against your emotional health and wellbeing?

If you had an emotional problem where would you go to, what would you do?

How would you help someone else who had emotional difficulties?
An extended set of questions were developed for face to face interviews.
Discussions and interviews were recorded using notes and audio-tape and transcribed.
13.2.6 Analysis
Analysis of the data involved identifying key themes from the issues discussed with the children and
young people. These themes were then used to construct a broad framework to be used for further
analysis. Data generated by the engagement activities were also considered against the Five Ways to
Wellbeing for adults outlined by the New Economics Foundation (see Figure 13.2). The 5 ways are a
set of evidence based actions known to improve wellbeing. Using these themes helps to support an
assets-based approach by placing an emphasis on health and wellbeing. This approach recognises that
children and families already have strengths and resilience at their disposal that supports good
emotional health and wellbeing.
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Children and Young People’s Emotional Health and Wellbeing
Figure 13.2 The Five Ways to Wellbeing6
Connect
With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in
your local community. Think of these as the cornerstones of your life and invest time in developing them.
Building these connections will support and enrich you every day.
Be Active
Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance.Exercising makes you feel good.
Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.
Take Notice
Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the
moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world
around you and what you are feeling. Reflecting on your experiences will help you appreciate what
matters to you.
Keep Learning
Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility
at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you
will enjoy achieving. Learning new things will make you more confident as well as being fun.
Give
Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a
community group. Look out, as well as in. Seeing yourself, and your happiness, linked to the wider
community can be incredibly rewarding and creates connections with the people around you.
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Children and Young People’s Emotional Health and Wellbeing
13.2.7 What children, young people and parents say about emotional health and wellbeing –
findings from the engagement activities
The following section explores the main themes emerging from the engagement work at the different
age stages.
Early years 0-5 years
Parents of very young children attending Home Start and/or local Children’s Centres identified the
following themes as important for child development and emotional wellbeing:
Family and friends
Parents of very young children identified the importance of family and social networks for supporting
emotional health and wellbeing. Extended family such as grandparents were regarded a source of
advice, support and company for themselves and their children.
Most parents interviewed value local community groups including Children’s Centres, nurseries and
church groups. These venues are meeting places for socialising with other parents and provide a range
of activities for children. However many parents found it difficult to find information on local
community and voluntary groups.
Positive parenting and access to support
Parents recognised the importance of their own emotional and mental health and the impact this can
have on children. High self-esteem was also regarded as a key factor for parenting. Providing daily
routine and consistency emerged as common themes that support children’s emotional health and
wellbeing. Providing a safe and nurturing home environment was also considered to be important.
Factors working against good emotional health included family conflict particularly between parents
and a lack of consistency around routines, e.g. snacking and erratic bed times. Parents reported that
professionals such as health visitors put too much emphasis on assessing mental ill health issues.
Some suggested that there should be more support around dealing with ‘day to day’ problems and
emotional health and parenting issues.
A number of parents also found that financial worries and poor housing had negative impact on the
family and their own wellbeing.
‘Being a good role model for children.. ‘positive parents make positive children’
‘As a parent I need to be aware of my own emotions and understand how they
affect the children’
‘As adults we should understand them better. Children pick up on conflict’
Home Start parent
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Children and Young People’s Emotional Health and Wellbeing
Parents identified a number of key professionals, groups and services who they could turn to support
for children’s emotional health and wellbeing. Parents wanted to talk to people and professionals who
they felt had the best skills in dealing with children’s emotional health and wellbeing. Health Visitors,
Social Workers, G.Ps and play therapists were given as examples of supportive professionals. Others
felt that there was that there could be more support and information around issues such as sleeping,
eating and routines. Some parents wanted to be able to discuss issues around emotional and
behavioural issues with teachers in schools where there were older siblings and/or half siblings in the
family.
Children’s Centres and organisations such as Home Start were found to be useful for helping parents
understand their child’s emotional health and wellbeing. Some parents felt that there could be more
advice and support around emotional health and wellbeing issues delivered by health visitors and
other professionals. Accessible drop-ins or groups at Children’s Centres for Q&A sessions on emotional
health were suggested. Informal peer support networks were also found to be of value and this was
mentioned as a potential area for development.
Many parents access support through formal service provision. However, self-care and selfmanagement also emerged as a theme. Several parents felt that they needed more advice and
information around emotional health and wellbeing so that they can take responsibility and care for
their children better themselves. However parents reported that trusted information was difficult to
locate and access.
Childcare
Some mothers identified going to work as important for their emotional health and wellbeing and
discussed the importance of access to quality affordable childcare. The need for childcare for under-2’s
where there was no social worker involved was identified as a gap. Some felt that as working parents
they were penalised in terms of access to childcare compared with non-working families.
‘It is important for the children to have a working parent as a role model, giving
them something to aspire to.
Being financially better off will impact on the
children’s emotional health and wellbeing as it will reduce stress, improve
relationship networks, improve health and make a more positive future for
children.’
Home Start Report
Being active and physical exercise
Many parents emphasised the importance of play, physical exercise and being active for emotional
wellbeing for young children and the family as a whole. Access to open green space emerged as a
theme and various outdoor activities were discussed including going to the park, going for walks in
woods and having picnics. However some concerns were expressed around the state of disrepair and
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Children and Young People’s Emotional Health and Wellbeing
lack of safety of local parks and amenities. Surprisingly none of the parents mentioned specific places
they use and visit as a family.
Some parents discussed children accessing organised activities such as dancing and swimming clubs.
Others wanted to see more affordable activities within the community that could involve the whole
family. Financial worries and a lack of transport also prevented some parents being able to afford trips
outside the local area. Again a lack of information on local activities for families with young children
was raised.
None of the parents mentioned the importance of their own physical/ mental health and wellbeing for
themselves and their children. There is strong evidence that parental mental and physical health
deteriorates in the first two years following the birth of a child as parents adapt to their new roles and
cope with organising the new arrangements at home.
Helping Others
Some parents felt that they could offer advice and support to friends and other parents based on their
own experiences. Parent-to-parent peer support and attending appointments with other parents were
suggested as possible ways of helping. Barriers to sharing problems were also mentioned. Themes of
stigma attached to emotional and mental health issues were also apparent and some people felt
ashamed asking others for help for fear of being judged.
Although parents mentioned low-level peer support they could offer or receive no one mentioned
formal volunteering roles they were involved in.
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Children and Young People’s Emotional Health and Wellbeing
School aged children
The following themes were identified in the engagement activities carried out in primary and
secondary schools. This includes findings from the Citizens Jury carried out by pupils from a local
high school, and focus group work with young carers affiliated to Child Action North West.
Family and friends
Family relationships, friends and pets were identified as very important for emotional health and
wellbeing across all ages. Issues relating to security, closeness and being ‘safe and happy’ within the
home were recurring themes for children and young people. There were slight differences in how
children and young people viewed support on emotional issues from family. Young primary school
aged children tended to identify ‘being with’ family members in the home environment as important;
whereas older children and teenage talked about going to family for support around emotional issues.
Friendship circles were important across all age ranges. Young children were interested in playing
whereas older children tended to focus on talking and being with friends. Older children also
expressed the importance of social networks and belonging to communities including school, clubs,
mosques and churches
Where to go to for help and support
Families, friends and teachers were identified as sources of help at times of emotional difficulties.
Across all ages mums were often mentioned as the key person to help with problems whereas dads
tended to support by being active. Issues of disharmony amongst family members were mentioned by
older children. Mid–teenage girls in particular mentioned difficult relationships with parents and
having issues they could not speak to their mums about.
A number of young people suggested that more work could be done to support parents and families so
that they are able to give accurate support and advice to children and young people.
Older children in secondary education referred to support they could get from teachers and schoolbased counsellors. However, perceptions relating to support from teachers was variable. There were
recurring themes of young people mistrusting teachers and people in authority and many expressed
doubts over assurances of confidentiality when sensitive information is shared. Suggestions of more
training for teachers on emotional health and wellbeing were made.
Specialist services did not feature strongly in the lives of young people as sources of support. Amongst
young people not connected directly with services, there was a low level of knowledge or even
vagueness around available services and support. Many young people had not seen marketing
information on local services that may support emotional health and wellbeing. Some young people
suggested that they preferred to seek support from family rather than services. There were also
concerns that children and young people attending school are unable to attend services due to many
being based in Blackburn town centre with inflexible opening times and no weekend provision. There
were perceptions that whilst there were plenty of services available locally, very few were aimed at
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secondary school aged children. There were suggestions around developing channels to provide
better information and signposting to services for parents and family members.
Recent insight work conducted by Blackburn with Darwen Borough Council has also indicated that
there are mixed views on the use of social media for communicating key health messages. Some
digital platforms, e.g. Facebook, were preferred over others. Furthermore some young people
reported that they would be suspicious about the authenticity of unsolicited health communications.
Peer-to-peer support was suggested by older children as a possible means of providing support to
children and young people.
Engagement and participation
Many young people valued taking part in the engagement activities and felt that services would
benefit from an ongoing dialogue and putting young people at the core of service planning and
delivery. Professionals and service providers involved in the Citizens Jury work as key commentators
also highlighted that longer-term consultation and collaboration with young people would be
beneficial for continuous service improvements.
Pressures and problems
School-based worries relating to homework, exams and pressures to succeed were common from
older primary school children upwards.
‘I think about being younger, feel sad, want to be young.
Now I got lots of
pressure, lots of hard work.’
Primary School pupil
Gender-specific issues were also apparent amongst adolescents. Bullying was highlighted as a key
issue by boys; concerns around appearance and self-image were higher amongst girls, along with
difficult interactions with parents. Evidence from a large national survey indicates that young people’s
wellbeing starts to decline from around the age of 8 years to the age of 15 years and the decrease in
wellbeing is more pronounced for girls than boys.
Virtually all children and young people involved in the engagement work had access to social media via
smart phones and computers, and used this for socialising and keeping in touch. However an
overwhelming majority of young people had negative perceptions of social media and frequently cited
factors such as cyber bullying and intimidation.
Recreation, physical activity and relaxation
Many children and young people identified physical activity as beneficial to emotional health and
wellbeing. Activities for younger children included playing in all forms. Young people also mentioned
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Children and Young People’s Emotional Health and Wellbeing
structured sporting activities including swimming, horse riding and football. The importance of
relaxation was a recurring theme particularly amongst secondary school aged children.
‘Being chilled and relaxed’
‘Listening to music and singing’
Some children reported using relaxation to forget about worries and concerns. Relaxation often
involved chilling out and listening to music. Some children and young people used gaming as way of
“feeling shielded” from pressures in life.
Giving and volunteering
Few children and young people in the course of the engagement work gave specific examples of
‘giving’ and participating in formal voluntary activities. However many children and young people felt
that they could support friends and others with emotional difficulties. Surprisingly the young carers
who participated in a focus group did not refer to their own caring responsibilities for a parent of
significant other. Young people involved in the Citizens Jury exercise thought that peer-to-peer
support could be beneficial for promoting health and wellbeing.
The Children’s Society found mixed evidence for concepts of ‘giving’ amongst children and young
people and reported that creativity was a more useful dimension contributing to young people’s
wellbeing.
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Young people and adults aged 16-24 years
It should be noted that the older groups involved in this part of the engagement strategy were very
diverse in nature and included: college students and south Asian young people (interviewed by
youth forum members of the inter-Madrassah organisation). Other ‘vulnerable’ groups were
identified and these included young NEET care leavers, drug and alcohol service users, and homeless
young people. It is recognised that these sub-groups essentially make up a broader category of
young people and adults aged 16-24 years. Many of the issues raised around emotional health and
wellbeing were common across all young people. However there were some emerging themes there
were more relevant to some subgroups than others. Therefore views of young adults of young
people 16-24 years are reported under specific groups.
Blackburn College
Stresses and pressures
Students from Blackburn College identified a number of issues affecting their emotional health and
wellbeing. Stress around exams and pressures to succeed from parents were common themes. Many
young people wanted validation of the effort they put into work and ‘doing their best’, rather than
feeling obligated to meet the expectations of other people. Some suggested that there should be
more recognition and reward of personal goals being achieved.
Many young people discussed themes of peer pressure. Several students talked about feeling the
need to keep up with the latest trends, the importance of self image and constantly making
comparisons with other people. Others felt that many of their peers cared too much about what
others thought of them and that individuality should be celebrated.
“It is OK to be YOU! Self evaluation-think of your motives-be realistic to your
own cirmcumstances.”
Blackburn College Student
Some young people felt that parental and peer pressure could possibly lead to risk-taking behaviours
such as drug misuse, violence and self-harm.
Loneliness and isolation were also themes identified by the students. Some young people reported
often feeling lonely and having no one to talk to. Some felt that they were unable to express their
emotions and if they did, this would be perceived as weakness by others. However many of the young
people recognised that keeping problems to yourself was not good for their longer term emotional
health and wellbeing.
Help and support
Students were able to identify a number of factors that could help with their emotional health and
wellbeing. Peer support and helping each other through problems and difficulties were recurring
themes. Some of the young people also discussed ways they could self-manage personal problems
through taking time out for oneself, being listened to and learning to relax. Similar to other groups in
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the engagement work, many felt that exercise was very important to wellbeing. However, along with
physical exercise, themes of spirituality also emerged with this cohort.
A number of young people felt that there could have been more help around emotional health and
wellbeing issues within secondary schools. At times of need, such as bereavement, some students felt
that there had been little or no support available to them. Some suggested that they would have
benefited from having someone to talk with such as school counsellors. Others felt that parents and
family members did not understand emotional issues, and there was a need to recognise the value and
benefits of counselling and other support mechanisms.
“Would actively access a counselling service in high school - talking allows you to
‘find yourself’…counselling would have given me the chance to find myself.”
The following statement was made by a student in relation to the death of a parent whilst still in
secondary school education. The student related that there had been a lack of support available in
school and how this had resulted in a series of problems including failing examinations. On entering
college, a tutor quickly identified that there were pastoral issues that needed to be addressed and
referred the student for counselling which helped a great deal.
“..Need to look at what is going on underneath..are anxieties for a reason ? I had
no social interaction and failed exams, because of a specific issue [bereavement]
..not just because I am a teenager.”
Blackburn College Student
South Asian young people
Factors supporting emotional health and wellbeing
As with most of the other children and young people involved in the engagement activities, friends and
family were identified as the most important factors relating to emotional health and wellbeing for
young people of south Asian heritage. Physical exercise was also linked with good emotional health.
Themes of learning and studying were also very important to these young people. Education, money,
employment, a worthwhile career and material wealth were frequently noted as factors contributing
to wellbeing. Similarly to other groups, the South Asian young people discussed parental pressure to
do well. However they tended to think this was positive encouragement rather than a source of stress.
Religion
Many of the young people identified religion as important for their emotional health and wellbeing.
This was possibly the most significant theme as it included factors relating to friends and family and
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Children and Young People’s Emotional Health and Wellbeing
was linked to sports and physical health. Prayer was linked with relaxation. This differed from most of
the other groups involved in the engagement activities, where religion/spirituality was not viewed as
particularly important in terms of emotional health and wellbeing.
Factors that work against emotional health and wellbeing
Again as with other children and young people there was limited awareness of local support services
that could support emotional health and wellbeing. Many of the young people mentioned Childline as
a source of support.
Another recurring theme related to social media. Again south Asian young people viewed social media
fairly negatively and were aware of issues such as cyber-bullying. However none of these young
people reported personal experience of such matters.
Drugs and alcohol were generally perceived negatively by this group of young people. None of the
interviewees reported they had ever used alcohol or illicit substances.
Vulnerable groups
A number of factors may contribute to a young person’s vulnerability to mental health problems and
certain individuals and groups are at higher risk than others including homeless young people and
those using drugs and alcohol problematically . Whilst it is recognised that many individuals belonging
to these groups have good emotional health, many do have complex needs which impact upon their
social, physical and psychological health.
Family and social connections
Many young people from the various groups in this part of the engagement work discussed various
pressures they had experienced at home. Estrangement from family members was a common theme
emerging from discussions.
Some of the young people discussed the value of friendships in terms of mutual support when they
were feeling down. Others discussed the negative aspects of having the wrong type of friends and peer
pressure to participate in risk-taking behaviours such as alcohol and drug misuse.
Issues of loneliness and isolation were apparent amongst some of the vulnerable groups involved in
the engagement work. For example homeless young people and care leavers expressed fears of being
alone at night and wanted to be able to participate in more evening activities. Others talked about
issues relating to spending long periods of time in hostel environments including boredom and the
negative impact on self-esteem. A lack of money and transport were reasons given for not be able to
get out and about. Improving transport links to young people’s activities in the evenings was
suggested as a possible improvement.
Social media
Generally all the young people had access to social media and regularly used social networking services
such as Facebook and Twitter. The majority of young people had negative perceptions of social media,
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linking it with bullying and intimidation. Furthermore young people expressed frustration that
complaints to social media providers or to the police came to nothing:
‘Facebook can make people feel down or suicidal. If you report something to them
[Facebook] nothing ever happens…you just get a reply saying the complaint’s being
logged.
Boys get their girlfriends to send pictures of themselves and then use it
against them when they break up.
Facebook is a bad place to be and shouldn’t
even exist. Children then feel frightened and too scared to tell their parents.’
Young person from Lifeline
‘Keyboard warriors….they think they can say what they want…they use it [socal
networking] as an excuse to bully people.
I don’t like the police they don’t do
nothing about it’.
Young homeless person - James Street Project
Sport and physical activity
Generally young people thought that physical activity and sport was very important for good
emotional health and wellbeing. Young people discussed their enjoyment of various activities
including bowling, table tennis and swimming. Most walked every day as they had limited funds for
other types of transport and regarded walking as an activity that was good for their physical and
emotional wellbeing.
Access to the Beez card is very important for many young people as this gives them discounted
membership to local gym and swimming facilities. Many of the young people have been signposted to
the Beez card through services they are involved in. For some this is therapeutic and has become part
of their schedule for dealing with/recovering from drug and alcohol problems. Some suggested that
the times when the Beez card could be used were inflexible particularly if they were engaging in
education and training during the day.
‘When I started going to the gym that improved my self-esteem and also the
Training 2000 course.
I also do football and table tennis.
Exercise makes me
happy and gives me energy.’
Homeless young person - James Street Project
There did seem to be some gender differences in accessing and participating in sporting activities.
Many of the males played sports on a regular basis and some were involved in weekly training and
matches affiliated to the services they were involved in. Many of the young women did not participate
in sport or physical activity although some did talk positively about past experiences.
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Children and Young People’s Emotional Health and Wellbeing
Risk-taking behaviours
Current and previous alcohol and drug use was common amongst these groups of young people and a
number were involved in local support/treatment services. Some described using substances as a way
to escape from the pressures of daily life and several suggested that they would help a friend with
difficulties by offering them drugs and alcohol. Other young people discussed how they had used
various substances in the past to deal with problems but reflected that this had resulted in longer-term
negative consequences.
‘Drinking get things off your mind - but then it makes you feel worse. I used to
get off my face..but it only made things worse’.
‘Cannabis makes you feel better about yourself at the time….but it’s the long run
isn’t it? If you smoke enough of it long enough it sends your head south. Stopped
using bubble you forget..it used to send me confused ..I feel better about myself
now.’
‘I stopped smoking weed and started Training 2000. Makes me feel a lot better
about myself.’
Young people from James Street Project
Smoking was very prevalent amongst all the groups involved in the engagement activities. One
volunteer suggested that more targeted cessation activities should be carried out with vulnerable
young people. She explained that other often issues took priority in the lives of young people with
complex needs and often heavy smoking was overlooked and regarded as acceptable and inevitable by
services and professionals.
Self-harm
Throughout conversations with some of the vulnerable groups there were discussions around selfharm, particularly amongst girls. Some girls reported that they had self-harmed in the past as a way of
coping with pressures. Others mentioned that they had friends or peers who had self-harmed or
frequently were exposed to self-harm through social media site such as Tumblr.
‘Self-harm makes you feel good about yourself.’
‘How can I help a friend who self-harms when I’ve done it myself?’
Young people leaving care
High knowledge around services
Many of the young people interviewed had complex needs and were involved in multiple services
including support for alcohol and drug issues and homelessness. They had extensive knowledge of the
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different services available locally and what they provided. The importance of a familiar and
consistent key worker in the lives of these young people emerged as an important theme to support
emotional health and wellbeing. Many spoke of the high level of support and trust they received from
their key worker.
Some young people, particularly those who had experienced being in local authority care, discussed
how having different key workers and support workers over the years had been very unhelpful.
However many felt the support they had received from leaving care workers was very helpful.
An emerging theme was the perceived lack of autonomy and choices amongst young people with
regard to certain aspects of healthcare. Some of the young people talked about being prescribed antidepressants and anti-psychotic medication when they felt they did not need it and not be able to
speak to anyone about these issues.
‘There is no one to take issues to around medication when it is not helping - my
GP just won’t listen.’
‘You always have to go to services on their territory - they never come to you.’
Young person leaving care
Autonomy and choice have also been identified in the Good Childhood Report 2013 by the Children’s
Society as one of the strongest predictors of children and young people’s life satisfaction, along with
money and family relationships.
Benefits and food poverty
Many of the young people involved in the engagement activities were in receipt of benefits and most
reported that they struggled to cope with day-to-day costs of living. A number of the young people
had experienced sanctions being placed on their benefits and felt that they had been unjustly
penalised. For some, sanctions had resulted in housing benefits being removed and rental arrears
even within hostel type accommodation. Use of food banks was commonly reported as young people
were struggling to afford basic food shopping.
‘I do think the government should drop the prices of food.
Sometimes I’ve only
got bread in at times.’
‘I have no money for food…there’s no money. I’ve used the foodbank a few times
now.’
Young people - James Street Project
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14.0 Discussion and Recommendations
14.1 Discussion
The following section summarises the key findings from the ISNA, drawing out implications and
challenges for policy and practice, and then goes on to make a number of recommendations.
National and local policy recognises that emotional health is more than simply mental ill-health and
needs to focus on all aspects of wellbeing. Good self-reported wellbeing is one of the strongest
predictors of health and positive lifestyles, and even determines life expectancy. It is crucial that the
Health and Wellbeing Board continues to support asset-based approaches that promote ‘parity of
esteem’, valuing both physical and mental wellbeing. Translating this approach into practice will
require influencing and systematically building emotional wellbeing into strategy and commissioning
functions, including:




Embedding and promoting the ‘Five ways to wellbeing’.
Building on community and neighbourhood-led asset-based approaches.
Utilising behaviour change programmes to promote wellbeing e.g. Making Every Contact
Count.
Integrating physical and mental health throughout all health and wellbeing commissions and
activities
This ISNA has highlighted that mental health problems in childhood are common, affecting around 10%
of school aged children - that is approximately 3 children in every average sized classroom. Most
children and families do not seek help for these problems due to a number of factors including stigma
and a lack of knowledge around support available. We have a responsibility in tackling the stigma and
discrimination associated with poor emotional and mental health by supporting campaigns that aim to
raise awareness around these issues.
The social and economic burden associated with mental ill-health is significant and a ‘deficits
approach’ to tackling emotional and mental health is unsustainable. In addition, commissioned
specialist services have only the resources and capacity to support just a fraction of children and young
people facing emotional difficulties. Population-based approaches that promote asset-based
wellbeing offer a fresh perspective and are cost effective.
This report has considered the importance of emotional health and wellbeing at different life stages of
childhood and adolescence. It is critical to consider these stages not only in terms of chronological age
but also in terms of emotional development.
Maternal mental health is very important for infant emotional development. Around 10-15% of
women will be affected by mental health problems such as anxiety and depression during the perinatal
period. Conversations with local parents highlighted that they understand the impact of their own
mental health on their child and value the support from local services such as health visitors and Home
Start.
The Early Help Strategy will focus on identifying and addressing the needs of the most vulnerable
children and their families. Alongside targeted interventions there is also value in supporting universal
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approaches that promote maternal health and wellbeing. A programme of work to support maternal
emotional health may include:


Developing trusted resources aimed at children and families which provide information on
health and wellbeing at the neighbourhood level including access to local groups and
affordable activities.
Promoting self-management approaches on emotional health and wellbeing issues during
pregnancy and beyond. Topics may include low-level anxiety, and depression, bonding and
attachment and healthy behaviours.
As responsibilities for the 0-5 years agenda as part of the Healthy Child Programme transfer to the
local authority in 2015 there are opportunities to promote emotional health and wellbeing as part of
the transitioning arrangements.
The majority of school-aged children and young people involved in the engagement work reported
that parents and teachers were a primary source of support at times of emotional difficulty. It is clear
that there are opportunities to strengthen the role of families, schools and community groups to
support children and young people’s emotional health and wellbeing. Whole school approaches are
collaborative and collective action involving teachers, families and the wider community working
together to improve wellbeing supported by NICE guidelines. There are a number of ways such
approaches can be encouraged, including:





Raising awareness and improving knowledge around emotional health through existing
training e.g. Mental Health First Aid Training/Youth Mental Health First Aid Training.
Supporting teachers and parents on specific ‘hot topics’ such as exam pressure, cyber bullying
and self-harm.
Schools may want to explore opportunities such as anti-bullying ambassadors.
School nursing teams have an important role in contributing to supporting children and young
people’s emotional health and wellbeing under the Healthy Child Programme. It is important
to ensure that the school nursing offer maximises family support and links to neighbourhood
resources that encourage wellbeing.
Schools will also be encouraged and supported to adopt routine enquiry approaches using
learning from the Adverse Childhood Event (ACE) study.
A recurring theme throughout the ISNA development was around the lack of trusted on-line
information specifically aimed at children and families on local health and wellbeing issues in
Blackburn with Darwen. There are existing resources but many of these are out of date or difficult to
locate. A new online resource could include information on affordable activities for all the family, and
low-level advice on emotional/mental health issues with links to local services and national mental
health charities. Possible options may include extending current resources, e.g. the RE:FRESH website,
or scoping out new resources.
National survey work backed up by our local engagement work suggests that between the ages of 8
years to around 15 years, subjective wellbeing (how young people think and feel) starts to decline,
particularly amongst girls. Self-rated aspects of health, family relationships and choice are lowest
around the mid-teenage years and start to improve again from around the age of 17 years. Evidence
from neurological studies indicates that the adolescent brain undergoes rapid development and
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functions responsible for emotional maturity are delayed accounting for increased impulsivity and risk
taking behaviours in teenagers.
Current approaches including the Early Help Strategy are focused on supporting vulnerable children
and families in the early years. However it is clear from the burgeoning evidence that we also need to
understand adolescence as a critical period of risk and put in place strategies to support young people.
Efforts should be focused promoting wellbeing and resilience amongst young people. These strategies
should include building positive climates for young people to talk about emotional health and
supporting activities that encourage wellbeing. For example there is strong evidence that participation
in sport and physical activity is one of the key factors in preventing mental ill health.
Listening to the authentic voices of children and young people has been critical to the development of
this ISNA. The engagement work involved over 250 conversations with a range of individuals and
groups from school children to some of our more vulnerable young people such as those leaving care.
It is evident that children and young people value being involved in engagement work. However for
some there was a sense of frustration on the lack of feedback they received when they had been
involved in previous engagement work. As a result of this ISNA work there are opportunities to involve
children and young people in long-term and sustainable engagement work. Some ideas for
consideration may include:



Establishing a young person’s engagement hub or young person’s health and wellbeing
shadow board , drawing membership from a network of local services/groups with an interest
in children and young people’s issues.
Developing feedback mechanisms for children and young people using different means
including social media.
A commitment to involving and co-producing service improvements in collaboration with
children and young people. For example, service re-design work at the Everybody Centre is a
good opportunity for young people to support local developments.
Throughout our discussions with young people around the ‘Five Ways to Wellbeing’ and concepts of
‘giving’ to others, very few young people could identify concrete examples of where they did things for
other people. This has also been highlighted in national survey work conducted by the Children’s
Society, who suggest that the concept of ‘giving’ should be replaced by ‘creativity’. However it was
clear that a number of young children do help others, for example as young carers or helping younger
siblings, but perhaps do not recognise these roles as a form of altruism. In addition, peer-to-peer
support was frequently suggested in the engagement work as a possible means of providing mutual
support. Volunteering and peer support does improve mental and physical wellbeing outcomes and
could be explored further as a future development.
There are several specific challenges that require further discussion and response. The overwhelming
majority of children and young people involved in the discussion work for the ISNA had access to
smartphones and social networking sites. Social media does offer opportunities to communicate key
messages around emotional health and wellbeing. The recent insight report commissioned by the
Council’s communications team highlights some key recommendations that can be used to inform
developments in this area. However it was also apparent from the engagement work that many
children and young people had personal experiences of bullying and intimidation through social
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networking sites. Evidence from national charities such as YoungMinds and Childline highlights how
this can have a profound effect on emotional and wellbeing. Parents and teachers often report a lack
of knowledge and skills on how to deal with these issues and are asking for more support.
The ISNA has also highlighted self-harm as critical issue for local young people. It is particular issue
during adolescence, reflecting emotional distress, and the majority of cases do not come to the
attention of professional services. Rates of self-harm in Blackburn with Darwen are higher than the
national average particularly amongst girls. It is important that we raise self-harm as an important
issue with our schools, families and local communities and adopt preventative approaches to tackle
this issue.
A key challenge in developing this ISNA has been around the lack of available measures on children and
young people’s wellbeing. ONS are currently developing a set of indicators at the national level and
WEMWBS has been validated from the age of 13 years. Consideration should be given to developing
measures of wellbeing at the local level. Approaches could include an annual local survey and
developing consistent approaches to measuring wellbeing outcomes across commissioned services.
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14.2 Recommendations
The following section sets out a series of key recommendations with accompanying narrative and
examples for policy development:
1.
Approaches that support positive outcomes for children and young people’s emotional
health and wellbeing should be built into all contracts and service specifications.


2.
A programme of work should be developed that recognises emotional health and
wellbeing in pregnancy as a public health issue with important life course consequences.






3.
Service specifications/contracts to include evidence-based approaches that support
positive emotional and physical health outcomes for children and young people e.g.
Five Ways to Wellbeing.
Adopt consistent wellbeing outcome measures/indicators for various commissioned
activities e.g. WEMWBS.
Explore ways of promoting positive public mental health messages to pregnant
women.
Undertake asset mapping for activities/resources that promote emotional health and
wellbeing during pregnancy and beyond, and look at ways of promoting information
to families.
Support and promote emotional health and wellbeing in pregnancy and beyond
including access to group activities in children’s centres and other venues.
Look at ways of identifying individuals and families experiencing loneliness and
isolation to offer targeted support.
Explore opportunities to develop formal and informal peer support networks during
ante-natal and post-natal periods.
Develop trusted self-care resources on emotional health and wellbeing issues during
pregnancy and beyond. Topics may include: low-level anxiety and depression,
bonding and attachment, and healthy behaviours.
Specific approaches should be developed that support teenagers at risk of self-harming.
Self-harm is an important public health issue affecting significant numbers of
children and young people. Approaches should include prevention, assessment and
ensuring appropriate treatment is in place.
4.
All Health and Wellbeing strategies and programmes should be informed through active
engagement and insight work with children and young people.



Look at opportunities to establish an ‘engagement hub’ or young person’s health and
wellbeing board drawing membership from a network of local services/groups with
an interest in children and young people’s issues.
Develop feedback mechanisms for children and young people on health and
wellbeing matters using different means including social media.
Offer opportunities for young people to support and co-produce service
improvements.
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5.
‘Whole school approaches’ to emotional health and wellbeing that involve teachers,
families and the wider community should be developed in line with national guidelines.




6.
A health and wellbeing website promoting physical and social activities should be
developed, specifically aimed at children, young people and their families.



7.
Currently there is a lack of trusted on-line information specifically aimed at children
and families on local health and wellbeing issues. There are existing resources but
these are out of date and difficult to locate. A new on-line resource could include
information on affordable activities within the local area for all the family. The
website could also provide low level advice and information on emotional and
mental health issues with links to local services and national support resources.
Explore programmes that promote physical activity and wellness such as access to
sporting facilities, taster sessions and other leisure activities. Efforts to target and
engage teenagers, particularly girls, in sports and leisure should be encouraged.
Consider promoting sport/physical activity as part of future public health
commissioning intentions.
Resilience within families should be promoted by providing parents and carers with the
information they need to handle issues of emotional and mental wellbeing.



8.
Encourage teachers, school staff, parents/carers to develop specific emotional health
and wellbeing competencies through participation in accredited training e.g. Mental
Health First Aid Training /Youth Mental Health First Aid Training.
Raise awareness and identify resources for teachers and others to support issues
specific to young people, particularly self-harm and cyberbullying. Explore
opportunities such as anti-bullying ambassadors.
Train teachers in the use of routine enquiry approaches to identify children and
young people who are experiencing emotional difficulties.
Explore how the role of school nurses can be maximised in relation to supporting
pupils’ emotional health and wellbeing.
Many children and young people reported that parents were a primary source of
support at times of emotional difficulty. Very few of these will ever come into
contact with specialist services that are currently aimed at young people with more
complex needs.
More insight work is needed around how parents and carers can self-manage day-today emotional issues within the family; how to deal with specific issues such as exam
pressures, peer pressure, bullying, risk-taking behaviours and problems around social
media; and when to access specialist support.
Opportunities may include more parents accessing courses such as the Mental
Health First Aid Training and also awareness around on-line resources.
Links between adolescence, risk-taking behaviours and the prevention of accidents and
unintentional injuries should be further explored.
 There is evidence to link a decline in emotional and wellbeing in the mid-teenage
years and an increase in risk-taking behaviours. Risk taking behaviours are also
associated with increasing risks of accidents and unintentional injuries. Participating
in leisure activities and physical activity is very important for young people’s
subjective wellbeing and for reducing risk taking such as smoking, drinking etc.
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9.
More insight work should be undertaken into the use of social media and the negative
impacts for children and young people’s emotional and mental health.


10.
Opportunities for children and young people to engage in peer-support programmes and
volunteering should be explored.

11.
Smoking prevalence is higher amongst certain vulnerable groups e.g. children of
substance-misusing parents, and looked-after children. This often leads to long-term
addiction and poor health consequences. More insight work and preventative
approaches should be undertaken in relation to such groups.
Insight work should be undertaken to understand factors contributing to low levels of
wellbeing amongst young people in adolescence.

14.
There are certain groups who are more at risk of social isolation and experience
more loneliness than others. Individuals from certain vulnerable groups may be
dislocated from families and spend long periods of time in temporary
accommodation putting them at further risk of mental health problems. There
needs to be more insight and understanding around ‘at risk’ groups such as careleavers in terms of loneliness and isolation.
All commissioners and services should challenge the culture of acceptance and inevitability
around smoking, particularly amongst vulnerable groups.

13.
Explore the evidence around peer-support programmes and how these may be
developed through existing commissioned services and community-led approaches.
Look at ways of encouraging volunteering opportunities to build community
capacity.
Work should be undertaken to identify groups of children and young people that may be at
risk of loneliness and social isolation.

12.
More insight work is needed into problems associated with social media such as
cyber bullying and on-line intimidation.
Ensure resources are available to provide advice for children and young people,
parents and professionals, including teachers. A number of charities have on-line
resources freely available.
Evidence suggests that wellbeing declines in adolescence due to complex
interactions of neurological, physical and emotional changes. Approaches should be
developed that identify and support young people during this ‘at risk’ period.
A review of specialist mental health services for children and young people should be
commissioned, including vulnerable groups such as looked-after children and care-leavers.

Consider the findings of the research study into looked-after children that has been
undertaken in Blackburn with Darwen.
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15.0 Existing strategies plans and policies
The following section sets out a number of strategies, policies and clinical guidelines relevant to
children and young people’s emotional health and wellbeing.
Chief Medical Officer(2013) Prevention pays –our children deserve better
This second annual report by the Chief Medical Officer Dame Sally Davies outlines 24
recommendations to improve the health and wellbeing of children and young people. The report
makes a strong case for society to listen to the voices of children and young people and to help them
develop emotional resilience to deal with life’s ups and downs.
Department of Health (2011) No Health Without Mental Health: a cross government mental health
outcomes strategy for people of all ages
This strategy sets out how the government will work with the community and takes a life-course
approach to improving population mental health and wellbeing and access to high quality services.
Department of Health (2014) A compendium of Factsheets: Wellbeing Across the Lifecourse
A series of factsheets on the growing evidence base on the importance of wellbeing and health across
the lifecourse from before birth through to older age.
Relevant Clinical Guidelines
The following NICE/SCIE guidance supports implementation of programmes to improve mental health
and wellbeing in children and young people:

Autism: the management and support of children and young people on the autism spectrum
(2013), NICE clinical guideline 170
Recommends ensuring access to mental health services, autism awareness training for staff,
making adjustments to care, psychosocial interventions, anticipation and prevention of
challenging behaviour, offering families/carers an assessment of their own needs, and
involving the young person in planning transition to adult services.

Antisocial behaviour and conduct disorders in children and young people: recognition,
intervention and management (2013) NICE clinical guideline 158
Children and young people with a suspected conduct disorder should be assessed using the
Strengths and Difficulties Questionnaire*. Those identified (aged 3-11 years) should have group
parent training programmes offered to their parents and children aged 9-14 years should be
offered group social and cognitive problem-solving programmes. Those with coexisting mental
health problems should be referred to CAMHs. Multisystemic therapy could be offered to
children and young people aged 11-17 years. Foster carers/guardians should have training
*
http://www.sdqinfo.org
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programmes. Schools should offer classroom-based emotional learning. Pharmacological
interventions should not be routinely offered.

Quality standard for the health and wellbeing of looked-after children and young people
(2013) NICE quality standard 31
Sets out the following standards:
Looked-after children and young people should experience warm, nurturing care.
Looked-after children and young people should receive care from services and professionals
that work collaboratively.
Looked-after children and young people should live in stable placements that take account of
their needs and preferences.
Looked-after children and young people should live in stable placements that take account of
their needs and preferences
Looked-after children and young people should have ongoing opportunities to explore and
make sense of their identity and relationships
Looked-after children and young people should receive specialist and dedicated services within
agreed timescales.
Looked-after children and young people who move across local authority or health boundaries
should continue to receive the services they need.
Looked-after children and young people should be supported to fulfil their potential.
Care-leavers should move to independence at their own pace.

SCIE Guide 40 Recommendations on looked-after children: Promoting the quality of life of
looked-after children and young people
Makes recommendations for practice on promoting mental health, health assessments,
personal quality of life, preparing for independence, workforce development and supporting
placements.

Quality standard for antenatal care (2012) NICE quality standard 22
Recommends pregnant women who smoke are referred to an evidence-based stop smoking
service. Pregnant women should be cared for by a named midwife throughout their
pregnancy. Those with a body mass index of 30kg/m2 should be offered personalised advice
on healthy eating and physical activity.

Social and emotional wellbeing: early years (2012) NICE public health guidance 40
Commissioners should ensure universal and targeted services to protect children’s mental
wellbeing. Health visitors, school nurses and early years practitioners should identify risk
factors using the ‘Early years foundation stage’ assessment process. There should be antenatal
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and postnatal home visiting for vulnerable children and their families which should include
home learning and parenting skills. Good childcare and early childhood education should also
be available for vulnerable children. Baby massage and video interaction guidance* is
promoted.

Pregnancy and complex social factors: A model for service provision for pregnant women
with complex social factors (2010) NICE clinical guideline 110
Recommends recording women with complex social factors; antenatal appointment
attendance; and putting together a multi-agency needs assessment. For women who misuse
substances, services should be coordinated and care plans developed. A local protocol should
be developed for women experiencing domestic violence to include a clear referral pathway,
safety information and sources of information and support. Recommends that information
about pregnancy and antenatal services should be provided in a range of formats and settings
(eg. faith groups, hostels) to target those who are recent migrants or who have difficulty
reading or speaking English. Recommends commissioning specialist services for young women
under 20 years old.

Promoting young people’s social and emotional wellbeing in secondary education (2009)
Commissioners and providers of children’s services should enable all secondary schools to
adopt an organisation-wide approach to promoting the social and emotional wellbeing of
young people. This includes: encouraging the LA scrutiny committee to assess progress made;
workforce development; sharing of practical advice; ensuring access to specialist skills and
advice; and ensuring policies and arrangements are in place. Headteachers, governors and
teachers should demonstrate commitment to the social and emotional wellbeing of young
people. There should be a curriculum that promotes positive behaviours and reduces bullying.
Schools should work in partnership with parents and carers, especially those living in
disadvantaged circumstances, to ensure they can participate in activities to promote social and
emotional wellbeing. They should also work in partnership with young people so that they can
contribute to decisions and encourage a peer mediation approach as well as providing
information about opportunities for them to discuss personal issues and emotional concerns.
Social and emotional wellbeing should be part of continuous professional development for
staff.

Promoting physical activity for children and young people (2009) NICE public health guidance
17
All JSNAs and local plans should outline the need for children to be physically active and there
should be a coordinated local strategy to increase physical activity among children and young
people. Physical activity initiatives should be regularly evaluated. A senior council member
should be a champion for children and young people’s physical activity. Provision of spaces and
facilities should be factored into to planning. Eg. ensuring children and young people have
*
http://www.videointeractionguidance.net
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facilities where they feel safe taking part in activities and that all groups have access, including
those with disabilities. Local transport and school travel plans should be aligned with other
local authority plans which have an impact on physical activity. School travel plans should have
physical activity as a key aim. Local plans should be informed by consultation with children
and their families to find out what type of physical activities children and young people enjoy
(particularly girls and young women). Staff providing sessions should have skills in delivering
those sessions and have qualifications for working with children eg. child protection. Multicomponent physical activity programmes should be developed including promotion of the
benefits, creating more breaks during and after school and setting up family fun days.
Environments should be developed that encourage children to explore, eg. adventure
playgrounds, woodland, fun trails.

Social and emotional wellbeing in primary education (2008) NICE public health guidance 12
Recommends schools adopt a ‘whole school approach’ to children’s social and emotional
wellbeing. This includes creating a supportive ethos for learning; a safe, secure environment
free from bullying or violence; help for children at risk of emotional or behavioural problems;
training for teachers; a curriculum that integrates the development of social and emotional
skills; and support to help parents develop their parenting skills. It also means ensuring that
teachers are trained to identify signs of mental distress, and providing a range of interventions
to support the child’s needs.

Physical activity and the environment (2008) NICE public health guidance 8
Recommends involving local communities in planning for new developments to ensure
opportunity for physical activity is maximised. Pedestrians, cyclists and users of other modes of
transport that involve physical activity should be given priority when designing roads. A
network of routes for walking and cycling should be developed and public spaces and paths
should be able to be reached by foot and bicycle. Public buildings should ensure attractive and
well-lit staircases to encourage people to use them. School playgrounds should encourage
varied, physically active play and create areas to promote individual and group activities eg.
hopscotch.

Children of prisoners – maintaining family ties (2008), Children’s and Families’ services SCIE
guide 22
This guide reviews the literature on policies and procedures, funding, partnerships, good
practice and training. Separation due to parental imprisonment is harmful for children because
of effects of separation, stigma and loss of family income. Notes the increase in the female
prison population in recent years. Advocates family learning programmes in prison and
interventions such as ‘Girl Scouts Beyond Bars’* (enhanced visits between children and
mothers) and ‘Storybook Dads’.
*
Girl Scouts (2012), Girl scouts beyond bars: Incarcerated Mothers, Empowered Daughters – and a Better Future
for All, Office of Juvenile Justice and Delinquency Prevention
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Children and Young People’s Emotional Health and Wellbeing

Antenatal and postnatal mental health: Clinical management and service guidance (2007)
NICE clinical guideline 45
Recommends establishing any history of mental illness or family history of perinatal mental
illness, and asking screening questions to detect depression at 4-6 weeks and 3 to 4 months.
Women requiring psychological treatment should be seen within one month of assessment.
For mild and moderate depression self help strategies, non directive counselling and brief
cognitive behavioural therapy should be considered. Women who have mental health issues
and who are taking medication should be given information about proper use and any side
effects.

School-based interventions on alcohol NICE (2007) public health guidance 7 Alcohol
education should be an integral part of the PSHE curriculum. There should be a whole-school
approach to alcohol from policy development to professional development of staff. Brief one–
to-one advice and referrals should be made for children who are thought to be drinking
harmful amounts of alcohol.

Interventions to reduce substance misuse among vulnerable young people (2007). NICE
public health guidance 4
Local areas should have a strategy in place to reduce substance misuse among vulnerable
people aged under 25. The Common Assessment Framework and tools from Public Health
England should help to identify young people who are misusing substances. Family-based
programmes of support should be offered. Children who are disruptive and assessed to be at
high risk of substance misuse should have group-based behavioural therapy before and during
transition to secondary school. One-to-one motivational interviews should be offered to
children and young people who are problematic substance misusers.

Postnatal care: Routine postnatal care of women and their babies (2006) NICE clinical
guideline 37
Women should have a postnatal care plan which should be constantly reviewed. Women
should be offered relevant information to promote their own and their babies’ health and
wellbeing and recognise and respond to symptoms. All maternity care providers should
encourage breastfeeding. At each postnatal contact, women should be asked about their
emotional wellbeing, what family and social support they have and their usual coping
strategies. They should be encouraged to tell their healthcare professional about any changes
in mood, emotional state and behaviour outside of the woman’s normal pattern.

Parent-training/education programmes in the management of children with conduct
disorders (2006). NICE technology appraisal 102
This guidance applies to the management of children 12 years or younger. Recommends all
programmes should be structured and have a curriculum informed by social-learning theory.
There should be 8-12 sessions, which should enable parents to identify their own parenting
objectives, incorporate role-play, and be delivered by trained facilitators who have
professional supervision and adhere to the programme developer’s manuals.
79
Children and Young People’s Emotional Health and Wellbeing

Depression in children and young people (2005). NICE clinical guideline 28 When assessing a
child or young person, the social, educational and family context including the quality of
relationships between family and peers should be recorded. Psychological therapies should be
provided by trained child and adolescent mental healthcare professionals. The parents’ mental
health should be taken into account and treated in parallel. Healthcare professionals in
primary care and schools should be trained to detect symptoms of depression. CAMHs tier 2 or
3 should work along with health and social care professionals in primary care and with schools
to provide training to detect, assess, support and refer children and young people who are
depressed or at risk of depression. Training should be made available to improve the accuracy
of CAMHs professionals in diagnosing depression. Antidepressant medication should not be
used for the initial treatment of children and young people with mild depression nor for
moderate to severe depression except in combination with psychological therapy. Those with
moderate to severe depression should be offered CBT, interpersonal therapy or shorter-term
family therapy of at least three months in duration.

Eating disorders (2004) NICE clinical guideline CG9 Assessment of eating disorders should
include physical, psychological and social needs and a risk to self. Healthcare professionals
should acknowledge that many people with eating disorders are ambivalent about treatment.
Family interventions that directly address the eating disorder should be offered to children and
adolescents. Family members should be included in the treatment but there should also be
appointments separate from family members. Healthcare professionals assessing children and
adolescents with eating disorders should be alert to indicators of abuse. Adolescents with
bulimia nervosa may be treated with CBT-BN as adapted to suit their age.

Self-harm: The short-term physical and psychological management and secondary
prevention of self-harm in primary and secondary care (2004). NICE guidance CG16
80
Children and Young People’s Emotional Health and Wellbeing
Where to find out more
For more information on the content and detail contained within this ISNA please contact:
Specialist Public Health Directorate
6th Floor
10 Duke Street
Blackburn
BB2 1DH
Telephone: 01254 585345
Email: [email protected]
81
Children and Young People’s Emotional Health and Wellbeing
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