Richard Shircore MSc FRSPH reflects on the challenges posed by the Departments of Health and Education's recent green paper Transforming children and young people's mental health provision.
The realm of young people’s mental illness is vast. It encompasses the common affective pains of growth and maturity through to severe affective maladaptation and includes various levels and incidence of psychiatric disorder.
It can encompass cognitive challenges (e.g. Asperger’s, dyslexia), whether involved in perception, cognition and/or response, and can be made manifest by significant self-harm and/or withdrawal (acting in) and by severe anti-social behaviour (acting out). This is the landscape the government's green paper is attempting to cover.
What are the challenges?
Challenge 1: where is public health?
If the green paper is about prevention and mental health promotion, then this is a public health issue, yet public health is not mentioned. NHS mental health support teams are expected to provide this expertise, but currently few Child and Adolescent Mental Health Services (CAMHS) personnel will have extensive knowledge of public health practice.
Up until 2014, the NHS had a public health operational arm in the shape of NHS Health Promotion Departments, and these Health Promotion Departments oversaw the successful introduction of the National Healthy Schools Programme.
Meanwhile, there are just 2,561 full-time equivalent school nurses employed in the NHS, compared with 2,725 the year before, a six per cent decline. School nurses as a profession have an understanding of normal development and the interplay of physical illness and psychological wellbeing. In the text, they are referred to as bit-players to counsellors and therapists. If we wished to set up a system to pathologise children, this would be it.
Challenge 2: what am I looking at?
At an operational level of child mental health, the greatest challenge is assessment of the child state. The 'What am I looking at?' question. What is seen initially is behaviour, yet the drivers for behaviour is itself a challenge to understand. Is the behaviour normal or abnormal? Serious or trivial? Equally important: am I looking at a symptom, or cause?
Implicit within the green paper is that mental health is primarily 'affective' and is related to feelings and emotions, and therefore children need to develop 'resilience' and learn about positive 'relationships'. Some children will have affective states that need help and support. Many children will exhibit affective states that result from or are caused by cognitive or other biological issues.
For example an undiagnosed dyslexic child in school may exhibit an affective disorder e.g. conduct disorder, but this is a predictable response. If distress is acted out, this is a logical reaction to the stress of living as a dyslexic in a lexic world.
Challenge 3: definitions and language
To implement a response to any health condition, you need to define your terms and meaning, but the green paper is a definition-free zone. It is built on papers making statements such as “...it is estimated that one in ten children and young people have a diagnosable mental disorder” - no definition is offered. As many mental states are contested, such statements are not very helpful.
The green paper also uses language to describe child mental health in seemingly random ways: mental illness, mental health problem, mental health, mental health issues, at the same time about talking about mental well-being.
Those involved in youth offending will find little of comfort in this green paper.
An alternative proposal
We need to recognise that a school is a community in its own right which therefore means we are talking about population interventions. A public health perspective would not divide health into physical and mental. The interplay of mental and physical was well known to the ancient Greeks, but less appreciated in this green paper.
A public health approach would feature parents to a significant degree. Some teachers say that it is difficult to get parents into school to talk about their child’s problems. Parents can be frightened, ashamed and embarrassed if their child is seen as a “problem”. This is understandable but without parents and their input progress for the child is difficult.
This is even more critical if domestic violence, mental illness of a parent or abuse is present. Again school nurses need to be part of this engagement process. They tend to be seen as non-threatening, impartial and trustworthy.
If a schools-based mental health programme must be public health-led, then the therapeutic element must be evidence-led. Many areas of child mental health are a contested field, and this is especially true of conduct issues such as attention deficit hyperactivity disorder (ADHD). Pretending this is not the case is unhelpful to child, parent and staff.
Once we have acknowledged that we are dealing with the challenge of assessment and diagnosis, we can then start by developing and refining a robust, detailed and effective assessment pathway. As a colleague recently stated: “In physical medicine, we have pathways for most conditions but none for child and adolescent mental health”.
Such a pathway must be a universal not solely a professional one. It needs to incorporate assessment of both mind and body, as a professional one will continue the bias into silo assessments that have been so confusing for children and parents.
It also needs to be recognised that physical illness, social and educational stressors can generate disturbed child affective and cognitive distress. This means the history-taking needs to cover medical, social and educational experience.