Mental and emotional health is fundamental to good health and wellbeing. There are strong links between the emotional wellbeing of children and young people and their personal and social development and educational performance. As such it is an important factor in ensuring that they achieve their full potential.
Emotional wellbeing includes confidence and self-esteem which contributes to an ability to form good relationships with family and friends. Poor emotional and psychological health or mental health problems may result in educational failure, family disruption, anti-social behaviour and offending. Unrecognised and untreated mental health problems create distress not only for children and young people, but also for their families and carers, continuing into adult life and affecting the next generation.
Social, emotional and behavioural difficulties are common and affect 30-40% of children and young people at some time. Normal development will include behaviour of concern to adults. Young children may show certain behaviours, such as poor concentration, aggression, lying, stealing, tantrums, toileting or bedtime problems, food fads, specific fears or anxiety; whereas teenagers may have relationship problems or poor anger control or conflict with adults over appearance, school progress or household rules. Mostly these are transient reactions to a particular life event, but for some they may be more prolonged.
Risk factors that increase the likelihood of a child experiencing a mental health problem include:
- environment, e.g. poverty, social housing, homelessness or refugee status
- family e.g. parental unemployment (20% of children where neither parent works have mental health problems, compared with 8% where both parents work. Poverty may also contribute); poor parenting; and circumstances which result in a child being looked after by the local authority
- child health e.g. physical disability, chronic health problems, learning difficulties
- school e.g. bullying and several of the above risk factors may result in relative social exclusion at school which may further increase the risk of bullying
Currently there is very little comparative information to give a good picture of the mental health and wellbeing of children and young people locally. The national indicator set from the Tell Us 4 Survey provided a useful summary of the views of children and young people and an indication of mental wellbeing. Data from the survey is included below, however the survey is no longer undertaken centrally, and latest data is from 2009-10.
More recent data from the Merton Annual Young Residents Survey 201213 indicates that young people are generally satisfied and happy, with 90% reporting they are either very or fairly satisfied and happy. The top four factors identified as most important to young people’s sense of wellbeing were:
- feeling safe in the local area (65%)
- satisfaction with family and social relationships (58%)
- satisfaction with school (42%)
- satisfaction with health and mental health (34%).
However, the survey also indicates that bullying is the third highest personal concern for 11-17 year olds in Merton, and this has increased significantly from 21% in 2011 to 31% in 2012, which is now the same as London overall.1
Emotional health of children 2009-10
Children who have experienced bullying
Young people’s participation in positive activities, 2009-10.
Estimates from national prevalence figures suggest that Merton would expect to have over 3,250 children or young people aged 5-16 years with specialist mental health needs, based on the 2012 population. At Tier 3 there is a gap of 34% between observed and estimated use of services (observed: 524 CYP on active caseload for Tier 3 CAMHS 201213; estimated: 825 CYP), indicating a level of unmet need
Estimated number of children and young people under 18 years with a mental health problem appropriate for a Child and Adolescent Mental Health Service (CAMHS) response 2012
% of children|
(17 and under)
| Tier 1 - CAMHS || 15% || 6,670 |
| Tier 2 - CAMHS || 7.5% || 3,115 |
| Tier 3 - CAMHS || 2.5% || 825 |
| Tier 4 - CAMHS || 0.5% || 222 |
Estimated prevalence of mental health disorders among children and young people, 2012
% of CYP|
| Conduct disorders || 5.3% || 1,525 |
| Emotional disorders || 4.3% || 950 |
| Being hyperactive || 1.4% || 410 |
| Less common disorders || 1.3% || 365 |
Mental hospital admissions for children 0-17 years, 2011-12
Key facts on services to support better mental wellbeing in children
CAMHS include universal services (health visitors, school nurses, early years staff, school staff) who identify and support the parents of children and other relevant staff in contact with children showing early signs of emotional and behavioural problems to manage their problems. These services are designated:
Tier 1 services: promote mental health and wellbeing, manage the majority of children and young people with emotional and behavioural problems and refer to more specialist services if appropriate.
Tier 2 services; offer more specialist assessment and intervention from a single mental health professional including primary mental health workers, psychologists and counsellors; and include services delivered in the community such as paediatric clinics, social care premises, schools and youth services.
Tier 3 services: usually multidisciplinary teams working in a community mental health clinic or child psychiatry outpatient service, providing a specialised service for children and young people with more severe, complex and persistent disorders. These teams can include child and adolescent psychiatrists, social workers, clinical psychologists, community psychiatric nurses, child psychotherapists, occupational therapists, and art, music and drama therapists.
Tier 4 tertiary level services: for children and young people with the most serious problems They comprise highly specialised outreach teams and inpatient units including secure forensic adolescent units, eating disorders units and other specialist teams (e.g. services for those with severe learning disabilities).
Most children and young people with mental health problems will be seen in Tiers 1 and 2 services. However, a child or young person may require services from a number of tiers at the same time, or referral between tiers and services at different times. Although most of the CAMHS service is delivered by Tiers 1 and 2, there is no systematic documentation of need for these services.
Following the NHS changes in April 2013, Tier 4 CAMHS is now commissioned by NHS England. Tier 3 CAMHS, commissioned by Merton CCG, and is provided by South West London and St George ’s Mental Health NHS Trust. This team includes child and adolescent psychiatrist, clinical psychologist, child and adolescent psychotherapist and clinical nurse specialist roles. In Merton, in 2012-13, 954 referrals by other professionals were made to this service, with approximately 542 children and young people on the active caseload.
Targeted Mental Health in Schools (TaMHS) aims to transform the way that mental health support is delivered to children, to improve their mental wellbeing and to tackle problems in a timely way. The intervention brings together the effective work that schools are already doing to build social and emotional skills and wellbeing and the clinical and therapeutic expertise available through CAMHS, providing an integrated approach to promoting mental health for children and young people and timely identification and prompt intervention for emerging mental health problems and disorders. There are 21 primary schools and one secondary school in Merton which have directly commissioned TAMHS in 2012/13.
Evidence about what works and best practice
NICE has produced a pathway for social and emotional wellbeing for children and young people, which bring together evidence-based guidance (NICE PH12 2008). This pathway covers recommendations for commissioners, including the following:
- Commissioners need to ensure arrangements are in place for integrated commissioning of universal services and targeted services for children aged under 5. This includes services offered by general practice, maternity, health visiting, school nursing and all early years providers. The aim is to ensure:
- vulnerable children at risk of developing (or who are already showing signs of) social, emotional and behavioural problems are identified as early as possible by universal children and family services
- targeted, evidence-based and structured interventions are available to help vulnerable children and their families – these should be monitored against outcomes
- all primary schools adopt a comprehensive, whole-school approach to children's social and emotional wellbeing.
- Commissioners of services for young people in secondary education should enable all secondary education establishments to adopt an organisation-wide approach to promoting the social and emotional wellbeing of young people. This should encompass organisation and management issues as well as curriculum and extra-curriculum provision.
NICE has also produced a clinical guidance and quality standards for young people with mental health disorders including: Depression in children and young people (NICE CG28 2005 and NICE QS48 2013); and Psychosis and schizophrenia in children and young people (NICE CG155 2013).
Key commissioning recommendations for services to support better mental wellbeing in children
- Given the link between deprivation, poverty and mental wellbeing in young people, better and more robust information is needed to gain a better understanding of the need for local services, so as to inform future commissioning strategies for CAMHS Tiers 1-4.
- Estimates of the expected number of children with a mental health problem appropriate for a mental health service response indicate that there is unmet need at Tier 3 CAMHS.
- Access to specialist CAMHS: assessment and intervention for children and young people on the threshold of care and looked-after children. There is a need to ensure pathways and links across partner agencies and areas of support, such as substance misuse, transition to adult mental health services, Youth Justice, Multisystemic Therapy (MST) and MST-PSB (problem sexual behaviour) and domestic violence.
- Information from the Tell Us 4 Survey has been invaluable in assessing mental wellbeing needs and the impact of key risk factors. However, given that it is now no longer undertaken centrally, local systems need to be used to gather information, including full use of the Residents Surveys. Consideration should be given to doing this on a wider scale, possibly regionally, to allow benchmarking.
^ Merton Residents Survey (2012/13), London Borough of Merton.