Introduction
Children and young people’s mental health services (sometimes called CAMHS: Child and Adolescent Mental Health Services) refers to a range of services that provide assessment and treatment to children and young people (CYP) who are experiencing mental health needs. Following the Health and Social Care Act (2012) [1], the government has increased its focus on mental health services, and has now committed to providing ‘parity of esteem’ for mental and physical health services. Parity of esteem means that mental health is valued as much as physical health including equal access to care and allocation of resources proportionate to need.
Health care is devolved, so all the home nations will have their own mental health policies. This chapter will explore the different policy frameworks but will go into more detail concerning policy in England and look at the changes to the National Health Service (NHS) and how the system works.
Epidemiology
In the UK, mental health disorders are the leading cause of child disability [2]. The prevalence of mental ill-health in CYP in England has increased steadily over the last 30 years. By 2017, a large national survey using the Development and Well-Being Assessment (DAWBA), indicated that 12.8% of 5–19-year-olds met the criteria for a mental health disorder, with higher rates for older adolescents [3].
When comparing between ethnic groups, surveys indicate that prevalence rates of mental health difficulties is higher for white children than children from ethnic minority backgrounds [3]. However, limitations of existing surveys include poor sampling of those from different ethnic minority communities in population level surveys.
The Covid-19 pandemic has affected all of us in one way or the other. CYP have been disproportionately adversely affected, as they have had to adapt to extraordinary changes to the world around them. National surveys in England using the Strengths and Difficulties Questionnaire, found an increase in rates of probable mental health disorder in young people 6 to 16 years of age from 11.6% (2017) [3] to 16.4% (2020) [4] and subsequently 17.4% (2021) [5]. By 2023 20.3% of 8- to 16-year-olds and 23.3% of 17- to 19-year-olds were found to have a probable mental health disorder (2023) [6]. Of concern is the rising prevalence rates of mental health conditions in adolescent girls (2023) [6].
Children and young people with a probable mental disorder were more likely to also have a parent experiencing a higher level of psychological distress and to report poor family connectedness and functioning [3] (see Chapter 5 – Classification and Epidemiology for more information). However, considerable differences were observed between individuals, and most children remained mentally well.
The prevalence of self-harm and suicide in young people of 10–24 years of age had been on the increase before the pandemic struck. In England, the National Child Mortality Database Programme was established in 2018 to collate and analyse data on all children in England, who die before their 18th birthday. The data are collated from the 58 regional Child Death Overview Panels across England who provide a multi-agency joint response as part of the child death review process. A report from the National Child Mortality Database found that 108 young people (under 18 years) had died by likely suicide over a 12-month period (April 2019–March 2020) [7]. As for adults, causes of suicide are multifactorial. Common themes identified in deaths by suicide in CYP[7] include family factors such as parental mental illness, abuse and neglect, loss and bereavement, bullying, suicide-related internet use, problems at school, physical health needs, alcohol and drug use, mental health and neurodevelopmental needs and risk-taking behaviours including self-harm.
Health Inequalities
Health inequalities are unfair and avoidable differences in health across the population, and between different groups within society [8]. Health inequalities can contribute to young people experiencing higher rates of mental health needs, as well as poorer access, experience and outcomes from services.
The poorest young people are more likely to experience mental health problems than the wealthiest [4]. Young people and adults who identify as LGBT experience higher rates of poor mental health while those with intellectual disabilities have poorer mental health than their non-disabled peers [9]. Additionally, young people and adults from ethnic minority communities are less likely to be able to access services that could help to prevent any mental health problems from escalating [9,10].
Research also suggests individuals with neurodevelopmental disorders such as autism will experience severe health inequalities compared to their neurotypical peers: average life expectancy among those with autism is 25 years shorter [Reference Hirvikoski, Mittendorfer-Rutz, Boman, Larsson, Lichtenstein and Bölte11]. The annual cost of failing to adequately support autistic people in the UK is estimated to be at least £32 billion – more than heart disease, cancer and strokes combined [Reference Buescher, Cidav, Knapp and Mandell12]. The NHS Long Term Plan (LTP) (2019) made a commitment to reduce waiting times for assessment for young people with autism and to improve post-diagnostic support [10].
In addition, there are inequalities in the provision of CAMHS. A report by the Children’s Commissioner found that areas higher in deprivation were more likely to have longer waiting times, lower spend per child and a greater need for mental health services [13].
The pandemic is likely to have long-term economic and social effects. There are concerns about widening health inequalities with studies suggesting that CYP with special educational needs and those living in disadvantaged families were more likely to have higher and persistent rates of mental health needs [3,5,6].
Children and Young People’s Mental Health Policy
Wales
The mental health strategy in Wales covers all ages and is wide ranging [14]. In relation to CYP, the strategy will be delivered in accordance with the Welsh Government’s due regard to duty as part of the Rights of the Children and Young People’s (Wales) Measure 2011 [15]. A new 10-year mental health strategy is currently being developed.
Wales has been working to improve mental health support in schools for a considerable time; since 2013, local authorities have been required to secure provision of an independent counselling service for secondary age children and those in year 6 in primary schools [16].
The Together for Mental Health Delivery plan 2019–22 was reviewed in response to Covid-19 and includes several priority areas for CYP including improving access to mental health and well-being support in schools and improving young people’s mental health and crisis services and psychological therapies [17].
Scotland
The Scottish government published their all age, Mental Health and Wellbeing Strategy in 2023 [18], which includes 10 core principles. These include being outcome focused, trauma informed and trauma responsive, based on the whole person and on a no wrong door approach and it is informed by people with lived experience. It is based on a life stage approach and focuses on prevention, early detection, recovery and treatment of mental illness and poor mental well-being, minimising risk factors and enhancing protective factors and providing support at important stages of life, which include infant and early years, and children, young people and families.
The Children and Young People’s Mental Health Taskforce report from 2019 [19] was commissioned by the Scottish government and Convention of Scottish Local Authorities and looked at how CYPMH should be organised, commissioned and provided in order to make it easier for CYP to access help and support when it is needed. It sets out 13 wide-ranging recommendations for how to do this and focuses on both preventative approaches and specialist mental health services.
Scotland also has a perinatal and infant mental health programme board delivery plan 2019–20 [20], which has four key areas: improve capacity, increase the number of staff, invite more voices including people with lived experience such as parents and carers, and develop infant mental health networks and services.
Northern Ireland
Northern Ireland published its mental health strategy in 2021 [21] that sets the direction for mental health services over the next decade. It is a wide-ranging strategy and covers prevention through to specialist services, is aimed at all ages, covers workforce issues and links with the suicide prevention strategy.
The strategy includes several actions to improve prevention and early intervention, but also to improve access and the quality of CAMHS, which includes services for infants and better transitions between child and adult mental health services.
Northern Ireland also has an infant mental framework, which was published in 2016 [22]. It has three key priorities: promote the evidence around infant mental health; ensure frontline staff have the necessary knowledge and skills around infant mental health; and service development.
England
The current transformation work in England started with Future in Mind (FIM), which was published in 2015 [23]. One of the key proposals in FIM to help implementation was the development of transformation plans, where clinical commissioning groups (CCGs) work in partnership with local authorities, public health, education, youth justice and the voluntary sector to develop local plans.
The previous government published a new Special Educational Needs and Disability (SEND) and Alternative Provision Improvement Plan in 2023 to address the significant concerns raised about the SEND system. A road map was published to set out the various actions, which include establishing statutory SEND and alternative provision partnerships. However, given the change of government it is unclear to what extent this new policy will continue [24].
The Five Year Forward View for Mental Health (FYFVMH) was published in 2016 [25]. It covered all ages and set out several measurable commitments including improving access to mental health support and the roll-out of eating disorder and crisis care services. (The FYFVMH is detailed in various sections in the chapter.)
The government set out plans to further improve CYPMH provision in 2017, in the Transforming CYP Mental Health Provision Green Paper [26]. This included setting up Mental Health Support Teams in schools, that would be able to provide evidence-based psychological therapies to young people with mild to moderate mental health issues as well as the training of designated senior leads in schools, who will lead on whole school approach to mental health in schools. While significant progress has been made, further funding is required to roll out these services nationally.
The NHS LTP was published in 2019 and put forward a plan for the next 10 years but, in reality, only had funding for the next 5 [10]. There was a ring-fenced local investment fund for mental health as a whole, worth £2.3 billion per year by 2023/24. There were several commitments for mental health, which built on the progress made in the FYFVMH [25]. For CYP these include commitment to improve the number of young people accessing NHS funded mental health support, but a crucial difference was to improve support for young people aged 0–25 working across key stakeholders.
Also relevant to CYPMH were the proposals to transform perinatal mental health services. These included the development of specialist community perinatal mental health services, improving access for women with moderate to severe perinatal mental health difficulties including building new mother and baby units, enabling their partners to have an assessment of their mental health and developing maternity outreach clinics across England.
There is also a drive to reduce the reliance on using inpatient beds, reducing inappropriate out-of-area placements and improving community mental health provision. This is for people with mental health problems, including young people, but also for people with learning disabilities and autistic people. Transforming Care was published in 2012, following the Winterbourne View Hospital expose of abuse of patients with learning disabilities and/or autism [27]. The commitment was that following a review, everyone who was deemed inappropriately placed in hospital should be moved to community-based support. This commitment was also included in the LTP [10], the Mental Health Act reforms [28] and the Autism Strategy [29]. The new Mental Health Bill is currently passing through parliament and will have an increased focus on patient advocacy and choice and ensuring care is provided in the least restrictive environment.
Concerns have been raised about health and social care staff’s knowledge and training with regard to working with people with a learning disability and autistic people. The Oliver McGowan mandatory training is looking to address this by providing appropriate training for all staff [30].
A new government 10-year health plan to include mental health is due to be published in 2025. This will build on the findings of an independent investigation into the NHS in England and is likely to focus on a move away from hospital to community care, prevention and the role of various digital therapies and technologies to support care.
Changes to NHS Structures in England
Integrated Care Systems and Provider Collaboratives
England has been moving to a system that enables various organisations to work together more effectively for several years building from Sustainability and Transformation Partnership, which was first announced in December 2015.
Sustainability and Transformation Partnerships subsequently developed into integrated care systems (ICSs) that encourage closer partnerships between NHS organisations, local authorities and others to take collective responsibility for planning services across their local population. Changes to the Health and Care Act (2022) [31] have put ICSs on a statutory footing and replaced CCGs. There are 42 ICSs across England supported by seven regional teams, covering populations of around 500,000 to 3 million people. Through the development of Integrated Care Boards (ICBs) and Integrated Care Partnerships, ICSs must achieve four key aims: improving outcomes in population health and health care, tackling inequalities in outcomes, experience and access, enhancing productivity and value for money and helping the NHS to support broader social and economic development. Provider collaboratives are partnership arrangements involving at least two trusts working at scale across multiple places to reduce unwarranted variation and inequalities in health outcomes [32].
New models of care pilots (now referred to as provider collaboratives) covered CYPMH inpatient services. There were six pilots across England and the aim was to improve outcomes for young people in inpatient mental health services. These pilots focused on CYP who are treated outside of their area, often long distances from their home, by providing appropriate support locally, closer to their homes where possible. An economic evaluation of these pilots found that by investing in local services, each of the sites had achieved reductions in overall spending at the same time as a significant expansion of community-based care with comprehensive offers of 24-hour availability of highly skilled teams and innovative models of support [Reference O’Shea33]. Transformation of specialised children’s mental health services and delegation to ICBs supports delivery of care closer to home in less restrictive environments.
There have also been recent changes to primary care, with the setting up of primary care networks, which are groups of local GP practices [34]. Primary care already provides mental health support, and the aim is to increase this with the development of the mental health practitioner roles. The community mental health transformation work is to support the integration of primary and secondary care by delivering mental health services through new integrated neighbourhood hubs [35].
Referral and Access
Investment in mental health care for CYP has been underfunded for many years. In the FYFVMH [25], the UK government set a target for England that 35% of CYP with mental health needs should access services by 2021, based on the 2004 prevalence data. This was from a low baseline of only 25% of young people accessing mental health services in 2016.
Against the 2023 prevalence estimate, 48% of CYP with a mental health condition had contact from mental health services [36]. While access to children’s mental health services has improved with more CYP accessing support, the treatment gap has also contributed to longer waiting times for support.
The Office of the Children’s Commissioner (2021) assessed the provision of NHS children’s mental health services and found that there were enormous levels of variation between different local areas in expenditure and waiting times for services [13]. Those with the best outcomes typically spend more than average per person.
The NHS LTP sought to address this disparity by investing in CAMHS at a rate faster than both overall NHS funding and total mental health spending. The NHS LTP aimed that by 2023/24, at least an additional 345,000 CYP aged 0–25 would be able to access support [10].
Under proposals set out in the 2017 Green Paper on Transforming Children and Young People’s Mental Health, the government committed to trialling a four-week waiting time for access to specialist NHS CAMHS [26]. Further work is progressing to develop all-age standards across mental health services for both those requiring routine care as well as an urgent or emergency response (clinically led review of standards).
Service Delivery
The prevalence of mental health difficulties in CYP has risen significantly over the last 30 years in the UK and, consequently, mental health services aimed at supporting CYP have also changed.
It is now well established that mental health is an integral part of CYP’s general health and well-being, and therefore CYPMH provision needs to be embedded in a wide range of services for young people. This includes universal health promotion and prevention programmes to services provided in education and community settings, including targeted provision for vulnerable groups of young people such as those in local authority care or in contact with the criminal justice system.
Universal services (services available to everybody, such as children’s centres/family hubs, schools, colleges, primary care and youth centres) can be important in preventing mental health problems. Schools and colleges are an existing universal system to support prevention and early identification and support for mental well-being and mental health needs. A whole school approach refers to a universal, school-wide and multi-component approach to the promotion of well-being and mental health among the whole school community: children, young people, families and staff. In England all schools will be required to teach pupils about maintaining mental well-being through the new relationships and sex education and health education curriculum. Local authorities play an important role, in part through their statutory duties relating to public health, in promoting children’s and families’ physical and mental well-being.
The NHS LTP (2019) committed to providing services in an integrated and holistic way, working across agencies and settings and across physical and mental health care [10]. However, differences in language and culture between the wider systems (health, education, social care), as well as within systems (adult versus child and adolescent services), can make systems working difficult and co-ordinating service delivery challenging.
Values-based practice, working in partnership with evidence-based practice, can help to provide the skills and other resources needed to support balanced decision-making between stakeholders, within a framework of shared values. While all stakeholders have a shared values base for promoting good outcomes for CYPMH, they have different perspectives on what matters or is important in achieving those perspectives. Unaddressed, such differences can lead to barriers to providing joined-up care. However, when acknowledged, it is possible to develop a framework of shared values within which balanced decisions can be made in partnership.
Co-production acknowledges that people with ‘lived experience’ of a particular condition or services are often best placed to advise on what support and services will make a positive difference to their lives. Done well, co-production helps to ground discussions in reality and to maintain a person-centred perspective. It is part of a range of approaches that includes citizen involvement, participation, engagement and consultation. Co-production should be at the heart of developing any local offer and should start from the earliest stages of service design, development and evaluation. There is no single, universal model of co-production, and the way in which it is done is specific to the task, context and the people involved. It requires thinking about people (service users, carers and staff), power, partnerships and resources differently.
The Amplified programme (Young Minds) was funded by NHS England and NHS Improvement to support and build participation in every part of the CYPMH system [37]. As part of the Amplified project, a number of participation toolkits were created that combine learning from the project and best practice guidance, with the aim of supporting the development of participation practices within organisations.
Approaches to Service Delivery
The most well-known framework describing CAMHS was a model dividing service provision into four tiers. This model helped differentiate between the different forms of services that might be available to children and young people. However, more recent models focus on the needs of children and young people and include a systems-wide framework in considering how support can be delivered by a range of different practitioners and agencies, including the role of parents and carers.
Data and Quality Improvement
Data has become integral to how we now practice health care in the UK: health data can be used to benefit individuals, public health, and medical research and development. Digitisation and health information technology have expanded both the ability to collect data and to use it. Our use of electronic health records, electronic prescribing, patient portals and shared care records has enabled enhanced access to patient information to drive patient care.
The uses of health data are classified as either primary or secondary. Primary use data or data for ‘individual care’ is when health data is used to deliver health care to the individual from whom it was collected. Secondary use data, or data for ‘Improving health, care and services through research and planning’ is when health data is used outside of health care delivery for that individual [Reference Safran, Bloomrosen and Hammond38].
Patient data, when used for purposes beyond an individual’s care, for example understanding the health needs of a population, provision of operational and clinical assurance and for audit/research is known as ‘secondary use’ – secondary to the original reason for collection. Outcome measures may also be used as secondary data to determine service effectiveness or service improvement. In addition to the improvement of client outcomes, collecting ongoing progress data can also facilitate quality enhancement at multiple levels within organisations [Reference Chorpita, Bernstein and Daleiden39].
Routine Outcome Measures capture information from the clinician’s perspective and may be based on investigations or a functional assessment. Patient-reported outcome measures (PROMs) capture information from the client’s perspective. Patient-reported experience measures provide vital information on the experience of care.
PROMs assess patients’ experiences of their symptoms, their functional status and their health‐related quality of life and when collected across a patient treatment journey, can provide information on the effectiveness of the treatment for the individual patient and guide the therapeutic sessions. When using outcome measures it is imperative to ensure that the measure is validated for the intended use. The CYP-IAPT project has identified and validated the use of a range of outcome measures which cover the vast majority of presentations to CAMHS.
The process of collecting outcome data drives improvement in local services without any other change in the clinical model [Reference Wolpert, Harris and Jones40]. Using outcome data has been consistently found to reduce deterioration and improve outcomes [Reference Bickman, Kelley, Breda, De Andrade and Riemer41]. Despite this evidence and drive, there are concerns that primary data in the form of outcome measures still remains underutilised by clinicians and services within child and adolescent mental health.
It is increasingly possible to compare services through national benchmarking, as championed by NHS Benchmarking with their CYPMH data collection covering service modes, access, activity, workforce and finance [42]. Such comparison can identify variations in care. Getting It Right First Time is a national initiative using national and local data to identify unwarranted variations in care, and through the use of clinical leadership allowing services to understand the underlying cause of this variation and support the development of quality improvement plans to reduce it [43]. A GIRFT programme for CYP’s inpatient and crisis services identified a significant variation in most data metrics and clinical delivery of care, resulting in a significant variation in the length of admissions. A lack of robust outcome monitoring was also highlighted. The report identified a need for a whole pathway approach to crisis care, ensuring a seamless transition between services without the need for reformulation of the young person’s needs. There is a need to improve the quantity and quality of data collection and ensure that it is used in both strategic planning of services and everyday clinical work.
Secondary use of data has led to numerous positive benefits for patients. However, such benefits can come with concerns about the risk of privacy breaches. The General Data Protection Regulation (GDPR) provides a set of data protection rules, which enhance how people can access information about themselves, and places limits on what organisations can do with personal data. Explicit consent under the GDPR is distinct from implied consent for sharing for direct care purposes under the common law duty of confidentiality.
Quality improvement in health care is based on a principle of organisations and staff continuously striving to improve how they work. There is no single definition, but can be understood as ‘quality improvement is about giving the people closest to issues affecting care quality the time, permission, skills and resources they need to solve them. It involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement’ (Health Foundation) [44]. There is no single quality improvement methodology that is recommended for mental health; however, all of them have a strong emphasis on co-production and service user involvement. Techniques that have been applied in health care can all be adapted for use in mental health settings.
Quality improvement projects typically involve simple changes in staff behaviour and interactions. Generally, the interventions selected involve relatively minor practice modifications with minimal associated patient safety risk. Using quality improvement at scale also improves the experience of staff delivering care as well as driving efficiencies [Reference Shah and Course45].
Integrated and Holistic Models
Integrated care is about delivering health care in a coordinated and unified way where the different social, psychological and medical needs of a person are met together rather than separately, and where organisations work in partnership. Integrated services can reduce confusion, repetition, delay and duplication in service delivery.
The physical and mental health of a child or young person are not distinct entities that can be treated separately. Children with a long-term physical condition are at increased risk of a mental health condition [4].
The Mental Health Foundation have identified a number of factors for effective integrated care for those with mental health problems that include: (1) information-sharing systems; (2) shared protocols setting out the responsibilities of each; (3) joint funding and commissioning; (4) co-located services; (5) multidisciplinary teams [46]. The report stressed the need to refrain from thinking of physical and mental health separately and to consider the wider determinants of health. Having the ‘right people with the right skills and attitudes’ was also seen to be an important requirement for the successful integration of physical and mental health care.
Developing and supporting integrated and multi-agency services requires commitment and leadership across the relevant agencies. The government has recognised the effectiveness of integrated working. The Department of Health and Social Care white paper (2021) Integrations and Innovation: Working Together to Improve Health and Social Care Outcomes For All aims to build on the innovations that have been seen through the Covid pandemic, improving services at a time when the pressure on them has been the highest [47].
Trauma-Informed Approaches
Trauma-Informed Approaches (TIAs) are based on the understanding that many CYP in contact with services have experienced adversity and trauma and may consequently find it difficult to develop trusting relationships with staff providing care, and to feel safe within services [Reference Sweeney, Clement, Beth and Kennedy48]. TIAs are informed by neuroscience, psychology and social science as well as attachment and trauma theories, and give central prominence to the complex and pervasive impact that adversity and trauma have on a person’s world-view and interrelationships.
Within TIAs the basic safety of environments is prioritised (physical, psychological, social and moral). Training, reflective practice (including clinical supervision) and support for staff are seen as essential to help them recognise and focus on the impact of trauma on CYP and their support systems. TIAs incorporate key trauma principles and practices across the whole organisational and system cultures.
AMBIT [49], MAC-UK’s ‘integrate’ model [50], Trauma Recovery Model and Enhanced Case Management [51] are promising examples of trauma-informed approaches introduced in the UK.
Thrive
Thrive aims to replace the tiered model with a conceptualisation of a whole system approach. The Thrive categories are needs-based groupings [Reference Wolpert, Harris and Jones40]. The Thrive framework conceptualises five needs-based groupings for young people with mental health difficulties and their families: thriving, getting advice, getting help, getting more help and getting risk support. Each of the five groupings is distinct in terms of the needs and/or choices of the individuals within each group, skill mix required to meet these needs, dominant metaphor used to describe needs (well-being, ill health, support), resources required to meet the needs and/or choices of people in that group. The groups are not distinguished by severity of need or type of problem. Rather, groupings are primarily organised around different supportive activities provided by CYPMH services in response to mental health needs and influenced by client choice.
Supporting Children in the Early Years
The early years play a large role in determining mental health through childhood and beyond. In the early years, infants make emotional attachments and form relationships that lay the foundation for future mental health. The positive mental health and well-being of children and their parents during the first few months and years of a child’s life enable their future health and attainment. There is good evidence for a range of interventions that can promote mental health and well-being. Policy initiatives focusing on supporting parents, and particularly mothers with mental health needs and infant mental health, are increasingly common [10,25]. Targeted support for vulnerable parents, such as the Family Nurse Partnership programme and positive parenting programmes, can also improve outcomes for this group (see Chapter 4 – Infant Mental Health).
The government has recognised the pivotal importance of this time, most recently in its Early Years Healthy Development Review Report [52], supported with additional funding. Specifically, investment in health visiting, expansion of parent–infant mental health teams and investment in a national network of family hubs.
Transition and Support for Adolescent and Young Adults
It is well recognised that transition to adult mental health services can be challenging with many young adults failing to access services. Centre for Mental Health’s Missed Opportunities report [Reference Khan53] articulates the prepandemic issues faced by people aged 16–25. Just 22.7% of 16–24-year-olds with symptoms of common mental health problems were receiving treatment. The likelihood of a mental health difficulty increases with age. The pandemic has had a significant impact on the life chances of young people, and the long-term changes to income, employment and housing will impact their mental health.
The NHS LTP [10] aimed to create a comprehensive mental health offer for people aged 0–25, working in partnership across services and agencies. NICE transition guidance [54] emphasises the need for transition to be multiagency and to involve service users in the design and development of services.
Early support hubs are recommended in Future in Mind (Department of Health & NHS England 2015) [23] and described as an effective delivery mechanism of mental health care and support for young people in the community in less stigmatising and more accessible settings. Previous evidence from the UK, Australia, Denmark and Ireland also indicates that early support hubs are able to attract young people who are less likely to engage with NHS mental health support [Reference O’Keeffe, O’Reilly, O’Brien, Buckley and Illback55]. A hallmark of the hubs is that they develop and respond to specific local need and are often a partnership between voluntary, community and social enterprises and health care services. Expanding provision of hubs (young futures hubs) are a commitment from government with a plan for further pilot and evaluation.
Eating Disorder Services
Eating disorders are serious, potentially life-threatening conditions that affect a person’s emotional and physical health. Eating disorders commonly start in childhood and adolescence but affect people of all ages, genders and sexual orientation. Studies put the prevalence rates of lifetime eating disorders at 8.4% for girls/women (peak onset is often in adolescence) and 2.2% for boys/men [Reference Galmiche, Déchelotte, Lambert and Tavolacci56]. However, rates of eating disorders were found to have increased significantly for young people 17–19 years of age to 12.5% by 2023 [6]. Anorexia nervosa has the highest mortality rate of any psychiatric disorder, from medical complications associated with the illness as well as suicide. Evidence highlights the importance of early intervention as soon as eating disorder is suspected, to prevent development of entrenched, long-term illness [57].
In response, 70 community eating disorder services were developed across the England to deliver NICE evidence-based treatment as part of the FYFVMH Programme [25]. This was supported by whole team training and increasing access to IAPT training programmes for family and Cognitive Behavioural Therapy interventions. The access and waiting time standards set a target that 95% of CYP with an eating disorder should access treatment within 1 week for urgent cases and 4 weeks for routine cases [58].
NHS England guidance on eating disorders in CYP outlined a whole pathway approach from prevention and early identification with GPs, and schools to intensive outreach, ward admission or home treatment when required [58,59]. The revised guidance from NHS England also considers support for the increasing number of CYP presenting with disordered eating and ARFID (Avoidant Restrictive Food Intake Disorder).
Early Intervention Psychosis Services
Psychosis is a severe mental illness associated with significant impairment in social functioning and shorter life expectancy. A long duration of untreated psychosis is associated with poorer personal recovery, increased service use and poorer economic outcomes in both the short and long term [Reference Marshall, Lewis, Lockwood, Drake, Jones and Croudace60].
Early Intervention in Psychosis consists of multidisciplinary teams set up to seek, identify and reduce treatment delays at the onset of psychosis and promote recovery by reducing the probability of relapse following a first episode of psychosis [61]. Timely access to specialist treatment is shown to have a significant long-term impact on the lives of individuals with psychosis and their families.
All CYP, aged 14 and above, experiencing their first episode of psychosis should receive a comprehensive package of NICE concordant care within 2 weeks of referral to a specialist service [61]. A specialist service includes any team that is identified as delivering a component of the locality’s specialist early intervention psychosis response, which must be comprehensive across the full 14–65 years age range. The updated plan includes sections for CYP and those with At Risk Mental States (ARMS). The overall aim of ARMS provision is to delay or prevent the onset of severe mental health problems, including psychosis and also to support a reduction in the Duration of Untreated Psychosis (DUP).
Looked-After Children
The challenges faced by looked-after children are widely recognised as impacting on their mental health. The importance of supporting positive relationships in the young person’s care network and placement stability is well recognised [62]. Mental health services for children in care support young people in the care system, recognising that the impact of childhood trauma or neglect may present as pervasive difficulties that occur throughout the lives of young people, rather than diagnosable mental health problems.
Services for looked-after young people are overseen by social care, but many integrate mental health provision, through either systemic or psychology practitioners, to provide either direct input, consultation to social workers or training and advice to carers. To ensure that looked-after children are not disadvantaged by potential placement changes or more frequent moves, teams to support them often integrate education and physical health offers that wrap around the young person to ensure there is the same level of consistent oversight that would be expected of young people with a more stable caring relationship [62].
It is also recognised that higher levels of placement breakdown or change are associated with poorer outcomes against a wide variety of metrics, hence support is designed to scaffold placements (either family or residential homes) to maintain placements.
Crisis Services and Home Treatment Teams
A mental health crisis is a situation that the person or anyone else believes requires immediate support, assistance and care from an urgent and emergency mental health service.
A functioning crisis response unit is an essential part of mental health care. The NHS LTP aimed to have comprehensive crisis services available by 2024 [10]. The crisis offer should have the following four functions: (1) A single point of access, including through 111, to crisis support, advice and triage; (2) Crisis assessment within the emergency department and in community settings; (3) Crisis assessment and brief response within the emergency department and in community settings, with CYP offered brief interventions; and (4) Intensive home treatment services aimed at CYP who might otherwise require inpatient care, or intensive support that exceeds the normal capability of a generic CAMHS community team.
It is imperative that appropriate crisis response services are operational. Their absence has resulted in some CYP being sent far from home for treatment and/or placed in adult wards that are inappropriate for their age groups. The mobilisation of all age crisis helplines 24/7 by local mental health trusts is an integral part of the crisis care pathway.
Trials of community-based treatments for young people, both in the UK and abroad, have reported good clinical outcomes [Reference Ougrin, Zundel, Corrigall, Padmore and Loh63]. Although there is some variation in the results from randomised controlled trials, overall, the findings indicate that these outcomes are comparable to those of inpatient treatment [Reference Kwok, Yuan and Ougrin64,Reference Ougrin, Corrigall and Poole65]. There is also some evidence that the clinical improvements associated with intensive community treatments are equally stable at follow-up as those associated with inpatient treatment, although further research is needed to establish this more firmly [Reference Schmidt, Lay, Göpel, Naab and Blanz66].
Workforce Development
Transforming the mental health workforce is fundamental to creating sufficient capacity to deliver accessible, quality services and good outcomes for CYP. Stepping Forward to 2020/2021 [67] outlined the mental health workforce plan for England to support delivery of the Five Year Forward View for Mental Health [25]. The report highlighted the importance of addressing retention of staff as well as recruitment, recognising the importance of supporting staff mental health and well-being. The report also identified the need to develop new roles such as Child Well-Being Practitioners as well as a wider roll of recently developed roles, such as advanced practitioners, physician associates, non-medical prescribers, nursing associates and allied health professionals, including pharmacists. The NHS Long Term Workforce Plan (2023) sets out a comprehensive workforce plan to meet the needs of a changing population, including the expansion of psychiatrists, mental health nurses and psychological professionals [68].
Developing integrated care models means building flexible teams working across organisational boundaries and ensuring they have the full range of skills and expertise to respond to service user needs in different settings.
Professionals supporting children with mental health needs may work in a variety of different settings and come from a variety of different backgrounds. Therefore, consideration needs to be given to the training of the wider workforce within communities as well as those working in specialist mental health settings. Staff working in front line community services should also have access to regular supervision and consultation to support provision of effective services. Maintaining staff well-being is also crucial for sustaining the growth of the workforce, as poor well-being can culminate in problems with the retention of staff.
The children and young people’s IAPT (Improving Access to Psychological Therapy) programme provides an important opportunity for training the workforce. It seeks to combine evidence-based practice with user involvement and outcome evaluation to embed best practice in child mental health. It includes 5 key principles underlying transformation: participation, increasing mental health awareness and reducing stigma, improving access and engagement, delivering evidence-based therapy and demonstrating outcomes and accountability through data collection.
Summary
In recent years, there has been an unprecedented focus on mental health within the NHS, providing greater transparency regarding the needs of CYP, as well as the commissioning and service delivery required to meet those needs. A third of all mental health problems have been established by the age of 14, rising to almost two-thirds by age 24 [Reference Solmi, Radua and Olivola69]. It is likely that the Covid-19 pandemic has further broadened income gaps between households, putting more CYP at risk [6].
Important principles in delivering effective CYPMH services include the need to: build resilience, consider prevention and early intervention, as well as developing a clear joined-up approach linking services through care pathways. Delivering evidence-based interventions for young people with mental health needs requires a sustainable, well-supported workforce with the relevant skills and competencies working across the full system.
New models of care can stimulate effective collaboration between commissioners and providers to develop integrated, accessible services for all. Expanding access to digital services can enable more people to receive effective care and provide greater accessibility and choice. A system-wide focus on quality improvement can support staff and patients to improve care through effective use of data, with support from professional networks. All new models must be developed in partnership with experts-by-experience, carers and community and voluntary organisations. Systemic investment in services and the staff who provide them is needed to meet the ambitions set by governments.
