Emotional
Health and
Wellbeing
in Bristol
Needs
Assessment.
August 2015
Hannah Russell, Commissioning
Manager (Children), Alex
Layard, Service Development
Manager, Dr Jo Williams,
Consultant in Child Public
Health, Dr Julie Mytton,
Consultant in Child Public
Health, Bristol City Council.
Contents
Executive summary ........................................................................................................4
1.0 Introduction ...............................................................................................................5
2.0 The population of children and young people in Bristol ........................................9
2.1 Current population estimates of children and young people in Bristol. ......................... 9
2.2 Ethnicity of the child population ................................................................................. 11
2.3 Population projections ............................................................................................... 13
3.0 The emotional health of children and young people in Bristol. ...........................16
3.1 Estimates of the prevalence of emotional health problems in children and young
people in Bristol ............................................................................................................... 16
3.2 Attention deficit hyperactivity and hyperkinetic disorders ........................................... 17
3.3 Autistic spectrum conditions ...................................................................................... 18
3.4 Estimated need for Child and Adolescent Mental Health Services at each tier .......... 18
3.5 Estimates of neurotic disorders in young people ........................................................ 19
3.6 Eating disorders......................................................................................................... 20
3.7 Self-harm ................................................................................................................... 21
3.8 Estimates of learning difficulties and mental health problems .................................... 21
3.9 Behavioural emotional and social difficulties (BESD) ................................................. 22
4.0 Children & young people vulnerable to poor emotional health ...........................24
4.1 Risk factors for poor emotional health and wellbeing ................................................. 24
5.0 Services for children and young people with emotional health needs ...............30
5.1 Service use by current provider ................................................................................. 30
6.0 Stakeholder perspectives on children and young people’s emotional health and
wellbeing services and needs ......................................................................................34
6.1 Consultations on services for children and young people in Bristol ............................ 34
6.2 Messages arising from consultations ......................................................................... 34
7.0 Summary .................................................................................................................37
Appendix 1: Abbreviations ...........................................................................................38
2
List of Tables
Table 1: Bristol 2014 Population Estimates by five year age band ............................. 9
Table 2: Overview of child population in Bristol by Locality, 2007-12 ....................... 10
Table 3: Bristol population projections, 2012-2022 .................................................. 13
Table 4: Bristol projected child population, 2012-2022 ............................................. 14
Table 5: Estimated number of children in Bristol with mental health disorders, 2014
................................................................................................................................. 17
Table 6: Estimated number of children with Autism Spectrum Disorder, Bristol, 2014
................................................................................................................................. 18
Table 7: Estimated number of children and young people who may experience
mental health problems appropriate to a response from CAMHS, Bristol, 2014 ...... 19
Table 8: Estimated number of young people in Bristol with neurotic disorders, 2014
................................................................................................................................. 20
Table 9: Estimated new diagnoses of eating disorder, children aged 10-19y, Bristol,
2014 ......................................................................................................................... 20
Table 10: Estimated number of children with learning difficulties and mental health
problems, Bristol, 2014............................................................................................. 21
Table 11: Number of children in Bristol with BESD, 2014, by Locality ..................... 22
Table 12: Risk factors for mental disorders in children and young people, 2004 ..... 26
Table 13: Snapshot of CAMHS service use in Bristol, June 2014 ............................ 31
Table 14: Referrals to CAMHS Deliberate Self-Harm Service, under 18s, Bristol,
2013 ......................................................................................................................... 32
List of Figures
Figure 1: Previous tiered model of care...................................................................... 8
Figure 2: Children and young people population trends, 1991-2013 .......................... 9
Figure 3: Children and young people population change, 2008-13 .......................... 10
Figure 4: Total number of children, 0-15y, by CCG Locality, 2001-13 ...................... 11
Figure 5: Ethnicity and number of children (0-15y), by CCG Locality, 2011 ............. 11
Figure 6: Density of pupils with English as an alternative language, 2013 ............... 12
Figure 7: Bristol population projections, 2012-2022, by age band ............................ 13
Figure 8: Bristol child population projections, 2012-22, by age band ....................... 14
Figure 9: Number of children with BESD special educational needs, Bristol, 2014, by
ward ......................................................................................................................... 22
Figure 10: Risk factor profile for children and young people's mental health and
wellbeing, 2014 ........................................................................................................ 24
Figure 11: Young people 10-24y admitted to hospital for self-harm, rate per 100,000
population aged 10-24y, 2007-2013, Bristol ............................................................. 32
Figure 12: Children and young people's mental health and wellbeing profile,
Admissions data, Bristol ........................................................................................... 33
3
Executive summary
Emotional health and wellbeing is a wider concept than poor mental health. It covers
a whole spectrum of activities and behaviours, and promoting and maintaining
emotional health and wellbeing needs to be a system-wide and integrated activity.
This needs assessment attempts to draw together information on the emotional
health and wellbeing of children and young people in Bristol. It will provide an
information resource on which to develop a five year Emotional Health and
Wellbeing Strategy for children and young people in the city and an associated
action plan.
The needs assessment describes the size and composition of the population of
children and young people in the city in chapter 2. In chapter 3, national rates of
mental health problems are applied to the Bristol population to estimate need, and in
chapter 4 risk factors for poor emotional health are similarly estimated. Data on
current services are described in chapter 5, whilst chapter 6 summarises the views
of children, young people, their parents and carers on how local services should be
developed.
The number of children and young people living in the city has increased in recent
years and is expected to increase further in the future, though these changes have
occurred unevenly across the city and are expected to put additional demands on
existing services. Whilst national estimates of the prevalence of clinically diagnosed
disorders are in the region of 5400 children and young people, these figures are
likely to underestimate the true level of need. Diagnoses of mental health disorders
increase with age through childhood and are commoner in boys for all conditions
except emotional disorder and self-harm.
Most data available on service use reflects services for children and young people
with the most severe mental health needs; e.g. those being admitted to hospital,
attending emergency services, or accessing Tier 3 or 4 CAMHS services. The data
on children with lower levels of need is not available, nor is data on long term
outcomes for children with such needs.
Service users are clear that they want services for children and young people to be
joined-up, across the whole system, with a well-trained workforce. Ease of access,
choice and timeliness are very important and services should recognise the potential
of using digital and communication technology to improve service delivery and
experience.
This report aims to support Bristol Clinical Commissioning Group during its recommissioning of community child health and CAMHS for the city, and to facilitate
the development of an agreed multi-agency Emotional Health and Wellbeing
Strategy for children and young people to prevent poor emotional health where
possible and provide high quality and effective care for those affected by poor
emotional health.
4
1.0 Introduction
This document describes the emotional health and wellbeing of children and young
people in Bristol. It aims to inform the Bristol Emotional Health and Wellbeing
Strategy for Children and Young People for 2015-20 and the action plan that will
enable delivery of the strategy.
The Strategy and Action Plan will build on the challenges and successes of the
2009-2014 Strategy, will aim to prevent poor emotional health in children and young
people in Bristol and improve health where necessary.
What is emotional health and wellbeing?
In this document the phrase „emotional health and wellbeing‟ is used to refer to
emotional and mental health. „Mental health‟, while recognised as a positive term
by professionals, m a y b e seen as stigmatising by young people and may can
deter them from accessing services.1
Positive emotional health can be defined as:
“…not simply the absence of disorder but a state of wellbeing in which every
individual realises his or her own potential, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make a contribution to his or
her community”.2
Good mental health is considered a foundation for healthy development 3. The
development of mental health problems early in life can have adverse and long
lasting effects. The quality of parenting and attachment in the perinatal period
and early childhood are particularly important for future emotional health4,5. In this
period, developing stable attachment to a parent figure is key6. Good emotional
health is characterised by a person‟s ability to fulfil a number of key activities,
including: the ability to learn, the ability to feel, express and manage a range of
positive and negative emotions, the ability to form and maintain good relationships
with others and the ability to cope with and manage change and uncertainty” 7
1
Annual Report of the Chief Medical Officer (2012) Public Mental Health Priorities: Investing in the Evidence.
London: Stationery Office
2
World Health Organisation (2010) Mental Health: strengthening our response. Factsheet 220 in Guidance for
Commissioners of Child & Adolescent Mental Health Services’ (October 2013; page 5).
3
Joint Commissioning Panel for Mental Health (2013) Guidance for Commissioners of Child and Adolescent
Mental Health Services. (page 5) London
4
Children and Young People’s Health Outcome Forum (2012) Report of the Children and Young People’s Health
Outcome Forum – Mental Health Sub-group. Available at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216853/CYP-Mental-Health.pdf
(Accessed 2 June 2015)
5
Early Intervention Foundation (2015) The Best Start At Home. London
6
National Institute for Health and Clinical Excellence (2012) Social and emotional wellbeing: early years PH40
(2012), London
7
Available from http://www.mentalhealth.org.uk/help-information/an-introduction-to-mental-health/what-is-goodmental-health/ (Accessed 28 May 2015)
5
What is the impact of poor emotional health and wellbeing?
An absence of positive emotional health could be described as emotional ill health.
This will usually come to the notice of others by the presence of symptoms or
difficulties. The Mental Health Foundation explains that “most mental health
symptoms have traditionally been divided into groups called either „neurotic‟ or
„psychotic‟ symptoms. „Neurotic‟ covers those symptoms which can be regarded as
severe forms of „normal‟ emotional experiences such as depression, anxiety or
panic.
Less common are „psychotic‟ symptoms, which interfere with a person‟s perception
of reality, and may include hallucinations such as seeing, hearing, smelling or
feeling things that no one else can”8. Such disorders represent the most severe end
of the spectrum of problems and are associated with significant impairment.”9
Use of the term „mental disorder‟ with children and young people may cause its own
problems. It has been argued that poor mental health may have less of an impact
than the stigma associated with it10. The Surgeon General of the United States cited
that stigma is the most important problem facing the field of mental health.11
The links between poor emotional health and wellbeing and poor educational
outcomes are clear:



Almost half of young people with fewer than 5 GCSEs graded A* to C said
they „always‟ or „often‟ feel down or depressed compared to 30% of young
people who are more qualified.12
Children with persistent conduct or emotional disorders13 are:
 More likely to be excluded from school
 Less likely to engage with out-of-school programmes to help them
manage their behaviour and improve literacy
 More likely to be assessed as having Special Educational Needs
 More likely to leave school without educational qualifications
Children with conduct disorders and severe Attention Deficit Hyperactivity
Disorder (ADHD) may be four to five times more likely to struggle to attain
literacy and numeracy skills (Green, et al., 2005).14
8
Available from http://www.mentalhealth.org.uk/help-information/an-introduction-to-mental-health/what-aremental-health-problems/ (Accessed 28 May 2015)
9
HM Government (2009). New Horizons: A shared vision for mental health in Joint Commissioning Panel for
Mental Health; Guidance for Commissioners of Child and Adolescent Mental Health Services: (October 2013).
10
Children and Young People’s Health Outcome Forum (2012) Report of the Children and Young People’s
Health Outcome Forum – Mental Health Sub-group. Available at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216853/CYP-Mental-Health.pdf
(Accessed 2 June 2015)
11
Hinshaw 2005 quoted Young Minds publication ‘Stigma - A Review of Evidence’ Young Minds website.
12
Children and Young People’s Mental Health Coalition (2012) Resilience and Results. Available at
http://www.cypmhc.org.uk/media/common/uploads/Final_pdf.pdf (Accessed 1 June 2015)
13
‘Children and Young People’s Mental Health Coalition (2012) Resilience and Results. Available at
http://www.cypmhc.org.uk/media/common/uploads/Final_pdf.pdf (Accessed 1 June 2015)
14
http://www.cypmhc.org.uk/media/common/uploads/Final_pdf.pdf
6
Services for children and young people with poor emotional health and
wellbeing
Children and young people will have varying needs at different times in relation to all
aspects of their holistic health: physical, social and emotional. Child and Adolescent
Mental Health Services (CAMHS) have traditionally used a tiered model of care
(Figure 1). Children with the most severe needs, requiring access to Tier 4 services
in CAMHS, have often needed to travel significant distances to receive care. Current
policy is moving away from such a structured, tiered, model of care.
A delay in young people seeking help will delay receipt of interventions and support.
Early intervention may reduce the risk of later disorders and save money.15 Mental
health problems in childhood and adolescence in the UK result have been estimated
to cost of between £11,030 and £59,130 per child annually. 16 Studies have shown
that public service costs incurred in adulthood by individuals diagnosed with mental
health problems in childhood can be as much as 10 times more than the cost of
people with no such history.17
Policy context
Sir Michael Marmot in his report „Fair Society, Healthy Lives‟ identified that giving
every child the best start in life was the first priority18 , and this includes support for
children to receive the nurturing environment that leads to good emotional health and
wellbeing. The National Institute for Health and Clinical Excellence published
guidance in September 201319 on the Social and Emotional Wellbeing of Children
and Young People which describes the role of all agencies to provide a cross-partner
strategy to promote and support good emotional health. Local Authorities are a lead
agency in this partnership, with the public health outcomes framework for England
2013-16 including measures to promote attainment of these outcomes20. Guidance
from Public Health England has recently described the actions that schools and
colleges can take to promote emotional health21.
The Children and Young People‟s Mental Health and Wellbeing Taskforce was
established in September 2014. This national multi-stakeholder group has recently
published guidance on ways to make it easier for children, young people, parents
and carers to access help when it is needed and to improve the way in which
services are organised commissioned and provided22. This includes the following
15
CMO Annual Report 2013-14; page 102
CMO Annual Report 2013-14; page 102
17
The NHS Confederation (2007) The Voice of NHS Leadership: London
16
18
Marmot M. Fair Society, Healthy Lives. Available from:
http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review
19
NICE (2013) Social and emotional wellbeing for children and young people. Available from
http://publications.nice.org.uk/lgb12
20
Public Health Outcomes Framework. Available from: http://www.phoutcomes.info/
21
PHE (2015) Promoting children and young people’s emotional health and wellbeing; A whole school
and college approach. Gateway reference no: 2014825. Available from
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414908/Final_EHWB_d
raft_20_03_15.pdf
22
NHS England (2015) Future in mind: promoting, protecting and improving our children and young
people’s mental health and wellbeing. NHS England Gateway Ref No: 02939. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Men
tal_Health.pdf
7
five themes:
1. Promoting resilience, prevention and early intervention
2. Improving access to effective support (simplifying structures and removing
barriers)
3. Care for the most vulnerable
4. Accountability and transparency
5. Developing the workforce
These themes will be considered during the preparation of the Bristol Emotional
Health and Wellbeing Strategy for Children and Young People for 2015-20 and
associated action plan.
Figure 1: Previous tiered model of care
Note: this tiered model of care has been included in this needs assessment as the
most recent data available on service use relates to the tiers described in this model.
8
2.0 The population of children and young people in Bristol
2.1 Current population estimates of children and young people in
Bristol.
The latest estimate of the total number of people living in Bristol (2014 mid-year
population estimate) is 442,50023 (Table 1). By broad age group, Bristol has 82,800
children under 16 (18.7% of the population), and 67,400 young people 16-24
(15.4%). The current estimate of children under 18 is 91,859 and for children 5-16y
is 56,316.
Table 1: Bristol 2014 Population Estimates by five year age band
Age band
0-4y
5-9y
10-14y
15-19y
20-24y
Total
Males
Number
% total
male pop
15,900
13,200
10,800
13,100
23,100
76,100
7.2
6.0
4.9
5.9
10.5
Females
Number
% total
female
pop
15,100
6.8
12,800
5.8
10,600
4.8
13,200
6.0
23,400
10.6
75,100
Total
Number
% total
pop
31,000
26,000
21,400
26,300
46,500
151,200
7.0
5.9
4.8
5.9
10.5
Source: Population Estimates Unit, ONS: Crown Copyright 2015
In the last decade, Bristol‟s child population has been rising24; about three times
faster than national average, and numbers are at the highest level since the mid1980‟s (Figure 2).
Figure 2: Children and young people population trends, 1991-2013
23
Available from
http://www.bristol.gov.uk/sites/default/files/documents/council_and_democracy/statistics_and_census_informatio
n/Briefing%20Note%20-%20Mid-2014%20Population%20Estimates.pdf (Accessed 17Aug2015)
24
Bristol City Council Joint Strategic Needs Assessment; Available at http://www.bristol.gov.uk/page/adult-careand-health/joint-strategic-needs-assessment-jsna (Accessed 1 June 2015)
9
Source: Population Estimates Unit, ONS: Crown Copyright 2014
The change has not been equal across the city. Bristol‟s child population has risen
fastest in the increasingly diverse Inner City & East, where since 2001 numbers of
children in Inner City alone have increased 48% (Bristol +11%). But in the last 5
years, 2008-13, children (under 16) have risen significantly in all areas (Figure 3 and
Table 2). However, for young people (16-24) the 3% city-wide rise has been very
concentrated in Inner City & East, with that age group reducing in other areas.
Figure 3: Children and young people population change, 2008-13
Source: JSNA 2014; Children and young people update. V5 final.
Table 2: Overview of child population in Bristol by Locality, 2007-12
Live Births,
2012
0-4 year olds,
2013
0-15 year olds,
2013
Bristol total
Inner City &
East
North & West
South
N (% increase
2008-13)
N (% increase
2008-13)
N (% increase
2008-13)
N (% increase
2008-13)
6780 (14%)
2250 (19%)
2190 (11%)
2340 (14%)
30,900 (17%)
10,000 (25%)
10,300 (12%)
10,600 (15%)
81,800 (11%)
25,000 (18%)
28,600 (9%)
28,200 (8%)
Source: JSNA 2014; Children and young people update. v5
Bristol‟s child population is rising in all areas, and rising fastest in Inner City & East,
which has the least number of wards. Figure 4 illustrates the average rate of
increase within wards, highlighting the increasing pressures within the Inner City &
East locality area. The North & West locality area now has the highest total number
of children but the lowest average number in each ward.
10
Figure 4: Total number of children, 0-15y, by CCG Locality, 2001-13
Source: ONS Mid-year estimates 2001-2013, updated 2014
2.2 Ethnicity of the child population
The child population in Bristol is increasingly ethnically diverse. The most recent
estimates suggest that 28% of children (under 16) belong to a black or minority
ethnic (BME) group, considerably higher than the average for the total population of
16% BME. Using an alternative definition of population diversity 25, 32% of children
belong to the non-„White British‟ population, compared to the all-age Bristol
population average of 22%.
Rates vary considerably across the city; 50% of children in the Inner City & East are
BME, a much larger ratio than the 20% in North & West and 13% in South (Figure 5).
Across wards the variation is even greater, ranging from 6% BME in Whitchurch
Park to 83% in Lawrence Hill.
Figure 5: Ethnicity and number of children (0-15y), by CCG Locality, 2011
Source: ONS Census 2011
25
Black or Minority Ethnic group (BME) population includes all groups with the exception of all White groups.
Non-‘White British’ population includes all groups with the exception of White British.
11
According to the 2013 School Census, there were 14,000 BME school age children
in Bristol council-maintained schools (27.3% of the student population) and 9,150
(17.8% of students) had English as an Alternative Language (EAL) (Figure 6). The
largest groups are Black Somali (5.2%), Mixed White and Black Caribbean (3.4%)
and Pakistani (3.1%).
Figure 6: Density of pupils with English as an alternative language, 2013
Source: Bristol School Census, 2013
National research26 shows that families with an African, Caribbean or Black British
mother are more likely than families with a white mother to be lone parents (45%
compared with 25%), live in social housing (44% compared with 20%) and be in the
lowest income quintile (30% compared with 16%). Pakistani and Bangladeshi
families experience the highest rates of poverty, with 65% of children living in poverty
(calculated after housing costs). 30% of children in Black families and 28% of
children in families of Indian origin also live in poverty. On the other hand, parents of
South Asian and Chinese origin are least likely to be lone parents.
26
Cabinet Office (2007) Reaching Out: Think Family (2007) p. 59. Available at
http://webarchive.nationalarchives.gov.uk/20080804201836/cabinetoffice.gov.uk/social_exclusion_task_force/fa
milies_at_risk/reaching_out_summary.aspx (Accessed 1 June 2015)
12
2.3 Population projections
The latest official projections27 for the population of Bristol is to increase by 95,700
people over the 25 year period (2012-2037) to reach a total population of 528,200 by
2037 (projected increase of 22.1%, higher than England 16.2%).
Over the 10 year period (2012-2022), Bristol‟s population is projected to increase by
41,900 to 474,400 (a 9.7% increase, above England 7.2%). The child population is
projected to rise fastest, by 15.4% (12,400 children), but the young person
population (16-24 yrs) remains stable during the next decade (Table 3 and Figure 7):
Table 3: Bristol population projections, 2012-2022
Age (years)
0-15
16-24
25-49
50-64
65-74
75 +
All ages
2012
2017
2022
Change to 2022
80,700
86,700
93,100
12,400
15.4%
66,800
67,900
66,200
-600
-0.9%
163,900
171,500 178,600
14,700
9.0%
63,900
67,900
71,200
7,300
11.4%
29,100
32,300
33,100
4,000
13.7%
28,100
28,600
32,200
4,100
14.6%
432,500
454,900 474,400
41,900
9.7%
Source: 2012-based Sub-national Population Projections, ONS (© 2014)
Figure 7: Bristol population projections, 2012-2022, by age band
Source: 2012-based Sub-national Population Projections, ONS (© 2014) Supplied by: BCC
Performance, Information and Intelligence Service
Over this time period, the main drivers of population growth are expected to be due
to natural change (i.e. more births than deaths) rather than migration.
27
2012-based Sub-national Population Projections, published by ONS end May 2014. Note – These are trendbased projections, which mean assumptions for future levels of births, deaths and migration are based on
observed levels, over 2008 to 2012. They show what the population will be if the trends continue, and do not
attempt to predict the impact of future policies, economic circumstances, local development, or other factors.
13
The number of children under 5 years is projected to remain very high and increase
slightly, due to Bristol‟s high birth rate, but the main increases over the next decade
will be the rise in the 5-9 and from 2016 the rise in 10-14 age bands (Table 4 and
Figure 8). This means that the proportion of children under 16 in Bristol, and the
proportion under 18 years are projected to rise by 15.4% and 14.6%.
Table 4: Bristol projected child population, 2012-2022
Age
(years)
0-4y
5-9y
10-14y
15-19y
2012
2017
2022
30700
24100
21500
25700
31600
28000
23000
25500
32800
28800
26600
26700
% change
2012-22
6.8%
19.5%
23.7%
3.9%
0-15 y
0-17y
80,700
89,400
86,700
95,100
93,100
102,400
15.4%
14.6%
Source: 2012-based Sub-national Population Projections, ONS (© 2014) Supplied by: BCC
Performance, Information and Intelligence Service
Figure 8: Bristol child population projections, 2012-22, by age band
Bristol child population projections, 2012-2022
(by 5-year bands)
0-4
5-9
10-14
15-19
35,000
30,000
25,000
20,000
15,000
10,000
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Source: 2012-based Sub-national Population Projections, ONS (© 2014) Supplied by: BCC
Performance, Information and Intelligence Service
14
The population of children and young people in Bristol: summary and
implications

The number of children and young people living in the city has increased in
recent years and is expected to increase further in the future.

The increase in the number of children has not occurred equally; the increase
in the under 5s group is greater than the increase in older children; the
increase in non-white ethnic groups is greater than white ethnic groups; and
the increase in the Inner City and East area is greater than in other areas of
the city.

These increases may stretch the capacity of existing health, education and
care services in specific areas of the city and across the city as a whole.
15
3.0 The emotional health of children and young people in
Bristol.
3.1 Estimates of the prevalence of emotional health problems in
children and young people in Bristol
Measuring the prevalence of emotional health problems in children and young
people at a local level is challenging. As a proxy measure, we can use national
surveys of emotional health problems and apply them to the Bristol population to
estimate local needs.
In 200428 the Office of National Statistics conducted a survey of 7977 parents of 5-16
year olds living in England, Scotland and Wales, to update a similar survey
undertaken in 199929. This remains the most reliable source of prevalence data for
children and young people‟s emotional health in England; it has not been repeated
more recently. The Chief Medical Officer‟s annual report 2012 on children and young
people included a chapter on mental health problems30. Data in this chapter are also
based on information collected from the 2004 survey. The 1999 and 2004 studies
showed no evidence of increase in rates of emotional health problems between the
survey dates. Other sources of evidence have however shown an increase in
conduct disorders 31 . A follow-up survey 32 in 2007 of the participants in the 2004
survey showed that persistence and onset of disorders was linked to child, family,
household and social characteristics at 2004. It should be noted that these studies
did not investigate the prevalence of mental health disorders in children under the
age of five years and it is hard to obtain reliable data for this age group33.
The 2004 survey found that 1 in 10 children and young people aged 5-16 years had
a diagnosable mental health disorder. There were marked gender differences by
condition and generally the prevalence of difficulties increases with age. In 5-10 year
olds 10% boys and 5% girls had a mental health disorder compared to 13% boys
and 10% girls aged 11-16 years. The most common problems were conduct
disorders, attention deficit hyperactivity disorder (ADHD), emotional disorders
(anxiety and depression) and autism spectrum conditions. These conditions are not
mutually exclusive as one in five children with a disorder was estimated to have
more than one condition. The most common combinations were conduct with either
emotional disorder or hyperkinetic disorder (0.7 per cent in each case)34.
28
Office for National Statistics (2005) The Mental Health of Children and Adolescents in Great Britain, London.
Summary report available from http://www.hscic.gov.uk/catalogue/PUB06116/ment-heal-chil-youn-peop-gb-2004rep2.pdf
29
Office for National Statistics (2000) The Mental Health of Children and Adolescents in Great Britain: London
30
Murphy M, Fonagy P (2012) Chapter 12 Mental Health Problems in Children and Young People: London.
Available at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/252660/33571_2901304_CMO_Ch
apter_10.pdf (Accessed 20 May 2015)
31
Collishaw S, Maughan B, Goodman R, Pickles A (2004): Time trends in adolescent mental health. J Child
Psychology and Psychiatry, 45(8):1350-1362.
32
Parry-Langdon N (2007) Three years on: Survey of the development and emotional well-being of children and
young people: Office for National Statistics
33
Wichstrom, L (2012) Prevalence of psychiatric disorders in preschoolers. The Journal of Child Psychology and
Psychiatry, 53:6, pp. 695-705.
34
Office for National Statistics (2005) The Mental Health of Children and Adolescents in Great Britain Chapter 9,
London.
16
The Children and Maternal (ChiMat) Health Intelligence Network have applied these
national prevalence estimates to Bristol‟s estimated population of 5-16 year olds in
2014 35 indicates that ~5,400 children and young people have some level of
emotional ill health likely to require support from trained workers (Table 5).
Table 5: Estimated number of children in Bristol with mental health disorders, 2014
Condition
5 to 10 year olds
Boys
Girls
All
11 to 16 year olds
Boys
Girls
All
All children (5-16 yrs)
Boys
Girls
All
Conduct disorders a
1100
445
1545
1080
675
1755
2180
1120
3300
Emotional disorders b
335
390
725
595
780
1375
930
1170
2100
Hyperkinetic disorders
460
80
540
325
55
380
785
135
920
340
95
435
225
105
330
565
200
765
1600
790
2390
1685
1320
3005
3285
2110
5395
Autistic spectrum
conditions, tics, eating
disorders, mutism
Any mental health
problem
Source: 2014 ONS Mid-year population estimates for Bristol applied to ONS report; Mental health of
children and young people in Great Britain, 2004.
a
Notes: Conduct disorders are characterised by awkward, troublesome, aggressive and antisocial
b
behaviours. Emotional disorder includes depression, anxiety and obsessions. Factors associated
with having an emotional disorder included living in a stepfamily, having parents with no educational
qualifications and having poorer physical health. 27% may have another clinically recognisable mental
disorder
3.2 Attention deficit hyperactivity and hyperkinetic disorders
ADHD is a behavioural syndrome characterised by the core symptoms of
hyperactivity, impulsivity and inattention. While these symptoms tend to cluster
together, some people are predominantly hyperactive and impulsive, while others
are principally inattentive. ADHD is thought to affect about 3–9% of school-age
children and young people in the UK36. Attention deficit hyperactivity disorder
(ADHD) and hyperkinetic disorder are marked by similar symptoms, such as poor
attention, hyperactivity and impulsivity, and the terms are sometimes used
interchangeably37.
The 2004 ONS survey reported above, found that 1.5% of families surveyed had a
child aged 5-16 years with a hyperkinetic disorder. 86% of these children were boys.
66% of these children had another clinically recognisable mental health disorder.
35
CAMHS Needs Assessment Bristol Local Authority
http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=34&geoTypeId= Accessed 24Aug15
36
National Institute for Health and Clinical Excellence (2008) Attention Deficit Hyperactivity Disorder: Diagnosis
and management of ADHD in children, young people and adults (CG72). Available at
http://www.nice.org.uk/guidance/cg72/chapter/Introduction (Accessed 1 June 2015)
37
Available at
http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/adhdhyperkineticdisorder.aspx
(accessed 12 May 2015)
17
62% had conduct disorder and 12% had an emotional disorder. 71% of these
children were officially recognised as having special educational needs.
The differences in prevalence estimates may reflect differences in definitions and / or
improvements in the detection of ADHD / Hyperkinetic conditions.
3.3 Autistic spectrum conditions
Autism spectrum disorder (ASD) is a condition with impairments in reciprocal social
interaction, social communication, usually restricted interests and repetitive
behaviors, and usually becomes apparent in childhood. Estimating the prevalence of
autistic spectrum disorders is difficult because of the absence of long term studies
and inconsistencies in the use of definitions over time.
A study by Baird in 2006 of ~57,000 children in London estimated the prevalence of
autism in children aged 9-10 years old to be 38.9/10,000 children, and that of other
ASDs to be 77.2/10,000 giving a total prevalence of all ASDs of 116.1/10,00038. A
study by Baron-Cohen in 2009 of 5-9 year old children estimated the prevalence of
autism spectrum disorder to be 157/10,00039.
Table 6: Estimated number of children with Autism Spectrum Disorder, Bristol, 2014
Disorder
ASD in children aged 5-9 yearsa
Autism in children aged 9-10 yearsb
ASD in children aged 9-10 yearsb
Total of all ASDs in children aged 9-10 yearsb
Estimated prevalence in
Bristol, 2014
410
40
75
110
Source: adapted from CAMHS Needs Assessment Bristol Local Authority
http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=34&geoTypeId= Accessed 24Aug15
a
b
Notes: Baron-Cohen (2009), Baird (2006)
3.4 Estimated need for Child and Adolescent Mental Health
Services at each tier
Estimates of the number of children and young people who may experience mental
health problems appropriate to a response from CAMHS at Tiers 1, 2, 3 and 4 have
been provided by Kurtz (1996)40. Although this data may appear old, and it relates to
tiers of care that are not currently promoted in policy documents, it is the best data
currently available and these data are recommended for service planning by the
National Child and Maternal (ChiMat) Health Intelligence Network. Table 7 shows
the estimated number of children and young people aged 17 and under who may
38
Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism
spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP).
Lancet 2006; 368 : 210–5.
39
Baron-Cohen S, Scott F, Allison C et al. Prevalence of autism spectrum conditions: UK school based
population study. British Journal of Psychiatry. 2009;194:500-509
40
Kurtz, Z. (1996). Treating children well: a guide to using the evidence base in commissioning and managing
services for the mental health of children and young people. London. Mental Health Foundation.
18
experience mental health problems appropriate to a response from CAMHS, based
on 2014 mid-year population estimates for Bristol.
Table 7: Estimated number of children and young people who may experience mental
health problems appropriate to a response from CAMHS, Bristol, 2014
Tier
Service provided by
Support provided
Tier 1
Professionals whose main role is
not in mental health (e.g. GPs,
Health Visitors, school nurses,
social workers, teachers, youth
workers, Youth Offending Team,
Voluntary sector)
Specialist trained mental health
professionals who may provide
input to multiagency teams (e.g.
Community Paediatricians, Child
psychologists, Educational
Psychologists, Child psychiatrists,
Child psychiatric nurses)
Multidisciplinary CAMHS team
(e.g. child and adolescent
psychiatrists, social workers, child
psychologists, psychiatric nurses,
psychotherapists, occupational
therapists, music and drama
therapists)
Services provided by specialist
teams based in residential, day or
outpatient settings (e.g. inpatient
units, forensic units, eating
disorder units, specialist teams
for sexual abuse)
Offer general advice;
promotion and
prevention work;
Identify problems
requiring more
specialist advice
Support those not
responded to Tier 1.
Provide consultation
and training for staff
in Tier 1.
Tier 2
Tier 3
Tier 4
Number of
children in
Bristol
13,780
6,435
Support those with
complex mental
health problems.
Support staff at Tier 2
1,700
For children with
severe, highly
complex and lifethreatening
conditions
70
Source: CAMHS Needs Assessment Bristol Local Authority
http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=34&geoTypeId= Accessed 24Aug15
3.5 Estimates of neurotic disorders in young people
The term „neurotic disorders‟ is used to describe a range of conditions including;
anxiety, depression, phobias, obsessive compulsive disorder and panic disorders.
Estimates of the prevalence of neurotic disorders in young people have been made
by Singleton41. Applied to the population of young people in Bristol they suggest that
3050 young people may have a neurotic disorder (Table 8).
41
Singleton N, Bumpstead R, O’Brien M, Lee A and Meltzer H (2001) Psychiatric morbidity among adults living
in private households, 2000. Office for National Statistics. London. HMSO
19
Table 8: Estimated number of young people in Bristol with neurotic disorders, 2014
Disorder
Males 16-19
years
Mixed anxiety and depressive
disorder
Generalised anxiety disorder
Depressive episode
Phobias
Obsessive compulsive disorder
Panic disorder
Any neurotic disorder
Females 1619 years
Total 16-19
year olds
555
1370
1925
175
100
70
100
55
935
125
300
235
100
70
2115
300
400
305
200
125
3050
Source: 2014 ONS Mid-year population estimates for Bristol applied to ONS report; Mental health of
children and young people in Great Britain, 2004.
3.6 Eating disorders
A study of a nationally representative sample of general practice records between
2000 and 2009 an incidence of new diagnoses of eating disorders of 164.5/100,000
in girls aged 15-19y, and 63.5/100,000 in girls aged 10-14 years 42. In contrast,
rates were lower for boys; 17.4/100,000 for boys aged 15-19y and 17.5/100,000 for
boys aged 10-14y. These rates applied to the Bristol population are shown in Table 9
below, and suggest 29 girls and 4 boys aged 10-19 may be diagnosed with an eating
disorder each year in Bristol.
Table 9: Estimated new diagnoses of eating disorder, children aged 10-19y, Bristol,
2014
Females
Males
All
Bristol population
(ONS, 2014 mid-year
estimate)
10-14
15-19
10,500
13,200
10,700
13,000
21,200
26,200
Estimate of new GP diagnoses of eating
disorders per year based on data from
Micali et al (2013)
10-14
15-19
All 10-19
7
22
29
2
2
4
9
24
33
42
Micali N, Hagberg KW, Petersen I, Treasure JL (2013) The incidence of eating disorders in the UK in 2000–
2009: findings from the General Practice Research Database; British Medical Journal. Available at
http://bmjopen.bmj.com/content/3/5/e002646.short (Accessed 1 June 2015)
20
3.7 Self-harm
A collaborative study across European countries surveyed 6000 young people aged
11, 13 and 15 during 2009/2010 43. This survey showed that up to one in five (20%)
15 year olds reported they self-harm. Similar data were found from the Avon
Longitudinal Study of Parents and Children in a paper reporting in 2012. In this
study adolescents aged 16-17years reported self-harm rates of 18.8%, with selfcutting being the most common method of harm 44. In 2014 the Bristol Safeguarding
Children‟s Board school audit surveyed primary and secondary schools. Of 11
(52%) secondary school settings responding, all reported they perceived self-harm
as a growing concern in their school. Of 32 (31%) of the 32 primary school settings
responding, 11 (34%) reported that they had similar concerns. Nine of the 11
secondary schools reported having a self-harm policy/strategy in place, compared
to only 6 out of the 32 primary schools.
3.8 Estimates of learning difficulties and mental health problems
The prevalence of children and young people with learning difficulties in different
age groups is difficult to estimate. Information from Special Educational Needs
registers may underestimate true rates. Emerson et al 45 calculated the prevalence
of learning difficulties in children aged 5-9 years of 0.97%, 10-14 years, 2.26%, and
15-19 years, 2.67%. These rates have been applied to the mid-year population
estimates for Bristol by the Child and Maternal Health Intelligence Network
Table 10: Estimated number of children with learning difficulties and mental health
problems, Bristol, 2014
Children 5-9y
Children with a
learning disability
Children with a
learning disability
and mental health
problems
Children 10-14y
Young people 15-19y
255
485
705
105
195
285
Source: CAMHS Needs Assessment Bristol Local Authority
http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=34&geoTypeId= Accessed 24Aug15
43
Currie C et al., eds. (2012) Social determinants of health and well-being among young people. Health
Behaviour in School-aged Children (HBSC) study: International report from the 2009/2010 survey. Copenhagen,
WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, No. 6).
Available at http://www.euro.who.int/__data/assets/pdf_file/0003/163857/Social-determinants-of-health-and-wellbeing-among-young-people.pdf?ua=1 (Accessed 07 May 2015)
44
Kidger J, Heron J, Lewis G, Evans D and Gunnell D (2012) Adolescent self-harm and suicidal thoughts in the
ALSPAC cohort a self-report survey in England, BMC Psychiatry 2012, 12:69. Available at
http://www.biomedcentral.com/1471-244X/12/69# (Accessed 1 June 2015)
45 Emerson E and Hatton C. (2004) Estimating current need/demand for support for people with learning
difficulties in England. Institute for Health Research, Lancaster University, Lancaster.
21
3.9 Behavioural emotional and social difficulties (BESD)
Behavioural, emotional and social difficulties (BESD) describe a range of conditions
including depressive attitudes, school phobia, substance misuse, anti-social
behaviour, anger and threat/use of violence. Following assessment for Special
Educational Needs (SEN) children may be categorised as having BESD. Data from
reports of SEN can therefore be used as a proxy indicator of health need.
The number of children with BESD in Bristol was 1010 in 2014, estimated from the
Bristol School Census 46 ; however the prevalence varies across the city with the
greatest number of cases diagnosed in Bristol South (Table 11 and Figure 9).
Table 11: Number of children in Bristol with BESD, 2014, by Locality
Number of Children
with BESD in Area
Bristol North
East Central
South
Bristol Total
310
280
410
1010
Average number of
Children with BESD
per Ward in area
21
35
34
28
Figure 9: Number of children with BESD special educational needs, Bristol, 2014, by
ward
Number of Children BESD SEN
4 to 19
20 to 35
36 to 52
53 to 68
69 to 85
Source: School Census
2014
OS data © Crown copyright & database
rights 2013 Ordnance Survey 100023406
46
Bristol School Census 2014. Available from
http://www.bristol.gov.uk/sites/default/files/documents/children_and_young_people/schools/school_admissions/S
chool%20Organisation%20Strategy%202013%20-%202017%20Final%20(2)_0_0.pdf p.34
22
Prevalence of emotional health problems in children and young people in
Bristol: summary and interpretation

Mental health disorders identified through the ONS British Child and
Adolescent Mental Health Survey (2004) and applied to the Bristol population
of 5-16 year olds in 2014 suggest there may be 5400 children with a mental
disorder in Bristol.

One in five children with a mental health disorder may have more than one
mental health condition (co-morbidity).

Diagnoses of mental health disorders are more common in boys than girls for
all conditions except for emotional disorders and self-harm which are
commonest in girls.

The prevalence of mental health disorders increases with age through
adolescence. This may reflect the fact that some conditions develop during
adolescence, but may also reflect a reluctance to apply a diagnostic label too
early to a child with behavioural difficulties. These children may later receive a
formal diagnosis to better describe their difficulties and enable them to access
services.

The number of children and young people with a mental health need that does
not meet the threshold for formal diagnosis is likely to be higher than data
presented in this section.

Application of national estimates (particularly where these estimates are 10
years old) to local populations should be undertaken with caution and
interpreted with care.
23
4.0 Children & young people vulnerable to poor emotional
health
Some children and young people are more at risk of emotional ill-health than others.
The British Medical Association in June 200647 found a higher prevalence of mental
health problems among children experiencing socio-economic deprivation, those
with poor educational and employment opportunities, poor physical health, poor peer
and family relationships, witnessing domestic abuse, having a parent that misuses
substances or suffers from mental ill health, or having been physically or sexually
abused. Asylum seekers and refugee children have also been shown to have higher
levels of mental health problems. Data on the emotional health of these groups is
presented in this chapter, where available.
4.1 Risk factors for poor emotional health and wellbeing
Public Health England published a risk profile for Bristol as part of their Children and
Young People‟s Mental Health and Wellbeing Profile48. An extract from this report is
presented in Figure 10Figure 10.
Figure 10: Risk factor profile for children and young people's mental health and
wellbeing, 2014
47
BMA Board of Science (2006) Child and adolescent mental health – a guide for healthcare professionals:
British Medical Association.
48
Children and Young People’s Mental Health and Wellbeing Profile. Available from;
http://fingertips.phe.org.uk/profile-group/mental-health/profile/cypmh accessed 17/08/15
24
Source: http://fingertips.phe.org.uk/profile-group/mental-health/profile/cypmh
Notes:
6,7
49
Figures from the National Child Measurement programme for 2013/14 show that 19.1% of
children in Year 6 (aged 10-11) and 9.5% of children in Reception (aged 4-5)
8,9
The number of children born to young mothers (under the age of 20) in Bristol reduced from 320 in
50
2010 to 220 in 2013 .
14
Bristol School Census records for 2014 indicate 130 Gypsy or Traveller children of either Irish
heritage or Roma, approximately three times the number in 2008. An estimated 2/3rds are thought to
be Roma. These figures are likely to be significant underestimates because (a) Traveller children may
not be in school (b) families may choose not to identify themselves as Travellers or Roma
17
51
Nationally, there were nearly 2.0 million lone parents with dependent children in the UK in 2014 .
20
In 2014, Bristol Multi Agency Risk Assessment Conferences (MARAC) discussed 1331 individual
52
children exposed to Domestic Violence, some of whom would have been discussed multiple times .
Data show that the proportions of children in poverty, with lone parents, in
households where no adult is in employment and where parents are in drug
treatment are all statistically significantly higher than the average rate for England.
49
Available at http://www.noo.org.uk/NOO_about_obesity/child_obesity (Accessed on 4 June 2015)
Data collated in child health records held by Avon Primary Care Support Agency, extracted and collated by
Public Health Bristol Intelligence Unit (Bristol City Council), 2013
51
Available at http://www.ons.gov.uk/ons/rel/family-demography/families-and-households/2014/families-andhouseholds-in-the-uk--2014.html#tab-Lone-parents (accessed 07 May 2015)
52
Personal communication – Rachel Griffiths, Bristol CCG MARAC worker, 2 June 2015
50
25
Risk factors found to be associated with higher rates of mental disorders in children
and young people were reported in the ONS the British Child and Adolescent Mental
Health Survey in 2004 5354 and were published in the CMOs Atlas of Variation 55
(Table 12)
Table 12: Risk factors for mental disorders in children and young people, 2004
Risk factor
Prevalence of
mental disorder
in children and
young people in
CMOs Atlas of
Variation
Number of children estimated to have
mental disorders in Bristol, where
data available
Looked after children
45%
Children with SEN
requiring statutory
assessment
44%
Children with learning
difficulties
36%
Children absent from
school for >15 days in
previous term
17% for emotional
disorders
14% for conduct
disorders
11% for hyperkinetic
disorders
20%
In March 2014 the number of Children
Looked After in Bristol was 712, suggesting
that 320 of these children may have
emotional health needs if these national
prevalence estimates are applied. In
addition, 442 children were subject to a
Child Protection Plan and 2788 were
considered Children in Need
The 2013 Bristol School Census recorded
3,900 (7.6%) children aged 5-16y with
special educational needs, suggesting 1716
may have mental disorders.
2013 Bristol School Census recorded 776
children with LDs; Profound & Multiple LD
n=84, Severe LD n=199, Moderate LD
n=493. If 36% of these children also have
mental disorders, this equates to 279
children and young people
No dataa
Children from
households with no
working parent
Children from families
receiving disability
benefit
Children from families
where the household
reference person is in
53
24%
The number of children 0-16y in low-income
familiesb in Bristol is 25.3% (17% in Bristol
North, 28% in Bristol South and 32% in
Bristol Central).
15%
Green, H, et al (2005) Mental health of children and young people in Great Britain 2004. Palgrave: London.
54
Joint Commissioning Panel for Mental Health (2013). Guidance for commissioning public mental health services. Updated
July 2013. Available from: www.jcpmh.info/resource/guidance-for-commissioning-public-mental-health-services/.
55
Annual report of the Chief Medical Officer 2012. Our Children Deserve Better: Prevention Pays. Atlas of
Variation. Annex 9: Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/252672/33571_2901304_CMO_Ch
apter_Anx_9.pdf
26
a routine occupational
group (e.g. unskilled
manual worker)
Children of parents
with no educational
qualifications
Children in „hard
pressed‟ areas (i.e.
high prevalence of
unemployment and
poor qualifications)
Children from
households with
weekly income of
<£100
11-16y old from
households with a
weekly income of
<£200
Children in
stepfamilies
Children from lone
parent families
17%
15%
16%
20%
14%
No dataa
16%
No dataa
a
No Bristol specific data available at the time of compiling this report
Children in low income families are defined as the proportion of children (under 16) living in families
that are either in receipt of out-of-work benefits, or in receipt of tax credits with a reported income
which is less than 60% of the national medium income. The compared to the England average of
56
20.2
b
Additional factors which may increase children‟s vulnerability to poor emotional
health outcomes are shown below
Young offenders
Research has shown that 95% of imprisoned young offenders have a mental health
disorder, and many have more than one disorder57. Young people in prison are 18
times more likely to take their own lives than others of the same age58. Not all young
offenders are imprisoned. In the period April 2013 to March 2014, the Bristol Youth
Offending Team (YOT) reported 446 young offenders up to the age of 18 sentenced
to a „Substantive Outcome‟59, committing a total of 793 offences. 56 of those 446
were assessed as having mental health needs. This is 12.56% of Bristol YOT‟s
caseload. The majority of these were white males aged 16-17 years. Between
January to December 2013 the Bristol YOT‟s CAMHS nurse assessed and worked
56
Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/325416/householdsbelow-average-income-1994-1995-2012-2013.pdf (accessed 07 May 2015)
57
Office for National Statistics (1997):Psychiatric morbidity among young offenders in England and Wales.
London: Office for National Statistics
58
Children and Young People’s Health Outcome Forum (2012) Report of the Children and Young People’s
Health Outcome Forum – Mental Health Sub-group. Available at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216853/CYP-Mental-Health.pdf
(Accessed 2 June 2015)
59
Substantive Outcome: a pre-court or court disposal. Relating to a reprimand, a final warning with our without an intervention,
or a court disposal for those who go directly to court without a reprimand or final warning.
27
with 37 cases which met YOT CAMHS threshold criteria60 (i.e. displaying some
mental health difficulties and with no other mental health service involvement, taking
into consideration risk to self/others, and for which the young person consented to
assessment)61:
Bullied children and young people
The Chief Medical Officer‟s annual report 201362 describes bullying, or repeated
exposure to the negative actions of others where an imbalance of power is present,
is reported by 34-46% of English school children in recent surveys. Cyber-bullying
through digital media may now be the most common type of bullying. The 2015
Annual Bullying Survey63 reported that 74% of those reporting bullying have at some
point been physically attacked, 17% have been sexually assaulted and 62% have
been cyber bullied. The Bristol Pupil Voice survey (2013)64 found that 31% of pupils
in year 4 and 6 are afraid to go to school because of bullying sometimes, and 25%
reported they had been bullied at or near school in the last 12 months.
Female genital mutilation
The mental health consequences of female genital mutilation (FGM) include posttraumatic stress, flashbacks, fear, anxiety and depression65. A House of Commons
Home Affairs Committee report in 2014 estimated that 170,000 (0.48%) women and
girls are living with FGM in the UK and that a further 65,000 girls aged 13 and under
are at risk of FGM in the UK 66 . 2014 mid-year population estimates for Bristol
suggested there were 51,700 young women and girls aged 0-19y in Bristol.
Assuming the 0.48% prevalence figure applies to this population, suggests that 248
girls and young women would have experienced FGM.
60
CAMHS YOT Nurse did not deliver work to all 56 YP Assessed as having Mental Health needs for numerous
reasons. Some YP who enter the YOT are already being worked with by CAMHS so this would not be
duplicated. Some YP are not ready to engage, or already have a number of agencies involved, others require
further monitoring and engagement. These would be documented within the consultations of which there were
287 for this period.
61
Personal communication – Sam Waterhouse, Youth Offending Team, 6 August 2014
62
Annual Report of the Chief Medical Officer (2012) Our Children Deserve Better – Prevention Pays. London:
Stationery Office
63
http://www.ditchthelabel.org/the-annual-bullying-survey-2015-is-here/ (accessed 19 May 2015)
64
Personal communication – Anne Colquhoun, Service Manager BCC, 8 June 2015
65
UNFPA, International Conference on Research, Health Care and Preventive Measures for Female Genital Mutilation/Cutting
and the Strengthening of Leadership and Research in Africa, (2011) Nairobi, Kenya.
66
House of Commons Home Affairs Committee, Female Genital Mutilation; the case for a national action plan. Second report of
Session 2014-15. http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhaff/201/201.pdf
28
Children and young people vulnerable to poor emotional health and wellbeing: summary and interpretation

A range of risk factors are associated with increased prevalence of poor
emotional health outcomes in children and young people
o Household level factors include; growing up in a household with a
single parent, where there is a low income, where household members
are in receipt of disability benefits, the household is in a socioeconomically disadvantaged area, being homeless, or being in a
household where there is domestic violence.
o Family level risk factors include; having a teenage mother, growing up
in family where parents have low educational attainment, or have been
in prison, or have alcohol or drug problems.
o Child level factors include; being a child in the care of the local
authority, being in the criminal justice system, having special
educational needs, being bullied, overweight or having experienced
female genital mutilation or being LGBT.

Most of these factors are associated with adverse physical as well as mental
health outcomes. Children and families with these experiences are likely to
come into contact with multiple agencies.
29
5.0 Services for children and young people with emotional
health needs
5.1 Service use by current provider
Use of Child and Adolescent Mental Health Services in Bristol
Community children‟s mental health services in Bristol and South Gloucestershire
are provided by a partnership between North Bristol NHS Trust and Barnardos,
known as the Community Child Health Partnership (CCHP). The contract for this
partnership ends in April 2016, when an interim provider will take over, prior to a
formal re-commissioning of the service to commence in April 2017.
In addition to the tiered CAMHS service, the Community Child Health Partnership
supports other services for children and young people in Bristol including;
 The Young People‟s Substance Misuse Service (based at No 38 Southwell
Street, and known as „No 38‟), providing advice for those with drug and
alcohol misuse problems.
 Thinking Allowed, a clinical psychology service for children who are looked
after or adopted and their carers in Bristol.
 Deliberate Self Harm team (now known as the Young People‟s Mental Health
Assessment Team) are based in Southwell Street and accept referrals from
the Emergency Departments in the acute hospitals in Bristol
Current service use by CAMHS tier can be estimated using data from the local
service provider for Bristol CAMHS who provided a snapshot of service use in June
2014 (Table 13). Data in the table reflect the primary presentation to each of the
three CAMHS services (East Central, North and South), the Young People‟s
Substance Misuse Service, Thinking Allowed and the Deliberate Self Harm team.
The service snapshot indicated 915 episodes of service use during June 2014, which
if applied to a 12 month period would indicate 10980 episodes of service use over
the course of a year.
At present there is limited data available to estimate the prevalence of psychosis in
children and young people in Bristol. In June 2014 Bristol CAMHS reported that
6/915 (0.66%) of referrals to their service were for psychosis. A new Early
Intervention in Psychosis service was introduced in Bristol in 2014 supporting the
14-35 age range which may improve data availability for this group of patients.
30
Table 13: Snapshot of CAMHS service use in Bristol, June 2014
East
Central
CAMHS
North
CAMHS
South
CAMHS
Total
June
2014
Est.
total for
2014
Emotional
Disorders
49
67
62
178
2136
Conduct
Disorders
<5
<5
<5
27
324
Hyperkinetic
Disorders
<5
<5
<5
16
192
Substance
Abuse
Developmental
Disorders
<5
<5
<5
261
3132
<5
<5
<5
5
60
Autistic
Disorders
Eating
Disorders
7
11
10
28
336
16
21
9
46
552
Primary
Presentation
YPSMS
Thinking
Allowed
DSH
Hospital
Team
260
Deliberate Self
9
17
14
51
91
Harm
Habit
<5
<5
<5
15
Disorders
Psychotic
<5
<5
<5
6
Disorders
Not possible to
<5
<5
<5
14
50
define
Other
11
9
8
28
Disorders
More than one
48
28
88
164
disorder
172
180
238
260
14
51
915
Total Cases
Note: to protect anonymity, where referral numbers were less than 5 the actual figure has been
suppressed (indicated by <5).
YPSMS = Young Persons Substance Misuse Service
1092
180
72
600
336
1968
10980
Use of Hospital services
Admission to hospital for self-harm
The most severe episodes of self-harm will be admitted to hospital. Routinely
collected Hospital Episode Statistics indicate that there were 411 admissions to
hospital for self-harm in children and young people aged 10-24y in Bristol during
2012/13, a directly standardised rate of 430.2/100,000 significantly higher than the
England average (346.3/100,000)67. There has been little change in the rate of
admissions in recent years (Figure 11).
67
Extract from the Child Health Profile for Bristol 2014. Public Health England/ChiMAT
(http://www.chimat.org.uk/profiles/static)
31
Figure 11: Young people 10-24y admitted to hospital for self-harm, rate per 100,000
population aged 10-24y, 2007-2013, Bristol
Source: Hospital Episode Statistics, Health and Social Care Information Centre reported in Bristol
City Council JSNA 2014; Children and young people update v5 final
Attendance at Emergency Departments for self-harm
The STITCH Health Integration Team (Improving care in self-harm), a Bristol wide
multi-agency collaboration68, has established a self-harm register in the Emergency
Department at Bristol Children‟s Hospital. In 2013, there were 173 presentations for
self-harm by 157 patients (16 repeat attendances). Over three quarters of patients
were female, and 58% were already in contact with mental health services.
Studies suggest that only a proportion of self-harm patients present to hospital
service. An international study reporting in 2008 estimated that only 12.4% of selfharm episodes reported by 15-16 year olds presented to hospital69. If this estimate
were applied to the Bristol presentation rate of 157 cases over one year in 2013,
this would suggest there could be as many as 1266 episodes of self-harm occurring
in Bristol each year.
Referrals to CAMHS Deliberate Self-Harm service
In 2013 there were a total of 147 referrals into the CAMHS Deliberate Self-harm
Service from the Bristol under 18 population (Table 14)
Table 14: Referrals to CAMHS Deliberate Self-Harm Service, under 18s, Bristol, 2013
Bristol Locality
North West
South
East Central
Total
Number of Referrals
33
48
66
147
Percentage of Referrals
22.45
32.65
44.90
100
68
Available at http://www.bristolhealthpartners.org.uk/health-integration-teams/improving-care-in-self-harm-hit/
(Accessed 20 May 2015)
69
Madge N, Hewitt A, Hawton K, Wilde E J d et al (2008), Deliberate self-harm within an international community
sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study.
Journal of Child Psychology and Psychiatry, 49: 667–677.
32
The ChiMat Children and Young People‟s Mental Health and Wellbeing Profile 2014
reports routinely collected data for hospital admissions for conditions related to
emotional health and wellbeing. An extract of the table is presented in Figure 12.
This indicates that admissions data for Bristol are not significantly different
compared to the England average, apart from young people‟s admissions to
hospital for self-harm, where the rate for Bristol is statistically significantly higher
than the England average.
Figure 12: Children and young people's mental health and wellbeing profile,
Admissions data, Bristol
Source: http://fingertips.phe.org.uk/profile-group/mental-health/profile/cypmh
Services for children and young people with emotional needs; Summary and
interpretation

Most data available on service use reflects services for children and young
people with the most severe mental health needs; e.g. those being admitted
to hospital, attending emergency services, or accessing Tier 3 or 4 CAMHS
services

The limited data available to compare service use in Bristol with the England
average suggests that service use is similar, except for admissions to hospital
due to self-harm which were higher in Bristol during the period 2010/11 –
2012/13 than the average for England.

Little data is available for the much larger number of children and young
people whose emotional health and wellbeing needs to not reach the
threshold for accessing hospital or Tier 3-4 CAMHS

National or local long term outcome data is not available.
33
6.0 Stakeholder perspectives on children and young
people’s emotional health and wellbeing services and
needs
6.1 Consultations on services for children and young people in
Bristol
Since the previous children and young people‟s health needs assessment in 2008,
there have been a number of consultations with local people regarding service
developments and delivery;
1. NHS Bristol Clinical Commissioning Group Child and Adolescent Mental
Health Services (CAMHS) Re-commissioning Local Consultation – Children,
Young People and Families
2. Bristol Healthwatch - #YHWBeingMe event
3. Documented messages from children and young people part of Barnardo‟s
informal work
4. Barnardo‟s Eating Disorder care pathway consultation
5. Barnardo‟s Learning Difficulty specialist service care pathway consultation
Barnardo‟s Learning Difficulty specialist CAMHS Young People Friendly
6. Barnardo‟s Deliberate Self Harm specialist CAMHS Young People Friendly
7. Barnardo‟s Youth Offending Team Young People specialist CAMHS Friendly
8. Barnardo‟s Drug Treatment Service specialist CAMHS Young People
Friendly
9. Barnardo‟s South CAMHS Young People Friendly Document December
In addition there have been consultations with practitioners and providers;
1. NHS Bristol Clinical Commissioning Group Child and Adolescent Mental
Health Services (CAMHS) Re-commissioning Local Consultation –
Professionals
2. Consultation with Bristol Head Teachers
Further, relevant messages were collated from Bristol NHS Clinical Commissioning
Group Re-commissioning Adult Mental Health Services Consultation.
6.2 Messages arising from consultations
The results of the consultations with children, young people and their parents and
carers tended to produce similar messages. Children and young people,
parents/carers and professionals need whole-system mental health services and
approaches:

Mental health is everyone‟s business.
34

Everyone needs to know how to support children and young people with
mental health needs – e.g. GPs need more training, as do all frontline staff,
including school staff.

Services need to be clearly communicated – “we know where to go when we
start to feel unhappy, anxious, angry” and that communication within
services is effective (both between professions and with children and young
people and parents/carers) and appropriate (harnessing use of technology).

Services are integrated across a number of organisations to form a wholesystem (multi-agency) with built-in flexibility; clear, timely, efficient and
accessible with clear referral criteria and routes, effective pathways and
informed signposting; the right service, in the right place, first time.

The commissioning of services is integrated and outcome-based.

Technology is embedded within services to enhance delivery, access and
join up.

Services support prevention and early intervention with enough lower level
support; e.g. via counselling, emotional support in schools, music and art
therapy, services offered by the voluntary and community sector partners.
Good links are required with Children‟s Community Health Services, School
Nurses, Health Visitors etc.

Professionals and services should understand the link between mental
health and physical health.

Services should meet the access and support needs of children, young
people and their families/carers. For example, they need to;










Be age and gender appropriate and culturally competent with a workforce
reflective of the needs/demographic of the local community.
Understand and address the needs of young people who are LGBTQ.
Be child and family support-centred.
Be flexible - meeting the needs of children with complex needs,
disabilities, Looked after Children and others who are vulnerable and to
include outreach and crisis services.
Be user-led.
Address and challenge the stigma associated with mental health e.g.
awareness raising, change the name, education in schools, use of
creative approaches.
Be welcoming - in terms of both staff and premises; where CYP have had
input into recruitment, training and how the premises are presented.
Have staff that are appropriately trained and to a high standard, are
passionate, honest and non-judgemental and have the capacity ability to
build trusting relationships and understand the pressures faced by young
people in the 21st Century.
Provide opportunities for safe and appropriate peer support.
Provide more support for children and young people with Autism/ADHD.
35




Be appropriately confidential.
Account for children and young people as „digital natives‟ (see note below)
and address the positives and challenges related to this, including the
provision of safe online services.
Have the resources (dedicated transition workers) and mechanisms in
place to ensure the smooth, managed and timely transitions to adult
services (including having good links with Adult Mental Health Services).
Ensure that young people have choice in relation to the
interventions/support they receive (and provider)
The Chief Medical Officer‟s annual report 201370 describes how we are raising a
generation of „digital natives‟, who differ from previous generations in the way they
communicate, seek information, interact and entertain themselves. Service
commissioners and providers need to be aware that this may have both beneficial
effects (such as the ability to access support and services remotely) and potentially
harmful effects (such as the risk of cyber bullying, physiological arousal, social
isolation, access to inaccurate or misleading-information, or technological addiction).
Stakeholder consultations; summary and interpretation

Service users want joined-up, „whole-system‟ provision of services for children
and young people with emotional and mental health needs.

Ease of access to services for children and young people is very important;
flexibility, choice and timeliness are paramount.

Appropriate use should be made of digital and communication technology
both for service users and by service providers.

Training of staff and the wider health and education workforce will enhance
the experience of service users
70
Chief Medical Officer (2012) Public Mental Health Priorities: Investing in the Evidence. London: Stationery
Office
36
7.0 Summary
This children and young people‟s emotional health and wellbeing needs assessment
has brought together the available evidence of population change, estimated service
need and actual service use, and the views of recent services users.
The report describes a service at a period of significant change. The child population
of the city is expected to continue rising and the demography is becoming more
diverse, though these changes are not occurring evenly across the city. These two
issues will place increased demand on services. In addition, the provision of
community child health services, including Child and Adolescent Mental Health
Services, is at a time of significant change; with the conclusion of services by the
current provider, and delivery of services by a one year interim provider during 20162017 whilst a new, longer-term, provider is commissioned to take over from April
2017.
Much of the data on estimated service need is based on national data which is now
10 years old, or, on occasions, older still. Considering the rapid changes in the size
and diversity of the child population in Bristol, application of these national estimates
to local figures should be undertaken cautiously. Local data on emotional health and
wellbeing needs is crucial for service planning that will meet local need.
The limited availability of local service use data, including for children and young
people with the most severe needs, and the absence of data from some areas of the
service is noted. The inadequacy of routinely collected data on mental health has
been identified as an issue nationally. A Child and Adolescent Mental Health
Minimum Dataset has now been defined and incorporated into a larger, all age,
Mental Health Services Dataset71. This dataset has been approved and data
collection using this tool will be a requirement of services from January 2016. This
dataset will include collection of information to support Children and Young people‟s
Improving Access to Psychological Therapies (IAPT), and elements of the Learning
Disabilities Census. This development will greatly strengthen the quality and
comparability of local data on which to base service developments and benchmark
quality of care. It will not however preclude the need for locally collected data on
children and young people with emotional health and wellbeing needs that do not
meet the threshold for access to services.
There is an absence of local data on the long term outcomes for children and young
people with emotional health and wellbeing needs. We know at a national level that
young people with risk factors for poor mental health (e.g. being looked after, being
in the criminal justice system, growing up in poverty) and adults with mental health
problems, have poorer physical health and more limited life chances. We will not
know if local services are effective unless we establish measures to record the
longer term outcomes of service users.
71
http://www.hscic.gov.uk/CAMHS Accessed 24Aug15
37
Appendix 1: Abbreviations
ADHD
ALSPAC
ASD
BCC
BESD
BME
BNSSG
CAMHS
CCG
CHIMAT
CMO
CYP
FGM
GRT
JSNA
LD
LGBT
NICE
NBT
NHS
ONS
PCT
PHIU
SEN
SW
TPU
UHB
VCS
YOT
Attention Deficit Hyperactivity Disorder
Avon Longitudinal Study of Parents and
Children
Autism Spectrum Disorder
Bristol City Council
Behavioural, Emotional and Social
Difficulties
Black and Minority Ethnic
Bristol/North Somerset/South
Gloucestershire
Child and Adolescent Mental Health
Clinical Commissioning Group
Child and Maternal Health Intelligence
Network
Chief Medical Officer
Children and Young People
Female Genital Mutilation
Gypsy, Roma, Traveller
Joint Strategic Needs Assessment
Learning Disabilities
Lesbian, Gay, Bisexual, Transgender
National Institute for Health and Care
Excellence
North Bristol NHS Trust
National Health Service
Office for National Statistics
Primary Care Trust
Public Health Intelligence Unit
Special Educational Needs
South West
Teenage Pregnancy Unit
University Hospitals Bristol NHS
Foundation Trust
Voluntary and Community Sector
Youth Offending Team
38