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The size of the problem
The alarmingly high incidence of behaviour and emotional disorders in children in the United Kingdom was established 30 years ago.1 A minimum annual incidence of 5–10% for children living in relatively stable semirural communities and 10–20% for those in inner cities was found. Recently, an overall annual national incidence of 10% has been reported.2 Authoritative reviews suggest that there has, if anything, been a rise in the incidence of at least some of these disorders over the past 40 years.3 Illustrative case reports have shown that, among mainly undiagnosed, young, untreated children identified with psychiatric disorders in the community, even those with less serious levels of disturbance are suffering major impairment of social functioning.4
The community response
Until about five years ago, the official response to these striking epidemiological findings was disappointing. From 1970 to 1995, there was a slow increase in the number of consultant posts in child and adolescent psychiatry and in the number of training positions, but the need to improve services for mental health problems in the school setting, for children receiving paediatric care, and for children in contact with social services (especially those in public care), and for young offenders was not clearly recognised, and, insofar as it was, the measures taken to improve the situation were inadequate and sometimes, as in the case of young offenders, calculated to do more harm than good.
However, in the past five years there has been a very substantial change in the attitudes of central government, beginning with the previous administration and gathering pace under the present one. The degree to which the change in attitude will be reflected in willingness to bring about improvement in the relevant structures, tackle difficult interprofessional issues, and provide increased resources is unclear, but a definite and promising start has been made. Child mental health is a great deal nearer centre stage than it was five years ago.
In 1994 Zarrina Kurtz and her colleagues published what amounted to a consumer survey of child and adolescent mental health services (CAMHS).5 The findings were, to put it mildly, not complimentary to the service. For example, 67% of hospital paediatricians stated “their local service was woefully inadequate, very limited, overwhelmed by referrals, barely adequate, or with enormous waiting lists”. Community paediatricians, who reported that a substantial amount of their work was psychiatric in nature, were reported to feel even more strongly that CAMHS resources were quite inadequate. Among social services respondents, almost a half reported that the “service was virtually nil, inadequate or limited with long waiting times”. Although the opinions of family doctors were not canvassed in this survey, it is improbable that the replies would have been substantially different. For the sake of balance, it should be added that, at the same time, surveys of attendees at child psychiatric clinics suggested a reasonably high level of satisfaction.6 The problem appeared to be the inadequacy and uneven distribution of resources rather than the quality of the service received by those who did, in fact, receive it.
Kurtz et al 5 made a number of recommendations including the need for more sophisticated purchasing, greater use of child psychiatrists for consultation and liaison, regular audit, and a wider and more appropriate use of community child psychiatric nurses. Interestingly, in line with the philosophy of the time, they did not mention the need for increased resources.
In 1995 the Departments of Health and Education and the Social Services Inspectorate produced a Handbook on child and adolescent mental health.7 This document introduced the concept of a tiered CAMHS, proposed earlier by P Hill (personal communication, 1999), with tier 1 providing primary care, tier 2 being represented by uniprofessional groups relating to others through a network, tier 3 providing a locally accessible specialist service, and tier 4 a more specialist service for children with unusual needs. In the same year, the NHS Executive commissioned a thoroughHealth care needs assessment in child and adolescent mental health,8 and the health advisory service produced a substantial document entitledTogether we stand giving guidance on the commissioning, role, and management of CAMHS.9
In 1997, the House of Commons select committee on health produced aReport on child and adolescent mental health services,10 which noted that “the current provision of child and adolescent services is inadequate both in quality and in geographical spread”, and supported the four tier model of services. In 1999, the Mental Health Foundation published the report of a committee of enquiry chaired by Tessa Baring, entitledBright futures: promoting children and young people's mental health.11 The title of this annotation is taken from that report. In the same year the Audit Commission, whose brief is to promote the best use of public money, came out with Children in mind,12 a report on CAMHS which disclosed that there was as much as a sevenfold difference in CAMHS resources in different parts of England and Wales.
This volume of attention given to CAMHS is impressive, but, as Dr Seuss's cat in the hat13 exclaimed, that is not all, that is not all! Various other relevant government initiatives and reports must be cited, including: Home Office legislation on young offenders setting up multiagency youth offending teams; Department for Education and Employment (DfEE) guidance on reducing the risk of disaffection among pupils by, for example, rewarding achievement, supporting behaviour management, and working with parents14; “Quality protects”, a Department of Health programme setting standards for the care of children in public care as well as draft guidance from the same source on the multidisciplinary management of child abuse,15 and a report from the Social Exclusion Unit on children excluded from school.16
The attention given to child mental health problems and CAMHS over the past five years is staggering. But what, if anything, has really happened to improve the lot of children suffering from behaviour and emotional disorders? What has occurred to help those in non-CAMHS professions, such as paediatricians, to deal more effectively with such children?
Here there is inevitably less positive information, but nevertheless it would be ungrateful to fail to note really noteworthy progress. The approach that the present administration has taken is largely, but not exclusively, to put extra resources into non-CAMHS services that can be seen as preventive in relation to the development of mental health problems.
Prevention: relevant government initiatives
None of the preventive initiatives that the government has set in train have been given a specific mental health “spin”. However, virtually all of them can be seen as having potential preventive possibilities in child mental health. They include:
SureStart. This is by far the most substantial initiative. In introducing it, the ministers responsible stated “All the evidence shows that early intervention and support can help to reduce family breakdown; strengthen children's readiness for school; . . .Inside the home we want to offer support to enable parents to strengthen the bond with their children; outside it, we want to help families make the most of the local services on offer”. The cost of the programme is £540m (£452m in England) over three years. The money will go to provide outreach services, support for families, and a range of other activities. Initial contact with families is expected to be made before birth and to continue for the first three years.
The Family and Parenting Institute. This is a recently established body intended to fund research and publicise information about relationships and parenting. Part of its remit will be to identify what services should be available to families.
Health Action Zones. This initiative provides extra resources for particularly deprived areas to enable new initiatives to be undertaken in areas that require a multiagency response. Many of the funded initiatives have involved children's services, especially those concerned with abuse and mental health problems.
Education Action Zones. Again extra resources are provided for schools in deprived areas to enable them to improve support and other services, especially for children with special education needs. Many of these will be at risk of developing emotional and behaviour disorders, or will already have them.
Literacy initiatives. These include the National Curriculum, the introduction of the literacy hour in primary schools, and other attempts to improve the teaching of reading, for example, by the publication of league tables.
Personal, Social and Health Education (PSHE). The DfEE is promoting this component of the school curriculum. Although sadly it is not insisting that it forms part of the National Curriculum, nor providing additional resources for implementation, OFSTED inspections are now expected to cover an evaluation of the PHSE curriculum. This could go beyond the currently favoured topics of sex education, diet, smoking, and exercise to include the development of “emotional literacy”. The “Healthy Schools Initiative”, to which many schools are now signed up, requires that the school openly deals with “issues of emotional health and well-being by enabling students to understand what they are feeling . . .”17Children who are more “in touch” with their feelings may be readier to accept and understand that, when they are under stress, they may experience bodily sensations that are signs of emotional strain rather than physical illness, and that, if their family doctors are unable to identify a physical cause for their headaches and abdominal pain, there may be other useful explanations.
These initiatives have been generally welcomed, but have met with some significant reservations. Apart from SureStart, they have generally been introduced with an inadequate increase in resources. Even the generously funded SureStart has only been funded for three years, and there is concern that its budget will not be “built in” to the system after that time. The effectiveness of the initiatives has been queried. SureStart has been allocated a considerable sum for evaluation, but the other initiatives have not. It is unclear what evidence will be obtained to decide whether the new initiatives provide value for money. Some of the initiatives, especially those involving teachers, have been introduced without adequate concern for the sensitivities of the professionals concerned. Finally, as many of those in the field will be aware, there is increasing concern over the degree to which the activities undertaken by these initiatives are being coordinated, and little guidance to achieve joint working between them. At last, government is providing a better example of joint interdepartmental working. For example, the DfEE funded SureStart initiative is directed by a group based at the DfEE, but chaired by the minister of public health. However, there is often a different story at the local level. The need for local authority children's services plans has improved local joint working, but child health is still too often excluded from the planning processes. Most of the documents put out by the DfEE and many of those put out by the Home Office fail to mention the possible role of CAMHS in the assessment and management of intractable behaviour problems. Mental health may have come centre stage, but, to pursue the theatrical analogy, the play performed might be appropriately called Six characters in search of an author.
If, however, these initiatives are successful in improving parent-child relationships, in reducing educational underachievement, and in preventing the development of mild behavioural difficulties in school from escalating, then the rate of emotional and behaviour disorders should be lowered, and, of course, this would have an impact on the work of paediatricians. To suggest that it will have such an effect may seem overoptimistic, but there is a strong evidence base for thinking there will be a positive effect.
Treatment services: government initiatives
In February 1999, the government announced the allocation of an extra £84m over three years for child and adolescent mental health services. The extra resources are to be distributed between the NHS modernisation fund for authorities with pressing development needs in this field and initiatives promoting joint working between health trusts and local authority departments.
A number of other initiatives have been launched in areas that can be regarded as within the child and adolescent mental health fields. For example, the establishment of youth offending teams at community level will result in more coordinated arrangements for adolescents, most of whom, if seen by psychiatrists, would be regarded as showing conduct disorders. Drug action teams are expected to pay special attention to the young drug user. Mechanisms recommended for dealing with children excluded from school are intended to reduce the numbers of children who are excluded and increase the rate at which they can be returned to mainstream education. Although there is a deplorable lack of research in this area, it is known that many of these children are in the care of social services departments, and consequently it is certain that they suffer from high rates of conduct, attention deficit, and emotional disorders.
Implications for paediatricians
Few, if any, of these initiatives are directly targeted at the children who are of most concern to general hospital and community paediatricians. Yet the significance of child mental health and CAMHS for the work of paediatricians is well recognised and has been so for many years. The Diploma in Child Health has had a strong psychiatric input for about 15 years. The Royal College of Paediatrics and Child Health strategy document18 makes specific reference to the need to “promote child and adolescent mental health by the development of specialist psychiatrist and psychologist posts”. It is not clear if the intention is to create a new type of psychiatrist or psychologist dedicated to paediatric liaison work, or to increase the input of existing specialists in the field. Whatever the mechanism, it is clearly desirable to increase the CAMHS input into paediatric services. How might this best be achieved?
The lesson from the allocation of extra resources announced in February 1999 is clearly that monies are most likely to be made available for initiatives that involve collaborative working. Paediatricians, through the College, might consider how they could use this approach for making bids relevant to child mental health. It could be proposed that monies are earmarked for initiatives that link CAMHS to paediatric facilities, especially where CAMHS is delivered through community mental health trusts. Because of their administrative separation, such trusts are likely to find it more difficult to provide good paediatric liaison and back up. The provision of evidence based CAMHS services using, for example, cognitive behavioural techniques for the non-organic pain syndromes so commonly encountered in paediatric practice, could be an attractive option. Such resources could provide increased support for new and existing joint initiatives, for example in the management of attention deficit hyperactivity disorder.
The training of paediatricians also requires further consideration. A survey of paediatricians recently appointed to consultant posts carried out a few years ago showed that the areas of greatest lack were in the management of child mental health problems and in experience of administration. Those involved in laying down the curriculum for specialist registrars in paediatrics and the paediatric specialties really do need to reconsider their priorities in the light of this information. Current attempts to improve links between the training of paediatricians and child and adolescent psychiatrists (D Cottrell, personal communication, 1999) need strong official backing if they are not to founder in the same way as previous attempts.
Mental health is already much more centre stage than could possibly have been envisaged only five years ago. The fact that paediatrics has so far been given such a small part in the unfolding drama should be seen as a challenge to the specialty and to its College.