Emotional Health & Well-Being of Children JSNA | Boltons Health Matters
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Emotional Health & Well-Being of Children JSNA


This is the JSNA chapter on emotional health and wellbeing of children. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 


Emotional health and wellbeing forms part of the wider concept of mental health, which encompasses the promotion of positive mental health and also the tackling of mental health difficulties.
The good emotional health and wellbeing of children and young people is vital both to children and young people themselves and society as a whole.  Being emotionally healthy is an important end in itself but also linked to a range of positive outcomes later on in life.  Poor emotional health in children has been proved to be associated with teenage pregnancy, bullying, violent and criminal behaviour, and substance misuse.
A wide range of factors (biology, parents, peers, and wider society) all play a significant role in the development of emotional health.  Where there are problems in any of these, mental and emotional health can suffer resulting in anything from a minor behavioural disturbance through to possible severe mental illness.
The development of emotional health starts before a child is born, and the first few years of life are a vital period for laying the foundations for emotional health throughout childhood and later into adult life.  There are a number of interventions and approaches that help improve emotional health in older children.  Practitioners in a range of settings and services play a key role in helping children to have a good level of emotional health and wellbeing.  The early identification of children suffering with poor emotional wellbeing is vital to ensure that they receive the appropriate help as soon as possible.

Implications for Commissioning

• Continue to focus on early intervention working to ensure wider support through all partner agencies for children showing signs of poor emotional/mental distress.
• Continue to work with partners to ensure focus on positive emotional and social wellbeing across universal services.
• Ensure clear care pathways are developed to support integration across all tiers and to enable all children and young people to access the appropriate level of support that they need.
• Further review existing activity of specialist services to ensure that the services have sufficient capacity and can be accessed by children with learning disability, children from black and minority ethnic communities, and by Looked After Children (LAC).

Who's at Risk and Why

Factors affecting mental and emotional wellbeing in children and young people can include:
• Deprivation;
• Parental and social support e.g. family breakdown, domestic violence, parental abuse and neglect;
• Peer support;
• Bullying;
• Diverse needs - e.g. learning difficulties, sexual orientation, ethnicity etc.
National research shows that specific conditions are more prevalent in specific sexes, such as the increased prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in males and eating disorders in young women.
Mental health agency “Young Minds” identifies a list of types of behaviour which children and young people who don’t have good mental health are at increased risk of.  These include:
• Becoming very withdrawn or sad;
• Anxiety, panic attacks and phobias;
• Obsessive or addictive behaviour;
• Sleep problems;
• Eating problems;
• Problems focusing or concentrating;
• Aggressive or disruptive behaviour;
• Self-harming;
• Wetting or soiling;
• School refusing or difficult behaviour in school;
• Problems with friendships or bullying;
• Risk-taking behaviour;
• Drug or alcohol use.

The Level of Need in the Population

ONS data shows that the number of adults accessing specialist mental health services between 2009 and 2011 rose by 11% from 5,400 to 6,010.  This compares to a national rise of 6.5% over the same period.
Available data and ChiMat projections suggest that age and gender are key determinants of the risk of an individual child or young person developing mental health difficulties.

Pre-School Children
There are relatively little data about prevalence rates for mental health disorders in pre-school age children.  The Report of the Children and Young People’s Health Outcomes Forum "recommends a new survey to support measurement of outcomes for children with mental health problems.  In particular, we recommend a survey on a three-yearly basis to look at prevalence of mental health problems in children and young people.  This could build on the work of the survey, ‘Mental health of children and young people in Great Britain, 2004’”.  A literature review  of four studies looking at 1,021 children aged 2-5 years (inclusive), found that the average prevalence rate of any mental health disorder was 19.6%.  Applying this average prevalence rate to the ONS mid-year population estimates for 2011, gives an estimate of 2,873 children aged 2-5 years (inclusive) living in Bolton who have a mental health disorder.

School-Age Children
Prevalence estimates for mental health disorders in children aged 5-16 years have been estimated in a report by Green et al .  Prevalence rates are based on the ICD-10 Classification of Mental and Behavioural Disorders with strict impairment criteria – the disorder causing distress to the child or having a considerable impact on the child’s day to day life.  Prevalence varies by age and gender, with boys more likely (11.4%) to have experienced or be experiencing a mental health problem than girls (7.8%).  Children aged 11 -16 are also more likely (11.5%) than 5-10 year olds (7.7%) to experience mental health problems.
Using these rates, the list below shows the estimated prevalence of mental health disorder by age group and gender in Bolton.  Note that the numbers in the age groups 5-10 years and 11-16 years does not add up to those in the 5-16 year age group, due to the rates being different for each age group:
• 5-10 with mental health disorder = 1,575;
• 11-16 with mental health disorder = 2,461;
• 5-16 with mental health disorder = 4,019.
These prevalence rates of mental health disorders have been further broken down by prevalence of conduct, emotional, hyperkinetic and less common disorders.  The following tables show the estimated number of children with conduct, emotional, hyperkinetic and less common disorders in Bolton, 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).
Conduct disorders:
• 5-10 with conduct disorders = 1,003;
• 11-16 with conduct disorders = 1,412.
Emotional disorders:
• 5-10 with emotional disorders = 491;
• 11-16 with emotional disorders = 1,070.
Hyperkinetic disorders:
• 5-10 with hyperkinetic disorders = 327;
• 11-16 with hyperkinetic disorders = 300.

Current Services in Relation to Need

A great deal of emphasis is placed on the promotion of positive health and wellbeing and early intervention.
Early Years and Family Support services provide preventative services focused on children and their families. Referrals are taken from a wide range of agencies.
Play Services provide children with the opportunity to play safely, experience personal autonomy, discover their self-identity, and be active participants.
Behaviour Support Service works with school pupils and their families to tackle issues such as behavioural problems, bullying, school absence and school exclusion.
The Healthy Schools Programme defines health in its broadest sense and is therefore involved with issues as diverse as citizenship, raising attainment and emotional health and wellbeing as well as healthy eating, physical activity, drugs education, and sex and relationship education.
The 5-19 Service provides a wide range of activities for children and young people aged 5-19 years that aim to support young people’s personal and social development – which includes developing important skills and qualities needed for life, learning, and work – and raise young people’s aspirations.
Targeted Youth Support working to engage young people and provide diversionary activities for those most at risk of engaging in anti-social, risky, or extreme behaviours.
Educational Psychologists are concerned with children's learning and development and they aim to bring about positive change for children.  They have skills in a range of psychological and educational assessment techniques and in different methods of helping children and young people who are experiencing difficulties in learning, behaviour or social adjustment.
Youth Offending Team works with 10-17 year olds in or at risk of being in the criminal justice system.  It offers preventative and restorative programmes and supports young offenders to address underlying causes to prevent re-offending
The above services work at various points along the emotional health and wellbeing spectrum.
Child and Adolescent Mental Health Services (CAMHS) support those at the more severe end of the spectrum with mental illness.  The main provider of acute hospital and community health care services is Bolton NHS Foundation Trust.  Community-based child and adolescent mental health services (CAMHS) are provided by Bolton NHS Foundation Trust
Bolton's CAMHS are delivered as tiered services:
Tier 1 Primary Care Level
Services are delivered by non-specialists in order to identify mental health problems early, offer general advice for mild problems and promote positive mental health.  These services are provided by the voluntary sector, primary care and community services from many agencies. (GPs, health visitors, paediatricians, teachers and education professionals, social and youth workers).
Examples include support with faddy eating, mild behaviour problems, and conduct difficulties in adolescents.
Tier 2 Uni-professional Services
Services are provided for young people with moderate levels of mental health problem of all kinds and inputs are provided by a range of specialists and non-specialist mental health professionals.  Specialist mental health professional inputs include Primary Mental Health Worker Team, (the Young People's Emotional Health and Wellbeing Team) and teams in LA Children's Services and the voluntary sector.  The Locality Attention Deficit Hyperactivity Disorder (ADHD) service provides assessment and intervention for cases of non-complex ADHD.  Exclusions include severe presentations, those who are suicidal or where this is a risk - these are assessed at Tier 3.
Tier 3 Specialist Services
Tier 3 provides a specialist service for the more severe, complex, and persistent disorders, which require a multi-disciplinary team response and where there is clear evidence of significant mental health difficulties.  The service is focused upon young people with mental health disorders where there is evidence for intervention, upon consultation for other complex and chronic problems of childhood and adolescence.  The overarching criterion is that the condition should affect the child's mental health, or should be causing impairment to the child or to others.  In some cases an appropriate intervention at a lower tier will already have been tried, but on other occasions it is appropriate to refer directly to the specialist service if the circumstances clearly meet the criteria for this.
Bolton Local Authority mental health practitioners have developed a pathway for Looked after children’s mental health and this works closely with the LAC pathway within CAMHS Bolton.
CAMHS has adopted a CAPA (Choice and Partnership Approach) model of service including the development of internal ‘pathways’ for specific presentations.  There is now a Looked After Children (LAC) Pathway.  All referrals accepted to CAMHS are initially seen via a ‘Choice’ appointment and the Choice clinician may then decide to refer to the LAC Pathway for consultation, assessment and intervention.  The aim of this approach is to achieve adherence to the recent recommendations in the NICE/SCIE document ‘The physical and emotional health and wellbeing of looked after children and young people’.
A refreshed  multi-agency Anti Bullying Strategy for Bolton  is currently under development and will be launched in September 2013.
In step with the early help processes in Bolton, sufficient resources need to be available from CAHMS to ensure early access for those outside the Child Protection and LAC processes. Early intervention could prevent the need for future intervention via CP or LAC route for children and young people.

Projected Service Use and Outcomes

ONS projections based on the 2011 Census suggest that the number of children and young people aged 18 and under in Bolton will increase by just over 10 % over the next decade from 68,201 in 2011 to 75,124 in 2021.  In 2013 this population group numbers 69,338.
However, the rates of mental illness are not consistent across different cohorts of children and young people.  In particular, the numbers of young people aged between 11-18 years will remain relatively static over the next decade.  This is the age group that, as the prevalence research cited earlier suggests, is the most likely to need support from CAMHS services.  However, the numbers of younger children will increase creating pressures on those services that provide early intervention services at the younger age ranges.

Evidence of What Works

Bolton’s Health Matters has created a collection of evidence and intelligence to ensure best practice in decision within this area. To view this collection, please click here 

Community Views and Priorities

Young people say  that the things which have the biggest impact on their emotional health and wellbeing are:
• Having people to talk to;
• Personal achievement;
• Being praised;
• Generally feeling positive about oneself.
The key things that make them feel stressed are:
• Conflict;
• Confrontation with authority;
• Restriction of autonomy;
• Exclusion by their peers.
The National Advisory Council for Children’s Mental Health and Psychological Wellbeing provides a useful summary  of feedback from young people using CAMHS.  A number of key themes and issues emerge from children and young people’s views for what makes for good quality and effective CAMHS services including:
• The need for services to be accessible and flexible enough to respond to requests for help before a situation has reached crisis point;
• The importance of services operating in a way that doesn’t leave the Children and Young People that use them feeling stigmatized;
• The importance of the attitude of staff and their ability to empathise with the children and young people who use the service;
• The extent to which young people feel they have the information they need to make informed choices about their treatment.

Equality Impact Assessments

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters

Recommendations for Further Needs Assessment Work

Explore the impact of austerity on the mental health of Bolton’s children and young people.

Key Contacts


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