Skip to main content
Access keys Home News Site map Site help Complaints Terms Contact us

Children and young people’s mental health

Summary

Mental health and mental disorders are influenced by the economic, social and physical environment in which children live. Mental health risk factors encompass a wide range of fields from complications during birth, low self-esteem, family disharmony and instability, bullying, difficult life events to societal discrimination and isolation. Other risk factors associated with family circumstances include poverty, teenage conceptions, domestic abuse and alcohol and drugs misuse.

One in ten children aged 5-16 are estimated to have a diagnosable mental health problem in the UK.

A single risk factor is thought to result in a 1-2% chance of developing a mental health problem; increasing to an 8% chance in the presence of three risk factors, and a 20% chance with four risk factors. Without help and support at the right time and in the right place, risky behaviours and poor psychological resilience can persist into adulthood.

Prevalence of mental health disorders has been estimated from national prevalence as no South Gloucestershire data was available. Of the approximately 4,800 children and young people aged 5-19 with a mental disorder, 1,776 (3.7%) have emotional disorders; 2,784 have conduct disorders (5.8%); 720 (1.5%) have hyperkinetic disorders; and 624 (1.3%) have less common disorders out of which 432 (0.9%) are for autism.

The South Gloucestershire online pupil survey undertaken in 2014/15 found that 7.2% of secondary pupils were habitual self-harmers. Of these, 1.7% self-harmed sometimes (i.e. monthly) and 3.7% were chronic self-harmers harming weekly or more. The incidents of self-harm was 3 times higher in girls than boys. Just over half of self-harmers had told someone about their self-harm and 10% had medical treatment for the injury. Between September 2014 and March 2015, 127 young people in South Gloucestershire accessed Off-The-Record services. Nearly all young people were assessed for anxiety and depression and more than half for self-harm. The number of referrals for Talking Therapies in 16-18 and 19-25 year olds was 50 and 250 respectively for January 2015.

Referrals to Tier 3 Child and Adolescent Mental Health Services has increased in the last five years although the proportion of those referrals that are accepted has declined. Based on national statistics, 1,060 children aged 17 and under would require a Tier 3 service, twice the number who have been referred and accepted. Hospital admissions due to mental health conditions has increased over the last 5 years as have admissions for self-harm in those under 19. A full children and young people’s mental health needs assessment is being undertaken and is due in 2016.

Recommendations for consideration

Offer early intervention and a whole system approach; offer a consistent range of treatments and interventions which are evidence based and informed by practice; increase the range and availability of cognitive behavioural therapy, systematic family therapy and parenting courses; identify gaps in support needs in relation to children with social communication and interaction needs including autistic spectrum conditions; and undertake workforce development to include a trend towards staff on lower bands with more generalist and community-based roles.

Authors: Sara Blackmore, PH Consultant, South Gloucestershire Council; Steve Spiers, Programme Lead, South Gloucestershire Council; Meda Sandu, PH Intelligence Analyst, South Gloucestershire Council

Who is at risk and why?

Mental health and mental disorders are influenced by the economic, social and physical environments in which children live. Some populations are at higher risk of mental disorders because of their vulnerability to unfavourable circumstances and their gender. Mental health risk factors encompass a wide range of fields from complications during birth, low self-esteem, family disharmony and instability, bullying, difficult life events to societal discrimination and isolation.

Determinants for mental health include but are not limited to maternal factors such as birthweight, smoking during pregnancy, teenage conceptions, family factors such as poverty, parental unemployment, lone parents households, household with persons having long term conditions, domestic abuse, parental drug and alcohol use and households with looked after children. Other risk factors influence the mental health status of children during infant and school age period. These include learning difficulties, children providing unpaid care, child abuse and neglect, family dysfunction, school absence, smoking and obesity, bullying, drug and alcohol use.

This section of the JSNA focuses primarily on children and young people under 18. And also takes into account transition to adulthood (18-25 years of age).

The level of need in the population

There are 80,860 children and young people under 24 in South Gloucestershire. Table 1 below shows the population estimates for South Gloucestershire children and young people by 5 year age bands.

Table 1: Population estimates 2014

Males Females Total
Age band (years) Number % male population Number % female population Number % total SG pop
0 – 4 8,323 6.2 7,912 5.8 16,235 6.0
5 – 9 8,229 6.1 8,063 5.9 16,292 6.0
10 – 14 7,429 5.5 7,215 5.3 14,644 5.4
15 – 19 8,883 6.6 8,149 6.0 17,032 6.3
20 – 24 8,942 6.2 7,717 5.6 16,659 6.1

Source ONS 2015

Changes in the population age structure affect the need for health services. Population projections therefore have an essential role in assessing the future need for services. Current trends in births, deaths and migration are projected forwards and used to produce population projections. Further demographics for children and young people can be seen in the demographics section of the JSNA.

National estimates of prevalence are based on a survey carried out by the Office of National Statistics in 2004 (Green et al, 2004). Based on the national estimates of prevalence, there are approximately 4,800 children in South Gloucestershire, aged 5-19 who have a mental health disorder. According to the same survey, the following estimates for mental health disorders were observed.

Prevalence estimates for mental health disorders in children aged 5 to 16 years have been estimated in a report by Green et al (2004). Prevalence varies by age and sex. Table 3 below shows the estimated prevalence of mental health disorder by age group and sex in South Gloucestershire. Note that the numbers in the age groups 5-10 years and 11-16 years do not add up to those in the 5-16 year age group as the rates are different within each age group.
Table 3 – Estimated number of children with mental health disorders by age group and sex, South Gloucestershire 2014

Estimated number with mental health disorders
 boys aged 5-10 yrs  boys aged 11-16 yrs  boys aged 5-16 yrs girls aged 5-10 yrs  girls aged 11-16 yrs  girls aged 5-16 yrs
870 1,075 1,945 440 815 1,250

Source: Local authority mid-year resident population estimates for 2014 from Office for National Statistics. CCG population estimates aggregated from GP registered populations (Oct 2014). Green, H. et al (2004).
Estimated prevalence rates of mental health disorders can be further broken down by estimated prevalence of conduct, emotional, hyperkinetic and less common disorders (Green, H. et al, 2004). Table 4 below shows the estimated number of children with conduct, emotional, hyperkinetic and less common disorders in South Gloucestershire, by applying these prevalence rates (the numbers in this table do not add up to the numbers in the previous table because some children have more than one disorder). The estimated prevalence of mental health disorders is higher in South Gloucestershire amongst boys except for emotional disorders which is estimated to be higher for girls.
Table 4 – Estimated number of children with mental health disorders by age group and sex, South Gloucestershire 2014

  Estimated number with mental health disorders
children aged 5-10 yrs  children aged 11-16 yrs  boys aged 5-10 yrs  boys aged 11-16 yrs girls aged 5-10 yrs  girls aged 11-16 yrs
Conduct disorders 835 1,060 600 670 235 390
Emotional disorders 400 840 180 350 225 490
Hyperkinetic disorders 290 245 245 200 45 45
Less common disorders 245 220 185 150 60 70
Total 1,770 2,365 1,210 1,370 565 995

Source: Local authority mid-year resident population estimates for 2014 from Office for National Statistics. CCG population estimates aggregated from GP registered populations (Oct 2014). Green, H. et al (2004).

A study conducted by Singleton et al (2001) has estimated prevalence rates for neurotic disorders in young people aged 16 to 19 inclusive living in private households. The tables below show how many 16 to 19 year olds would be expected to have a neurotic disorder if these prevalence rates were applied to the population of South Gloucestershire. Table 5 below estimates that for 16-19 year olds more females are diagnosed with neurotic disorders such as ‘mixed anxiety and depressive disorder’ than males yet it should be noted more males are estimated to have a diagnosis of ‘generalised anxiety disorder’ and ‘obsessive compulsive disorders’.

Children aged 11 to 16 years olds are more likely than 5 to 10 year olds to experience mental health problems.

National data estimates that for 16-19 year olds more females are diagnosed with neurotic disorders such as ‘mixed anxiety and depressive disorder’ than males yet it should be noted more males are estimated to have a diagnosis of ‘generalised anxiety disorder’ and ‘obsessive compulsive disorders’.
Table 5 – Estimated number aged 16 to 19 with neurotic disorders, South Gloucestershire 2014

Males 16-19 yrs Females 16-19 yrs Total
Mixed anxiety and depressive disorder 370 830 1,200
Generalised anxiety disorder 120 75 195
Depressive episode 70 185 255
All phobias 45 145 190
Obsessive compulsive disorder 70 65 135
Panic disorder 40 45 85
Any neurotic disorder 625 1,285 1,910

Source: Local authority mid year resident population estimates for 2014 from Office for National Statistics. CCG population estimates aggregated from GP registered populations (Oct 2014). Green, H. et al (2004).

Autistic Spectrum Disorder (ASD)

A study of 56,946 children in South East London by Baird et al (2006) estimated the prevalence of autism in children aged 9 to 10 years at 38.9 per 10,000 and that of other ASDs at 77.2 per 10,000, making the total prevalence of all ASDs 116.1 per 10,000. A survey by Baron-Cohen et al (2009) of autism-spectrum conditions using the Special Educational Needs (SEN) register alongside a survey of children in schools aged 5 to 9 years produced prevalence estimates of autism-spectrum conditions of 94 per 10,000 and 99 per 10,000 respectively. The ratio of known to unknown cases is about 3:2. Taken together, a prevalence of 157 per 10,000 has been estimated, including previously undiagnosed cases.

The European Commission (2005) highlights the problems associated with establishing prevalence rates for Autistic Spectrum Disorders. These include the absence of long-term studies of psychiatric case registers and inconsistencies of definition over time and between locations. Nevertheless the Commission estimates that according to the existing information, the age-specific prevalence rates for ‘classical autism’ in the European Union (EU) could be estimated as varying from 3.3 to 16.0 per 10,000. These rates could however increase to a range estimated between 30 and 63 per 10,000 when all forms of autism spectrum disorders are included. Debate remains about the validity and usefulness of a broad definition of autism. The EU definition of rare diseases focuses on those diseases lower than 5 per 10,000. The Commission notes that ASD could be considered as a rare disease using the most restrictive diagnosis criteria but it seems more appropriate to not refer to ASD as a rare disease.
Table 6 below shows the numbers of children with autistic spectrum disorders if the prevalence rates found by Baird et al (2006) and by Baron-Cohen et al (2009) were applied to the population of South Gloucestershire.

Table 6 – Estimated number of children with autistic spectrum disorders, South Gloucestershire 2014

Autism in children aged 9-10 years Other ASDs in children aged 9-10 years Total of all ASDs in children aged 9-10 years Autism-spectrum conditions disorders in children aged 5-9 years
25 50 75 260

Source: Local authority mid-year resident population estimates for 2014 from Office for National Statistics. CCG population estimates aggregated from GP registered populations (Oct 2014). Green, H. et al (2004).
Public Health England has estimated that in South Gloucestershire the prevalence of potential eating disorders could be affecting 3,946 young people (16-24 year olds). In the 0-18 population it is predicted South Gloucestershire will experience a 9.4% increase by 2037.

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). The following table shows these estimates for the population aged 17 and under in South Gloucestershire.

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, for example over 8,000 children under 17 years requiring tier 1 CAMHS services, suggests significant unmet need for those children who do not meet the threshold of a formal mental health diagnosis. This is discussed further in the ‘services’ section of the CYPMNHA (see table 7).
Table 7 – Estimated number of children / young people who may experience mental health problems appropriate to a response from CAMHS, South Gloucestershire 2014

Tier 1 Tier 2 Tier 3 Tier 4
8,560 3,995 1,060 45

Source: Office for National Statistics mid year population estimates for 2014. CCG population estimates aggregated from GP registered populations (Oct 2014).
Kurtz, Z. (1996).

Online Pupil Survey and prevalence

The South Gloucestershire Children and Young People’s Health and Wellbeing Survey (Online Pupil Survey/ OPS) is funded by the Public Health and Wellbeing division of South Gloucestershire Council. The health and well-being survey has data from over 6,000 pupils aged 8 to 18 years old, from 59 schools. We initially developed the South Gloucestershire version of the survey in 2014 based on a similar survey that has been running in Gloucestershire biennially since 2006. It is hoped that it will be run as an on-going partnership project every 2 years following a cohort of children from year 4 to year 12.

Demographics of respondents is shown in table 8:

Table 8 Demographics of online pupil survey respondents

Key demographics Number of respondents % of total survey (%) % of target CYP population (n=12,948)
Total number of respondents 6,151 100.0% 47.5%
Year 4 (aged 8 -9) 1,037 16.9% 8.0%
Year 5 (9 – 10) 1,301 21.2% 10.0%
Year 6 (aged 10 -11) 1,415 23.0% 10.9%
Year 8 (aged 12 -13) 1,132 18.4% 8.7%
Year 10 (aged 14 -15) 794 12.9% 6.1%
Year 12 (age 16+) 472 7.7% 3.6%
Male 3,078 50.0% 23.8%
Female 2,993 48.7% 23.1%
Ethnicity – White British 5,106 83.0% 39.4%
Ethnicity – Other 735 11.9% 5.7%
Eligible for free school meals 640 10.4% 4.9%
Locality 1* 2,512 40.8% 19.4%
Locality 2* 1,412 23.0% 10.9%
Locality 3* 2,196 35.7% 17.0%
Parent(s) in armed forces 179 2.9% 1.4%
School phase – Primary 3,753 61.0% 29.0%
School type – Secondary 1,926 31.3% 14.9%
School phase – Year 12/ FE college 472 7.7% 3.6%

81% of pupils said they were good at making and keeping friends. 8% said they felt they were not good at making and keeping friends. 91% of primary pupils reported they had at least 2 good friends, only 1.3% felt they had no good friends. 34% of secondary and Year 12s are often so worried about something that they cannot sleep at night.

Families and relations were the main people with whom the majority of pupils would go to when they felt unhappy or worried (82% for primary and 59% of secondary) followed by their friends (45% primary and 48% secondary). Professionals such as teachers, youth workers, medical professionals, social workers also had a key role to play; 28% of primary and 12% of secondary would talk to professionals about their worries. 10% of primary and 25% of secondary said they had no-one to talk to.

Overall, 75% pupils (secondary and year 12s only) said that they were satisfied or quite satisfied with their life. 63% said they are confident about the future; girls tend to be less confident than boys and it declines sharply in years 10 and 12.

Overall, 76% of the pupils said they were happy most of the time and 11% were unhappy. 71% said they were happy at school and 14% were unhappy. There were some gender differences, girls tending to be less happy than boys and happiness decreased as they got older particularly between years 6 and 8.

Risk factors

The last survey of the prevalence of mental health problems in children and young people in the UK was conducted in 2004. At that time, nearly 850,000 (9.6%) children and young people aged 5-16 were estimated to have a diagnosable mental health disorder. The study found that the prevalence was greater among 11-16 year olds at 11.5%, or about 510,000 young people, compared to 7.7%, or nearly 340,000 children aged 5-10. [1]

It is well documented that a range of risk and protective factors can affect whether a child or young person will develop a mental health problem. These factors can relate to a child’s personality, family, socio-economic status and environment, as Table 9 shows. An awareness of these factors can support professionals to develop effective prevention and early intervention services, as well as services for those in need of more intensive support. [2]

Table 9: risk and protective factors, CYP mental health

Child risk factors Family risk factors External risk factors Protective factors

·       Poverty

·       Family breakdown

·       Single parent family

·       Parental mental ill health

·       Parental criminality, alcoholism, or substance abuse

·       Overt parental conflict

·       Lack of boundaries

·       Frequent family moves/being homeless

·       Over protection

·       Hostile and rejecting relationships

·       Failure to adapt to the child’s developmental needs

·       Caring for a disabled parent

·       School non-attendance

·       Learning difficulty

·       Abuse

·       Domestic violence

·       Prematurity or low birth weight

·       Shy, anxious or difficult temperament

·       Physical illness

·       Lack of boundaries

·       Looked-after children

·       Lack of attachment to carer

·       Academic failure

·       Low self-esteem

·       Young offenders

·       Chronic illness

·       Unclear discipline at school

·       Failure to recognise children as individuals at school

·       School exclusion, including school refusal

·       Bullying, including cyber bullying

·       Peer rejection/peer pressure

·       A good start in life and positive parenting

·       Being loved and feeling secure

·       Living in a stable home environment

·       Parental employment

·       Good parental mental health

·       Activities and interests

·       Positive peer relationships

·       Emotional resilience and positive thinking

·       Sense of humour

·       Full engagement with education

The development of effective services also needs to consider the relationship between mental and physical health, as approximately 12% of young people live with a long-term condition that can increase their risk of poor mental health between two to six times. Conversely, having a mental health problem puts children and young people at greater risk of physical illness, with depression increasing the risk of morbidity by 50%. Furthermore, individuals with mental health problems, such as schizophrenia or bipolar disorder, die 16-25 years sooner than the general population. [3]

The cumulative effects of adverse experiences and environmental circumstances, such as domestic violence, and poverty, all leave their mark. A single risk factor is thought to result in a 1-2% chance of developing a mental health problem; increasing to an 8% chance in the presence of three risk factors, and a 20% chance with four risk factors. [4] Without help and support at the right time and in the right place, risky behaviours and poor psychological resilience can persist into adulthood. [5]

Socio-economic disadvantage is a significant risk factor for poor mental health in children and young people, with those growing up in the poorest households at three times greater risk for developing a mental health problem compared to those growing up in less deprived homes(see Figure 6) [6][7],[8]. Furthermore, deprivation can underpin a range of other risk factors within the family unit, schools, and communities, touching on every aspect of a child’s future, including their mental health outcomes. [9]

Figure 6 – The map shows differences in deprivation within South Gloucestershire and the chart shows the percentage of the population who live in areas at each level of deprivation (from Public Health England’s South Gloucestershire Health Profile)

map showing differences in deprivation within South Gloucestershire and the chart shows the percentage of the population who live in areas at each level of deprivation (from Public Health England’s South Gloucestershire Health Profile)

To put a halt to the accumulation of risk factors in children and young people, early intervention services have proven effective at providing swift action in response to emerging problems from conception to young adulthood. Importantly, early intervention offers the chance to make lasting improvements to the lives of children and young people, terminating the transmission of persistent social problems from generation to generation. [10]

As previously described mental health and mental disorders are influenced by the economic, social and physical environments in which children live. Some populations are at higher risk of mental disorders because of their vulnerability to unfavourable circumstances and their gender. Mental health risk factors encompass a wide range of fields from complications during birth, low self-esteem, family disharmony and instability, bullying, difficult life events to societal discrimination and isolation. South Gloucestershire performance against key at risk indicators is shown in figure 7 below.

Figure 7: Children and Young People’s Mental Health and Wellbeing, South Gloucestershire 2015

table showing Children and Young People’s Mental Health and Wellbeing, South Gloucestershire 2015

Source: http://fingertips.phe.org.uk/profile-group/mental-health/profile/CYPMH

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 (ref) and were published in the CMOs Atlas of Variation (ref). Table 10 below maps estimated prevalence of mental health disorder against risk factors and shows significant numbers of children in South Gloucestershire at higher risk of developing mental health disorders.

Table 10: Estimated prevalence and actual activity at tiers 1-4, South Gloucestershire

Risk factor Estimated prevalence of mental health disorder based on national data (ref CMO atlas of variation)

South Gloucestershire estimates (numbers)

 

Looked after children 45% 81 (45% of 180)
Children with SEN requiring statutory assessment 44% 1,590 (44% of number of pupils with SEN support for South Glos 4,416 for 2015 [i])
Children with learning difficulties 36% 342 (36% of 950)
Children absent from school for >15 days in previous term

For emotional disorders 17%

For conduct disorders 14%

For hyperkinetic disorders 11%

Currently data not sourced
Children from households with no working parent 20% 748 (20% of analysis of the 2011 census shows that there were 3,738 [ii]families in South Gloucestershire where no parents were working)
Children from families receiving disability benefit 24% Currently data not sourced

Children from families

where the household

reference person is in a routine occupational

group (e.g. unskilled

manual worker)

15% Currently data not sourced

Children of parents

with no educational

qualifications

17%

 

Est 5,193 (Census data shows that there were 30,546[iii] parents in South Glos with no or low qualification (defined as having level 1 as highest qualification))

 

Children in “hard

pressed” areas (i.e.

high prevalence of

unemployment and

poor qualifications)

15%

 

Currently data not sourced

Children from

households with

weekly income of

<£100

16%

 

978 (16% of 2013 data showing there were 6,110 children in SG living in low income families. This is defined as dependent children under 20 living in families either in receipt of out-of-work benefits or in receipt of tax credits with a reported income which is less than 60 per cent of national median income)

11-16y old from

households with a

weekly income of

<£200

20%

 

Currently data not sourced

Children in

stepfamilies

14% Currently data not sourced

Children from lone

parent families

16% 1,230 (16% of data from the 2011 census showing that there were 7690 lone parent families in South Gloucestershire)

i https://www.gov.uk/government/statistics/special-educational-needs-in-england-january-2015 LA tables, Table 11B NB This is based on where the pupil goes to school not pupil’s LA of residence

ii Awaiting analysis to determine whether this relates to families or individuals

iii Awaiting analysis to determine whether this relates to families or individuals

Source: Annual report of the Chief Medical Officer 2012. Our Children Deserve Better: Prevention Pays. Atlas of Variation. Annex 9

Online pupil survey and risk factors

Risk factors for consideration identified via the findings from the OPS or relevance to the mental health and emotional wellbeing of CYP in South Gloucestershire are as follows:

  • Generally boys feel safer outside than girls – interventions that develop (girl’s) resilience and confidence to feel safe outdoors should be explored.
  • The majority of children and young people who report being bullied indicated this was verbal and physical bullying. E-safety support is being put into schools to safeguard children and young people cyber bullying. In addition the data suggests that strategies to combat verbal and physical bullying are equally as important and should not be ignored.
  • Whilst the majority of children and young people report eating breakfast regularly, this reduces as age increases. In addition there is a direct comparison between not eating breakfast and an increase in snacking habits. Breakfast club interventions could be extended to more schools.
  • Children and young people’s physical activity each week does not meet the recommended 6 hours. Girls report taking part in less physical activity than boys and the amount of time spent takin part in physical activity in secondary school decreases as age increases
  • One in three girls report being so worried they cannot sleep compared to 1 in 10 boys
  • Overall being a year 10 girl is a risk factor for: not eating breakfast; monthly/weekly alcohol use; experiencing cyber bullying; regular self-harm; being unhappy at school, less proud of their achievements.

More detailed data on specific risk factors is detailed below.

Drinking

For Year 8 to Year 10 cumulatively, 17.3% of pupils reported being drunk regularly, while for Year 12 only the percentage more than tripled, with 62.9% of the pupils reporting being drunk on a regular basis. Girls were more likely to drink compared to boys, with 67% vs 60% reporting being drunk in Year 12. Out of those who responded that they drink alcohol regularly, girls were more likely to report being drunk than boys, with 78% compared to 71.3%.

Illegal Drugs

An average of 6.3 % of the secondary school pupils have reported having tried illegal drugs, Year 12 reporting 16.3%.

Stress

While nearly 43.7% of secondary school pupils feel stressed about school work, more girls reported feeling this way compared to boys, 47.9% vs 39.4%. Year 12 reported higher percentages of pupils feeling stressed about schoolwork, reaching 60.7%.

Information recorded via the survey in relation to whether children have breakfast was correlated with ‘feeling stressed about school work’. It is interesting to note an observation linking breakfast frequency with feeling stressed about school work. Those who never have breakfast reported a prevalence of stressing over schoolwork of 65.3% as opposed to those who have breakfast every morning who reported 39.9% (see table 11).

Table 11. Breakfast Frequency and reported stressed about school work.

Breakfast Frequency
Positive response to: Never % Not Often % Some-times % Usually % Every Morning % Total %

Feeling stressed about school

work

124 65 201 58 87 46 170 47 389 40 971 47

Overall, 12.7 % of secondary school pupils considered themselves to ‘often be in trouble at school’. Younger pupils (Year 8 and Year 10) were more likely to report ‘being in trouble’ than older children (Year 12), 12% vs. 4%. Girls were less likely to ‘be in trouble’ when compared to boys, 9.4% vs 15.7%.

Gang Membership

Gang membership is also linked to pupils feeling they are often in trouble. Of those who are not part of a gang only 7.9% report feeling they are in trouble at school. This percentage increases to 25.6% for those who felt they should be in a gang at some point but did not join and to 41.5% to those who have joined a gang.

The same gradient observed for feeling stressed about school work (please see above) and breakfast applies to pupils feeling they are in trouble at school. Only 6.6% of those who have breakfast every morning report feeling in trouble at school, while the percentage for those who never have breakfast is 19.9%.

Domestic Abuse

Secondary and post 16 pupils were asked if they had witnessed or had been subjected to domestic abuse. Overall 84% had not. However 333 pupils reported they, or someone in their immediate family had been abused. 186 were female and 147 male. 292 said it was not happening now and 26 (8%) said it was still happening.

Self-harm

Secondary pupils and year 12 young people were asked is they had ever self-harmed. The 16.3% (357) who responded yes were then asked a series of questions about their self-harm, the first of which was how often they had self-harmed. 11% (36) replied “never” to this question – this means that the actual proportion of pupils who have self-harmed is actually 14.6% (357 minus the 36 “Nevers” = 321 divided by the number of pupils who responded 2,195).

A further 51.1% (163) pupils said they had self-harmed once or twice. In our experience these tend to be young people who have self-harmed as part of a game or challenge/dare and most do not go onto serious self-harm or related mental issues. This group of young people can be described as “Experimental” self-harmers and are therefore not included in the analysis of habitual self-harmers.

Therefore the number of habitual self-harmers that we are concerned with in this study is actually 7.2% (158) – that is our 321 actual self-harmers minus 163 experimental self-harmers = 158 regular self-harmers. It is very important that this 7% figure is quoted when reporting self-harm and not the initial 16% which could be misleading. 7% is in line with national figures (also based on regular self-harm). Experimental self-harmers should be reported as a separate figure.

Considering the regular self-harmers – these can be subdivided into habitual self-harmers – those who self-harm sometimes – e.g. monthly (38 pupils, 1.7%) and chronic self-harmers those who self-harm weekly or more (82 pupils, 3.7%) – see figure 8).

Figure 8 – frequency of self-harm, online pupil survey

chart showing frequency of self-harm, online pupil survey

In line with national trends and other local studies (OPS and in and around Bristol) the incidence of regular self-harm is about 3 times more prevalent in girls than in boys. Those boys who have self-harmed are more likely to have experimented than girls, and girls are more likely to be chronic self-harmers than boys.

Figure 9 – frequency of self-harm (gender differences), online pupil survey

chart showing frequency of self-harm (gender differences), online pupil survey

There are also some gender differences in the methods they use to self-harm – girls favouring cutting in the main and boys also using more physical means (e.g. punching walls etc).

Bullying

The majority (65%) of pupils in all year groups feel their school had dealt with bullying quite or extremely well. However there is a significant difference in year groups with a high point (77.8%) in year 4 and a low point (37.4%) in year 10. This is not correlated with the amount of actual bullying reported. 11% of pupils report being bullied sometimes, quite often or most days. This is higher in primary than in secondary phases. Reported bullying decreases as pupils get older but perception of school management in this area gets worse.

Children and young people with learning difficulties

People with learning difficulties are more likely to experience mental health problems (Emerson, E. et al, 2008). Estimation of the population prevalence of learning difficulty is problematic and should be treated with caution. Emerson et al (2004) calculated prevalence in children and young people with learning difficulties for different age groups as follows: 5 to 9 years: 0.97%; 10 to 14 years: 2.26%; and 15 to 19 years: 2.67%. The following table (12) applies these prevalence rates to South Gloucestershire.

Table 12 – Estimated total number of children with a learning difficulty, South Gloucestershire 2014

Children aged 5-9 yrs with a learning difficulty Children aged 10-14 yrs with a learning difficulty Children aged 15-19 yrs with a learning difficulty Total
160 335 455 950

Source: Office for National Statistics mid year population estimates for 2014. CCG population estimates aggregated from GP registered populations (Oct 2014).
Emerson E. at al (2004).
These rates for different age groups reflect the fact that as children get older, more are identified as having a mild learning difficulty. The Foundation for People with Learning Disabilities (2002) estimates an upper estimate of 40% prevalence for mental health problems associated with learning difficulty, with higher rates for those with severe learning difficulties. The following table shows how many children with learning difficulties who also experience mental health problems might be expected in South Gloucestershire.
Table 13 – Estimated total number of children with learning difficulties with mental health problems, South Gloucestershire, 2014

Children aged 5-9 yrs with a learning difficulty with mental health problems (2014) Children aged 10-14 yrs with a learning difficulty with mental health problems (2014) Children aged 15-19 yrs with a learning difficulty with mental health problems (2014)
65 135 185

Source: Office for National Statistics mid-year population estimates for 2014. CCG population estimates aggregated from GP registered populations (Oct 2014).
The Foundation for People with Learning Disabilities (2002)

[1] Green et al. (2005). Mental health of children and young people in Great Britain, 2004. A survey carried out by the Office for National Statistics on behalf of the Department of Health and the Scottish Executive. Basingstoke: Palgrave Macmillan.

[2] RCN (2014) Mental health in children and young people. Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0003/596451/RCNguidance_CYPmental_health_WEB.pdf

[3] Future in Mind

[4] DfEE (2001) Promoting children’s mental health with early years and school settings. Available at: http://www.mentalhealthpromotion.net/resources/promoting-childrens-mental-health-with-early-years-and-school-settings.pdf

[5] Law et al. How big an issue is children and young people’s mental health? Young Minds doc from Steve

[6] South Glos health profile PHE

[7] Green H, McGinnity A, Meltzer H, Ford T, Goodman R: Mental health of children and young people in Great

Britain, 2004. A survey carried out by the Office for National Statistics on behalf of the Department of Health and the Scottish Executive. Basingstoke: Palgrave Macmillan, 2005.

[8] CMO 2010 report

[9] Marmot review

[10] Cabinet Office (2011) Early intervention: the next steps. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/284086/early-intervention-next-steps2.pdf

[ii] Awaiting analysis to determine whether this relates to families or individuals

[iii] Awaiting analysis to determine whether this relates to families or individuals

Current services and assets in relation to need

Services for children and young people exist for the population of South Gloucestershire across the four tiers described in the introduction.

Table 14 gives an indication of services currently operating in South Gloucestershire at each tier and their current service usage where known. Although current service usage is not fully populated due to a lack of available data the table indicates that in comparison with estimated prevalence by tier there is unmet need at the various tiers, notably lower tiers including preventative services, potentially sub-threshold where children and young people have not received a diagnosis of a mental health condition.

Table 14: SG services mapped against tiers of provision

Tier Mental Health support provided

Services currently operating in South Gloucestershire with current service usage in brackets. NK = Not known

For more detailed service information see appendix xxx

Expected number of CYP at this tier in South Gloucestershire
1 Protective activities and strategies for self-management, awareness raising, advice, early assessment and signposting.

Breakthrough Mentoring (150)

Southern Brooks SAY Project (NK)

Southern Brooks Dreamscheme (NK)

SARI 1:1 empowerment (NK)

Indigo (NK)

Supportive Parents (NK)

Resound- Blackhorse (NK)

Parents and carers (NK)

Southern Brooks WoW groups (NK)

Kingsmeadow Community Flat (NK)

Our Place Community Flat Staple Hill (NK)

St Nicholas family Centre Yate (NK)

Bourne Family Project Kingswood (NK)

South Glos Community Sport

Street games and other initiatives (NK)

South Glos Library service (NK)

South Glos Community Learning (310)

OTR (Resilience Lab) (NK)

KTS (NK)

Ignite courses (NK)

NAS support group (NK)

Bouncing Babies. (NK)

Butterflies Haven (NK)

The Rainbow centre (NK)

Survive Freedom Programme. (NK)

REACH (NK)

Independent People 16-25 (NK)

South Glos Youth Housing (100)

EACH: Educational Action Challenging Homophobia (200)

Supportive Parents (NK)

Special Friends (NK)

Whizzkids (NK)

Fairbridge (NK)

Incredible Kids (NK)

Sure Start Children’s Centres (2236)

GPs (NK)

Youth Services (targeted in PNs) (NK)

School nurses (NK)

Health visitors (NK)

Mind Out – Training (NK)

Education other than at School (EOTAS) – Behaviour unit Severnside, (NK)

The Junction Mangotsfield (NK)

First Point (583)

Social workers (need breakdown by team)

— Children in Care (180)

— Children with child protection plan (156)

SAF process to co-ordinate team around the child (700)

Brook (NK)

 

8560
2 More specialist mental health support for those who needs are not met at tier 1. Training and advice for tier 1 staff.

Youth Intervention Support Service (YISS) (NK)

Family Intervention Support Service FISS (NK)

Educational psychologists (NK)

Southern Brooks family services team (NK)

Families in Focus (FIF) workers (NK)

Primary mental health workers

–Looked After (NK)

–Children of School Age (NK)

–Antenatal-4 years (NK)

— YOT (NK)

Psychologist for looked after children

Paediatricians (NK)

Young People drug & alcohol service—1:1 (70)

Enuresis service (NK)

Off The Record Talking Therapies 11-15 yrs (250)

South Gloucestershire talking therapies 16-18 yrs (250)

South Gloucestershire talking therapies 19-25 yrs (850)

3995
3 Support for those with complex mental health needs

South Glos early intervention in psychosis aged 14-35 experiencing a first episode of psychosis (NK)

Young people substance misuse treatment service (NBT) SG commissions 6 places a year for most complex YP

CAMHS services (830)

Not sure of full breakdown of services

  • Partnership Outreach Team (NK)
  • Eating disorders (75 inc 52 anorexia)
  • Be safe- harmful sexual behaviour for CYP (NK)
  • Section 136 suite (NK)

 

1060
4 Support for CYP with severe, highly complex and life threatening conditions

Riverside Unit (NK)

New Horizons (NK)

STEPS (NK)

45

Maternal and Infant mental health

Maternal and infant mental health has recently come under scrutiny both nationally and locally in the West of England area during 2015. As a result a local peri natal depression (PND) strategy group has been formed for South Gloucestershire. This group consists of representation from the voluntary sector (including service user voice), Avon & Wiltshire Mental Health Trust, North Bristol Hospital Trust, South Gloucestershire Clinical Commissioning Group and South Gloucestershire Council.

The group is in its early stages but has come up with some early areas for action based of professional feedback.

  1. It is not clear what local data is routinely collected across all levels of the pathway and an audit of current data sources in being conducted. This will be cross referenced with the new maternity dashboard being developed across the South West to develop a core indicator set.
  2. Possible data sources identified include, IAPT, GPs, Health Visitor notes (Care Plus), Children Centre data, voluntary sector waiting lists, AWP data, New Horizons data (Southmead) and general midwifery data.

Recommendations for service development are being collated after consultation with service users and professionals and data will be used to further build on this once it is gathered.

Talking Therapies

Talking therapies are part of the local service offer and support significant volumes of children and young people between the ages of 11-25. Locally this service is offered in two parts one covering 11-15 year olds and one covering 16-25 year old. The former is provided by Off the Record and the later by South Gloucestershire Talking Therapies.

Individuals can be referred by professionals (GPs being the main source) or self-refer. The three services together support around 2000 children and young people a year.

Off the Record (11-15 year olds)

Off The Record provides Tier 2 counselling service young people aged 11-15. This service was introduced in September 2014, having long been identified as a service gap in South Gloucestershire

Between September 2014 and March 2015 127 young people accessed the service.

Waiting times:

  • Kingwood (27 young people / 20 weeks),
  • Yate (13 young people / 17 weeks),
  • Patchway (8 young people / 15 weeks).

 

Figure 10 – South Gloucestershire Talking Therapies (16-25 year olds)

chart showing South Gloucestershire Talking Therapies (16-25 year olds)

As shown in figures 11 and 12 there is fluctuation in referrals into the service and an upward trend is seen in the 16-18 year old age group.

 

Figure 11: SG referrals to Talking Therapies (16-18 year olds)

chart showing SG referrals to Talking Therapies (16-18 year olds)

Source: Talking Therapies (16-18 year olds)

 

Figure 12: SG referrals to Talking Therapies (19-25 year olds)

chart showing SG referrals to Talking Therapies (19-25 year olds)

Source: Talking Therapies (19-25 year olds)

CAMHS service activity

Referrals to tier three CAMHS have increased in the last 5 years for South Gloucestershire while the percentage of acceptance has decreased (see table 15).

According to ONS 2014 published statistics, in South Gloucestershire an estimated number of 1,060 children aged 17 and under would require Tier 3 service. This is twice the number of children who have been referred and accepted for these services on an annual basis in recent years.

Table 15 – South Gloucestershire Tier 3 referrals

Year Total referred Rejected Accepted % of accepted given an appt. % accepted
2010/11 787 203 584 83% 74.2%
2011/12 721 184 537 78% 74.5%
2012/13 874 328 546 82% 62.5%
2013/14 967 328 639 79% 66.1%
2014/15 842 342 500 73% 59.4%
5 year average 838 277 562  N/A 67.1%

Source: CAMHS

The rates of referrals and accepted referrals have been fluctuating in the last 5 years, both seeing the same trends, with a steeper change in the referral rate compared to accepted referrals (see figure 13). It is noteworthy that although referral and accepted referral rates have experienced similar trends, the rate of rejected referrals has doubled in 2012/13 from that in 2011/12 and has stayed constant for the last three years at approximately 57/ 10,000 under 18 population, regardless of the drop in referrals.

 

Figure 13. Rates of referrals for CAMHS tier 3, 2010/11-2014/15, South Gloucestershire

chart showing Rates of referrals for CAMHS tier 3, 2010/11-2014/15, South Gloucestershire

Source: CAMHS

 

Figure 14. Percentage of rejected and accepted referrals, CAMHS tier 3, 2010/11-2014/15, South Gloucestershire

chart showing Percentage of rejected and accepted referrals, CAMHS tier 3, 2010/11-2014/15, South Gloucestershire

Source: CAMHS

The projections for CAMHS Tier 3 service usage was determined by averaging the changes from 2010/11 to 2014/15 and applying the same trend for the next 5 and 10 years (figure 15). If the services continue to experience the same trend seen in the last 5 years, the rejected referrals percentage will increased from 41% in 2014/15 to 59% and 77% in the next 5 and 10 years, respectively. If the rate stays constant to the 2014/15 levels and we account for the population change, 40 and 122 more referrals will be made in 5 and 10 years, respectively.

 

Figure 15. Rates of referrals into CAMHS Tier3 services, 2010/11-2014/15 and projections for 2020 and 2025

chart showing Rates of referrals into CAMHS Tier3 services, 2010/11-2014/15 and projections for 2020 and 2025

Source: CAMHS and Public Health Intelligence Team, South Gloucestershire Council

 

Figure 16 – Children and Young People’s Admissions Data, 2013/14

chart showing Children and Young People’s Admissions Data, 2013/14

Source: http://fingertips.phe.org.uk/profile-group/mental-health/profile/cypmh

Figure 16 summarises key indicators for South Gloucestershire in relation to admissions data. The rates shown in figures 17 and 18 were obtained by extracting all admissions where any of the diagnoses fields had an ICD code that started with F, in under 19 year olds, South Gloucestershire Residents. The data was extracted via SQL coding from the database supported by the SWCSU. Hospital admissions due to mental health conditions have increased over the last 5 years for South Gloucestershire (figure 17) as have admissions for self-harm for those under 19 years of age (figure 18).

 

Figure 17. Hospital Admissions due to Mental Health Conditions, 10-19 year olds, South Gloucestershire residents, 2010/11-2014/15

chart showing Hospital Admissions due to Mental Health Conditions, 10-19 year olds, South Gloucestershire residents, 2010/11-2014/15

Source: SUS Statistics accessed via Avon Business Intelligence, South West Clinical Commissioning Unit

 

Figure 18 – Self-harm admissions in under 19, South Gloucestershire Residents, 2010-2015

chart showing Self-harm admissions in under 19, South Gloucestershire Residents, 2010-2015

Source: SUS database. The data was extracted via SQL coding from the database supported by the SWCSU. The above rates were obtained by extracting all admissions where any of the diagnoses fields had an ICD code in X60-X85, in under 19 year olds, South Gloucestershire Residents.

Evidence of what works

A range of national guidance exists relating the mental and emotional wellbeing of children and young people. In response to calls for change, the report of the Children and Young People’s Mental Health Taskforce sets the strategic vision for delivering improvements to the mental and emotional wellbeing of children and young people. In particular, the new vision advocates for an integrated whole-system approach, with the NHS, public health, voluntary and community, local authority children’s services, education and youth justice sectors working together to create a system built around the needs of children, young people and their families, rather than rigidly defined in terms of the services on offer by an organisation. The future of the current service delivery model in South Gloucestershire is under discussion, and will draw on local service data and the views of patients, families and professionals to ensure that services are patient-centred and accessible. NICE guidance offers recommendations with a focus on key risk factors that can shape a child’s mental health and these are summarised in an appendix attached to the South Gloucestershire Children and Young People’s Needs Assessment (to be published 2016).

Key themes from ‘Future in Mind’ are relevant to future local strategy development and form the basis of themes for recommendations to commissioners and system leaders:

  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.

User views (on need, services / assets and gaps)

Recent events and focus groups in South Gloucestershire have gathered the views of young people, parents and carers, professionals and service providers. The events and focus groups were as follows:

  • Bristol and SG Children’s Community Health Services Stakeholder findings 2014 (Professionals and Parents/Carers)
  • Healthwatch Being Me event October 2014 (Children & Young People)
  • CYP Professionals service mapping event November 2014 (Providers & elected members)
  • Schools Health Survey February 2015 (6000 responses from students)
  • SEN conference March 2015 (Parents and Carers)
  • South Gloucestershire Youth Board August 2015 (Children & Young People)

During this process a broad range of views were expressed but a number of priorities were consistently identified by local stakeholders:

  1. Whole population and whole system development (mental health promotion)
  2. Targeted prevention (mental illness prevention)
  3. Strengthening the care pathway for young people with identified mental ill health (treatment and rehabilitation)
  1. Whole population and whole system development (mental health promotion)
    Key views as follows:

    • A joined up care pathway that is clearly mapped and understood by professionals and the public alike. What is the local offer?
    • Basic mental health awareness training for CYP professionals including strategies for promoting resilience and self-management along with the local knowledge to signpost.
    • More information/training for parents about how to promote positive mental health in their children.
    • More information/training for CYP about how to manage their own mental health positively.
    • Work with schools and parents to address exam and academic pressures.
    • Campaigns to address stigma and bullying across a range of risk factors (appearance, sexuality, disability, race).
  2. Targeted prevention (mental illness prevention)
    Key views as follows:

    • Approaches that support CYP in the context of the whole family situation including parental risk factors and co-ordinating with adult services.
    • Proactive support and development of protective factors for CYP most likely to experience mental ill health including children in care, children with disabilities, young offenders, young carers and gypsies and travellers.
    • More community based support for mums experiencing mild PND.
  3. Strengthening the care pathway for young people with identified mental ill health (treatment and rehabilitation)
    Key views as follows:

    • A range of alternatives for young people who do not meet the CAMHS service thresholds including increased capacity for talking therapies, key workers and peer support groups.
    • More capacity within CAMHS.
    • More support for young people before the transition into adult services.

Equalities

To be reviewed via full children and young people’s needs assessment due to be published 2016.

Unmet needs and service gaps

The population of children and young people is increasing in South Gloucestershire. Estimated population projections indicate the largest growth is likely to be within the 5-9 and 20-24 year age bands.

The demand on mental health and emotional wellbeing services for children and young people will increase in-line with population growth.

Based on national estimates of prevalence, there are approximately 4,800 children in South Gloucestershire, aged 5-19 who have a mental health disorder. The estimated prevalence of mental health disorders is higher in South Gloucestershire amongst boys except for emotional disorders which is estimated to be higher for girls. Children aged 11 to 16 years old are more likely than 5 to 10 year olds to experience mental health problems.

National data estimates that for 16-19 year olds in South Gloucestershire, more females are diagnosed with neurotic disorders such as ‘mixed anxiety and depressive disorder’ than males yet it should be noted more males are estimated to have a diagnosis of ‘generalised anxiety disorder’ and ‘obsessive compulsive disorders’.

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, for example over 8,000 children under 17 years in South Gloucestershire requiring tier 1 CAMHS services, suggesting significant unmet need for those children who do not meet the threshold of a formal mental health diagnosis.

Although current service usage is not fully populated due to a lack of available data the table indicates that in comparison with estimated prevalence by tier there is unmet need at the various tiers, notably lower tiers including preventative services, potentially sub-threshold where children and young people have not received a diagnosis of a mental health condition.

A range of risk factors affect whether a child or young person will develop a mental health problem such as looked after children. Based on a national estimated prevalence of mental health disorder mapped against risk factors there is likely to be a significant number of children and young people who do not meet the threshold for services and are therefore not accounted for within estimates of mental health service ‘need’ in South Gloucestershire.

Rich data exists within the recent online pupil survey of secondary school children within South Gloucestershire and identifies significant prevalence of children feeling worried, unconfident about the future and unhappy. Rich data on South Gloucestershire children falling into ‘at risk’ categories such as numbers self-harming, feeling stressed, consuming alcohol, not feeling proud of their achievements.

Services for children and young people exist for the population of South Gloucestershire across the four tiers described in the introduction. Accessing data for the lower tier services is challenging and suggests there is a less clear picture of both need and demand at a sub-threshold level both in terms of prevention and treatment of those children and young people with or at risk of developing a mental health disorder.

According to ONS 2014 published statistics, in South Gloucestershire an estimated number of 1,060 children aged 17 and under would require Tier 3 service. This is twice the number of children who have been referred and accepted for these services on an annual basis in recent years.

Hospital admissions due to mental health conditions have increased over the last 5 years for South Gloucestershire as have admissions for self-harm for those under 19 years of age.

Themes identified via stakeholder events and focus groups are as follows:

  • A request for whole population and whole system development
  • Improved support for families and individuals to manage their own mental health (mental health promotion)
  • Targeted prevention required focusing on established risk factor and groups such as services supporting maternal and infant mental health need improved mapping (mental illness prevention)
  • Strengthening the care pathway for young people with identified mental ill health is required (treatment and rehabilitation)

National guidance recommends an integrated whole-system approach, with the NHS, public health, voluntary and community, local authority children’s services, education and youth justice sectors working together to create a system built around the needs of children, young people and their families, rather than rigidly defined in terms of the services on offer by an organisation.

Key themes from ‘Future in Mind’ are relevant to future local strategy development and are currently a gap in current whole system commission and planning for mental health and emotional wellbeing services for children and young people in South Gloucestershire:

  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.

Recommendations for consideration by commissioners

  1. Develop an integrated whole system approach
    This process involves clearly defining and then communicating the local pathway to all stakeholders outlining commissioning responsibilities, performance monitoring and governance arrangements for the whole system to ensure the development of an accountable and transparent system.
  2. Promote resilience, prevention and early intervention
    Reflecting on population projections and identified unmet need for CYP in lower tier services including prevention and sub-threshold needs develop an integrated whole-system approach with the NHS, public health, voluntary and community, local authority children’s services, education and youth justice sectors working together to create a system built around the needs of children, young people and their families. This will involve proactively targeting known risk factors and groups.
  3. Improve access to effective support
    Commission appropriate provision at tiers 2 and 3 to account for population projections and increasing hospital admissions as shown within the above data. Ensure children and young people get the right support or intervention at the right time. This will be done via a consistent range of treatments and interventions which are evidence based and informed by practice. Referrals should be accepted from a wide range of sources such as GPs, schools as well as self-referral.
  4. Care for the most vulnerable
    Offer a range of information and interventions for parents and young people to promote positive mental health and emotional resilience individually and in the context of their family. This will include both widely promoted self-management information but also interventions such as cognitive behavioural therapy, systematic family therapy and parenting courses. Ensure at risk groups identified and targeted via for example health champions and inequalities workstreams. Develop a clear local pathway for maternal and infant mental health. Ensure there is a good understanding of local need and a joint approach to addressing that need with evidence based and performance measured services across all tiers of provision.
  5. Workforce development for non-specialist CYP workforces
    This should include a trend towards staff on lower bands with more generalist and community-based roles. Work towards embedding staff with non-clinical teams, e.g. schools, social care and universal services.

Recommendations for needs assessment work

A Children and Young People Mental Health Needs Assessment will be published in 2016.