Turning the tanker of child mental health

'Attainment at what cost?' was the question posed in a panel discussion organised by the British Psychological Society. Psychologists from Wales, England and Scotland were all represented at the event, which considered the balancing act between educational achievement and the wellbeing of children and young people. 

Developing policy is no small task; implementing that policy is an even more daunting one. Consultant Clinical Psychologist Dr Duncan Law, previously London and South East Clinical Lead for Improving Access to Psychological Therapies (IAPT) for Children and Young People, introduced some of the policies in place in England and the way he hopes they will evolve.

Law, who works with the Anna Freud Centre which plays a part in putting policy into practice, pointed to one of the main policy drivers in improving children's mental health care in England is the Transforming Children and Young People's Mental Health initiative, part of the NHS Long Term Plan. One part of that is the introduction of Child Wellbeing Practitioners and Educational Mental Health Practitioners – roles which emerged after the acknowledgement that 70 per cent of children in England with a moderate to severe mental health problem never see a mental health practitioner in person. 

Of course, as with any policy initiative, it is important to find out whether it makes a real difference, and in England the data on the effectiveness of mental health interventions is poor. Law has been involved with gathering data to find out if these new roles are helpful to children and their families, using a system called POD which allows young people to enter data into an iPad. So far the data suggests that the guided self-help used by these two new types of practitioner is helpful, but only if a child is able to access sessions and do work in between those sessions. 

Glasgow's Principal Educational Psychologist Alison Crawford introduced Glasgow for the international audience by pointing to the city's industrial past and the high levels of child poverty in its present. There are 16 national priorities in Scotland, including the aims for children and young people to be successful learners, confident individuals, effective contributors and responsible citizens, and ensuring children have the best start in that.  

These priorities are backed up by having the framework 'Getting it Right for Every Child' embedded in Scottish law. Scottish Education also has a Curriculum for Excellence which covers children and young people aged three to 18, and ensures that wherever a child is in the education system teachers are required not only to consider educational attainment but also health and wellbeing. 

Crawford explained the curriculum celebrates children's achievements in their wider communities. For example if a child volunteers or takes part in sport, that is counted as part of their wider achievement. When considering any extra support children might need this is considered not just in individual terms but in a way that also takes into account the system surrounding a child. 'Additional needs may be temporary or lifelong… we need planning to be flexible enough to accommodate a wide range of needs. We have a wellbeing assessment for children, when they need support we go back to that and think about a child's wellbeing to ensure we understand a child's needs in terms of an ecological model.' 

In Scotland there's a saying 'We're aw Jock Tamson's bairns', meaning everyone is an equal part of the same family. Crawford said we cannot rest with equality but instead must move towards equity – ensuring resources go to those who need them most. 

In Glasgow one third of children live in poverty, having a drastic impact on their wellbeing. Crawford showed a heartbreaking graphic from the Child Poverty Action Group which gathered comments from children on how poverty made them feel – words included insecure, judgement, bullying, and worry.   

Considering child poverty alongside Adverse Childhood Experiences (ACEs), Crawford said, sums up the challenges that lie in Glasgow and Scotland and raises the question of where resources should be directed. Nurturing approaches have been suggested in schools to address the impact of poverty and ACEs, approaches which can make the link between wellbeing and attainment. 

Consultant Clinical Psychologist Liz Gregory is Head of Child Psychology for the Aneurin Bevan Health Board, which covers five areas. Each of those areas, which include Newport, Monmouthshire and Caerphilly, has their own distinct culture, identity and way of working. 

Gregory has worked at the service for 25 years and led it jointly for more than 17. In her areas, she said, there is no 'one size fits all' approach. She and her colleagues have been on a mission over the years to promote the relational, developmental and contextual understanding of children's distress – and it's not an approach that has been accepted easily. 

While many interventions and services are based on individualised treatment, it is only recently Gregory and her colleagues have put their heads above the parapet to bring this different way of thinking to the attention of policy makers. Part of this was involved the development of the Iceberg Model – a way of describing all the factors which are important to child wellbeing. It points out that services in clinics and hospitals will only reach a certain population but there is an enormous amount of unmet need underneath that iceberg. 'Some of the children in the most desperate need are right at the bottom of the iceberg.'

At a Senedd committee meeting Gregory was asked to give evidence and spoke about the iceberg model and the need for broader thinking on children and young people's mental health. Happily the chair of that meeting was excited by the idea, and has been pushing for these values to be implemented in Wales. 

Around this time research on ACEs was gaining recognition. While Gregory warned against the idea that ACEs are the one and only answer, she was glad to see a recognition that the experiences of children affect their lives. She also pointed to the importance for trauma-informed work with children, 'We need to move to a more trauma and relational informed way of intervening with families if we're going to turn the tanker in terms of child mental health.'

Gregory has been working on developing services in the area to help reach populations who don't traditionally make use of mental health services. Some of the services in Gwent include an infant mental health service, Gwent Attachment Service, and community-based Family Intervention Team in Caerphilly.

Traditional mental health services require a person to be in the right place and have the right criteria to receive support. Schools offer good environments to support children going through difficulties but it is key that the whole school takes responsibility for supporting mental and emotional wellbeing. In schools, Gregory said, the things that matter are feelings of belonging, autonomy and efficacy – for children, teachers, parents and support staff. Gregory said it seems that thinking in Wales is moving in the right direction, for example the Welsh school inspection body Estyn recently published a report which recognised the importance of school culture and relationships on children's wellbeing.