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Services to meet the Mental Health needs of Children

Dr. Kedar N Dwivedi MBBS MD DPM FRCPsych
Consultant Child, Adolescent and Family Psychiatrist,

It is estimated that at least 10% of children suffer from mental health problems requiring specialist facilities but, only 1-1.5% of children are being referred to such Services. The reasons for an existence of such enormous unmet needs are inadequate human resources within the service and poor recognition of mental health problems in children at the primary care level. (Garralda 1994).

There are thus enormous unmet mental health needs of children, adolescents and their families which lead not only to an immense amount of distress and suffering, but also to adulthood psychiatric problems, personality disorders, violence, crime, accidents, deaths, drug and alcohol abuse, physical, sexual and emotional abuse of children, imprisonment, and the children of such adults being taken into care, etc. These outcomes are a considerable drain on the limited resources of a variety of health, welfare and Home Office resources.

There is no doubt that the environment in which mental health services are to be purchased is a turbulent one, that the product, in terms of the services provided, is varied across the country, and that there is lack of purchasing expertise. These are the kinds of circumstances in which commissioners of services need to be particularly cautious about allowing free market principles to apply (Unsworth and Bridge, 1992, p.20).

There is also a lack of adequate research on effectiveness in this area, yet the purchasers may demand evidence of effectiveness before purchasing, sometimes as an excuse for not purchasing an adequate service. It is only now that the Department of Health has started developing an outcome scale applicable in child mental health services (i.e. HONOSCA).

Vanstraelen and Cottrell (1994) found from their survey of the purchasers in the North East Thames Region, that their knowledge of Child Mental Health Services was extremely limited and they had made little or no attempt to set quality standards or to monitor them.

Unfortunately, a lack of appreciation by district health authorities in the past of the mental health needs of children in the population means that many services around the country are underdeveloped. This is just the kind of situation which, the goverment has argued, would be remedied by the NHS Reforms. (Vanstraelen and Cottrell, 1994, p.259)

As Parry-Jones (1992) has observed, the services for children with psychiatric disorders and their families have been a very low priority in this country:

"....there is evidence of prolonged underfunding, resulting in marked shortfall of manpower, by any standards, in poor working conditions rendering child and adolescent psychiatry a truly Cinderella Service"(p.5).

And in the words of yet another writer:

The tragedy lies in the disconnection between resources and the scale of the problem, between the services themselves, and between knowledge and policy.... It is a disturbing and increasingly desperate situation for what is ultimately at stake is the well-being of our children and the quality of their future lives, what is truly appalling is the extent and depth of misery and fear amongst so many of our children......Children who have been so disturbed that they need to be placed in inpatient units and then worse, because of closures, are returned back to their family 'night-mares' (Wilson, 1994, p.1)

The recent publications from the Health Advisory Service (1995) and the Department of Health (1995) have helped to focus the attention on these issues with a framework for evolving the child mental health services at various levels. However, very little appears to have evolved in actual practice.

The psycho-social context

A number of technological changes have an impact on family life and child mental health. In the recent past the pace of these changes have been very rapid. In recent years there has been a substantial increase in the rate of divorce, unemployment, abuse and in the impact of mass media, but a decrease in the role of religion and moral values. There is a greater risk of child mental health problems in families suffering from socio-economic disadvantage or family discord e.g. when parents are unemployed, divorced, living alone or homeless. During the last decade the rate of homelessness has doubled in this country (Oldman 1990). Decline in support offered by extended family networks and increased emotional and socio-economic strains in single parent families also influences children's mental health.

Children living in deprived conditions lack adequate facilities for their proper emotional and physical growth and are more likely to suffer from psychiatric disturbance. Low household incomes may trap families in substandard housing in which limited space prevents safe play and the development of family relationships (While 1989). Evidence indicates that many forms of child psychiatric disorders such as juvenile delinquency, suicide, eating disorders, alcohol and drug abuse are becoming much more frequent (Rutter 1991).

National Policies

There have been a large number of recent national policies and Acts, along with reorganisations and philosophical and practice changes with an impact on the need for and the nature of Child Mental Health Services.

The 1981 Education Act places emphasis on multi-disciplinary assessment and helping children with special needs to remain within mainstream schools. The Child Mental Health Services are often required to provide reports for the Statementing process and also to help with the increasing demands of children's escalating needs and diminishing resources

The Children Act 1989 emphasises that agencies should work together with parents and families to provide services to help children remain with their families whenever possible. Such an effective working together has enormous implications on time and energy demands on the already overstretched Child Mental Health teams.

The Act also gives powers to the Local Authority to take action through the courts to protect children for which assessments and reports from certain professionals of the Child Mental Health team may be deemed necessary. Similarly there are enormous needs for an integrated treatment and assessment programme to help the abused children, adolescents and their families.

The Act also stresses the need to prevent criminal offences by young people. A significant number of young people who commit offences have mental health problems which need help from the Child Mental Health teams either directly or through liaison and support with Diversion Unit, Community Safety Office, Social Services and other community agencies.

Health of the Nation (Secretary of State for Health, 1991) has set the target for reducing the rates of suicide and of teenage pregnancies. A substantial proportion of suicidal young people have serious psychiatric disturbance (Black, 1992). Similarly, early onset conduct disorder constitutes an important risk factor in teenage pregnancies (Kovacs et al, 1994). Promotion of health in adulthood through the promotion of child mental health is another area that has relevance to the Child and Family Consultation Service.

The Patients Charter emphasises the setting and achievement of service standards (e.g. waiting time, information and communication, etc) which all services must meet.

The Child Mental Health Services

The extent of the requirements for the Secondary and Tertiary Child Mental Health Services depend largely on the nature and extent of the services at the Primary Care Level such as the following:

(a) General Practice and the Primary Health Care Team.
(b) School Health Service.
(c) Educational support and educational psychology service
(d) Child care and child protection teams of social services departments
(e) Voluntary Organisations such as Home start, Youth Information and Counselling Services and so on.

At least mild to moderate child mental health needs could be met at the primary care level by organising the above services in such a way that they are able to respond to the children's mental health needs. This requires adequate staffing, training, coordination and support from the secondary services. The contracts for the provision of secondary child mental health services need to be separately defined and should cover the full range of disorders, assessment and treatments along with liaison and health promotion aspects. The referral rates to these services have escalated recently. This is inspite of the fact that even now these Services receive referrals for only a fraction of the child psychiatric disorders. This is because of their limited capacity and because of the poor recognition rate in the Primary Health Care Teams. However, there has been no commensurate growth in staffing levels. This has led to a potentially rather damaging effect on the quality of these services. Most services have far below the irreducable norms as regards the consultant population ratio (Royal College of Psychiatrists, 1993) and have very narrow range of therapy staff. There is an urgent need to establish at least the minimum permissible consultant population ratio and develop a variety of therapeutic programmes so that the services are able to offer therapies that are more and more specific to the particular clinical conditions (Dwivedi, 1993).

Light and Bailey (1993), by doing a cost benefit analysis, demonstrate the return on investment made by Child Mental Health Service as 10 fold in short term and 100 fold in long term. They argue that investing in mental health services for disturbed and abused children will yield immediate health gain and substantially reduce long-term social and financial costs.

In addition to offering direct clinical work with children, adolescents and their families the secondary child mental health services should also be able to offer adequate liaison and support to other services dealing with vulnerable children.Some of these are as follows:

(a) Departments of Child Health

Prevalence of psychiatric disorders is doubled in children with physical disorders (not affecting the brain) and becomes five-fold in children with brain disorders, dysfunction or damage. Emotional and family dynamic factors not only influence the development and treatment of physical disorders but also the physical disorders and their treatment influence the emotional life of children and their families.

Department of Health (1991) recommended that good liaison should be established between staff working in general paediatric departments and the child mental health services so that expertise, guidance and advice may be shared to the benefit of the children and their families.

In respect of general hospital services, district and provider hospitals are advised to agree that specialist mental health care staff are available to the children's department for advice when:

(b) Educational Agencies

Children with learning difficulty and disability are also more vulnerable to mental health problems. Similarly mental health issues influence school attendance and educational achievements.

(c) Social services

There is a greater risk of mental health problems in children from unstable family backgrounds, family discord and socio-economic disadvantage. Such disorders are also associated with emotional, physical and sexual abuse and neglect in children. Similarly, a considerable proportion of young offenders have psychiatric disturbance.

A recent national review (Kurtz et al 1994) highlighted that the Social Services Departments concentrate resources on children in need, many of whom have serious emotional and behavioural problems. They report unsatisfactory access to specialist expertise in children's mental health, from the NHS. There is an urgent need to improve access for Social Services to health service expertise in children's mental health for assessments and therapeutic work (p 21).

(d) Adult mental health services

The risk of mental health problems in children from families with mentally ill or personality disordered adults is also high and such families can greatly benefit by a joint approach.

(e) Primary Health Care Teams

With the support of the secondary child mental health services the primary health care teams can play a much greater role in child mental health than at present. The majority of children with mental health problems in contact with the primary health care team are either not recognised or offered no direct help. With such a support and guidance the primary health care teams can play a very significant role in following aspects. (Garralda 1994):

In addition to adequate primary and secondary child mental health services it is also essential to have in place adequate Tertiary Child Mental Health provisions such as the inpatient psychiatric facilities. Department of health (1991) recommends that children and adolescents who develop serious mental health problems - e.g. anorexia - requiring in-patient hospital care should be treated in specialist hospital units. At the moment such facilities are far fewer in number and are unable to meet the needs of many very disturbed youngsters as already pointed out earlier in this paper.


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