30/5/19
You may know that I’m a Children’s Nurse who initially trained as a Registered General Nurse back in the late 1980’s. My experience of caring for people with mental needs includes caring for a skeletally year thin young lady with anorexia nervosa on a general medical ward who required intravenous fluids. I struggled to understand why she couldn’t and wouldn’t eat and if I’m honest was totally overwhelmed as an 18 year old seeing her emaciation that wasn’t attributed to a physical health issue. Later in my training I spent a summer on a placement at Whitchurch Hospital in Cardiff, my memories of that time include enjoying the beautiful grounds with the patients being cared for, as well as accompanying patients to and from their ECT treatments. Much of my time was spent ‘being with’ people, not always chatting, just ‘being’. I remember a ward sister (who I respected greatly) remarking that that she didn’t think I’d make a mental health nurse, it takes all types to make the world turn I tell myself, as a result I have huge respect for my mental health nursing colleagues for the work they do.
As I moved throughout my career I’ve focused on nursing children and young people with renal, oncology and general paediatric ‘physical’ health related needs. Emotional well-being was an underlying theme throughout my career and whilst the mental health needs of young people have much greater focus than they’ve ever had previously, it’s something I’m still trying and if I’m honest often struggling to understand.
The Mental Health Foundation flags that while most children grow up mentally healthy, data suggests that more children and young people are having challenges with their mental health today than 30 years ago, they suggest its probably because of changes in society and it’s impact on feelings and behaviours. The transition to adulthood may also include experimenting with alcohol, drugs or other substances that can affect mental health too.
1 in 10 children and young people experience mental health issues and these can be a direct response to what is happening in their lives, issues such as:
- having a long-term physical illness
- having a parent who has had mental health problems, problems with alcohol or has been in trouble with the law
- experiencing the death of someone close to them
- having parents who have separated or divorced
- being separated from the family resulting in them becoming ‘looked after’ by their local authority
- having been severely bullied or physically or sexually abused
- living in poverty or being homeless
- experiencing discrimination, perhaps because of their race, sexuality or religion
- acting as a young carer for a relative, taking on adult responsibilities
- having long-standing educational difficulties.
I’m sure there are no doubt things that have been missed from this list. We’re all far more aware of ACEs ‘Adverse Childhood Experiences’ http://www.healthscotland.scot/population-groups/children/adverse-childhood-experiences-aces/overview-of-aces than ever before and the impact they can and do have on mental health and well-being.
Children and Young People don’t always know or are able to articulate what these adverse experiences are, leading to the complexity of management and care. On chatting to my 15 year old daughter, she offered the wisdom only a 15 can ‘see mum it’s not just about one thing, it’s often multiple stuff, the constant layering of difficult hard life things that makes life tough sometimes’. Beautifully put I think!
This infographic from Healthy London Partnership provides an overview of the challenges children and young people face in London.
The types of mental health issues children and young people can present with include:
- Depression, this affects more children and young people today than in the last few decades, but it is still more common in adults. Teenagers are more likely to experience depression than young children.
- Self Harm is a very common problem among young people. Some people find it helps them manage intense emotional pain if they harm themselves, through cutting or burning, for example. They may not wish to take their own life.
- Generalised anxiety disorder (GAD) can cause young people to become extremely worried. Very young children or children starting or moving school may have separation anxiety.
- PTSD or Post traumatic stress disorder can follow physical or sexual abuse, witnessing something extremely frightening of traumatising, being the victim of violence or severe bullying or surviving a disaster.
- Children who are consistently overactive (‘hyperactive’), behave impulsively and have difficulty paying attention may have ADHD Attention Deficit Hyperactivity Disorder.
- Eating Disorders usually start in the teenage years and are more common in girls than boys. The number of young people who develop an eating disorder is small, but eating disorders such as anorexia nervosa and bulimia nervosa can have serious consequences for physical health and development.
Shockingly the leading cause of death in the 5-19 age group is death by suicide according to the Office for National Statistics http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredinenglandandwalesseriesdr/2015#number-of-land-transport-accidents-among-5-to-19-year-olds-decreases-in-2015
Some of the children with mental health needs as we know present in Emergency Departments. The RCPCH in their ‘Facing the future’ Emergency Care Standards https://www.rcpch.ac.uk/sites/default/files/2018-06/FTFEC%20Digital%20updated%20final.pdf sets out what we need to be able to offer. 
The emerging crisis intervention and home treatment models of caring are hugely helpful in supporting children and young people in areas other than ED, it’s a far from therapeutic environment for those in mental health distress.
Of course we also need to support and provide support for the mental health of children and young people with complex ongoing health needs too, the RCPCH Facing the Future sets out the standards required https://www.rcpch.ac.uk/sites/default/files/2018-04/facing_the_future_standards_for_children_with_ongoing_health_needs_2018-03.pdf
We also need a workforce that has the skills to engage with children and young people, the @WeCanTalk programme developed by @RobinfromCAMHS in collaboration with young people and staff is a great example of addressing support and education of staff. Our skills as professionals to connect with children and young people to build trust, foster understanding, show value, respect and creation of safe spaces are key.
Our local mental health services NELFT and ELFT have been so welcoming to visits and collaborations, partnership working across STP patches has to be a key element of future working. Thank you @Nicola21762634 for hosting me this week, I learnt so much! Hoping to meet @bewseyr soon too.
Just as we’ve reflected on the opportunity to consider a RN Child/LD pathway to qualification in recent weeks, I wonder if going forward we could offer a RN Child/MH pathway? Perhaps it already exists? It surprises me that we have adult MH trained nurses caring for CYP and I think we encourage more Children’s trained nurses to work in MH settings?
And of course there are clear opportunities to ‘prevent’ and reduce deterioration of mental health illness too. As people who are passionate about children and young people’s well-being we can all promote and role model the importance of
- being in good physical health, eating a balanced diet and getting regular exercise
- having time to play, indoors and outdoors
- support being part of a family that gets along well (most!) of the time
- encourage taking part in local activities such as attending voluntary organisations as well as opening up volunteering opportunities.
- support going to a school that looks after the physical and emotional wellbeing of all its pupils, do we have governors who lead on well-being in all our schools?
I wonder what more we can do to work in partnership with schools too? The Schools Mental Health toolkit developed by the Healthy London Partnership team can be used to promote wellbeing in schools https://www.healthylondon.org/resource/schools-mental-health-toolkit/
These are the ‘asks’ from young people to schools which are powerful calls to action:
I also think we can do more investing and valuing of school nursing https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/forums/children-and-young-people/staying-healthy-forum/school-nurses-toolkit-2017.pdf, ensuring they have the skills and insight to support the mental health needs of pupil and the staff that support them. Why not recruit mental health nurses to be school nurses?
And what opportunities does Social prescribing offer Paul Jarvis-Beesley, Head of Health at StreetGames @PaulWJarvis blogs about what this can offer here https://www.ukyouth.org/2019/03/05/social-prescribing/
This is clearly a conversation that will continue, please do follow…
@CYPMentalHealth http://cypmhc.org.uk/
@YoungMindsUK https://youngminds.org.uk/
There are loads of really helpful resources from the @rcpsych that are worth dipping into too, they’ve got a great short film on anxiety https://www.rcpsych.ac.uk/mental-health/parents-and-young-people
@EmmySelby is a mental health nurse who is really keen to support digital development and be creative, do follow her on twitter.
@lizziebessell is an ED Matron who’s been awarded a Florence Nightingale Fellowship to explore how we can best support young people with mental health needs in acute hospital settings.
I’d really value hearing more about the challenges faced and the solutions that you’ve put in place to address some of the challenges…..
Have you employed Mental Health Nurses in general paediatric areas, what difference has this made?
Have collaborations with Mental Health Teams brought benefits? Are you working with primary care on this agenda?
Love these prompts from young people to parents 
Kath Evans Connecting 
Good review . You mention schools, as many do, as a preventative solution which I think has problems/weaknesses. Its not a reliable, consistant way of reaching all children. First of all there are many independent schools, for faith or private or whatever reason which state health services like school nursing don’t routinely reach. All schools have too much autonomy to ensure consistancy of delivery. Numbers of home school children, excluded children lose out….there are so many reasons focusing on school is problematic, also it puts the onus on teachers who are already challenged in educational tasks alone.
Which is also why I feel the green papers focus on schools is flawed.
School is a place children are educated and yes that should be holistic about all aspects of life but it should be embedded in the way schools operate. School is also a place where the family and parents are not present so it also to my mind, its not inclusive, or empowering parents to parent well, it takes away from the responsibility parents have to raise their children, it covers over issues where there those issues should be adressed, for child welfare, for safeguarding, for reducing mental health issues, for obesity. We keep wanting the solution to be school based maybe because its easier to put it in there than tackle parents/parenting!
I agree the short sightedness about schoolnursing generally is sad. They did have a good role in supporting teachers to address health screening promotion, early intervention of any health issue as well as supporting physical and health needs in schools. School nursing should have been developed instead of lost. If every school had a dedicated school nurse(paediatric trained, in CYP physical and mental skills) they could support health in school the diabetics, epileptics, inclusion of special needs, as well as much needed mental health early support.
Which brings me onto the omission of parents/family in your review, mental health needs to be more collaborative, tackling expectations exploring family resilience, and enabling families to fulfil their parental responsibilities in a crisis is what we do as an RSCN, and what should be done more in mental health. Mental health is isolating and at the moment mental health care exacerbates that. Family focussed therapy has been proven to work, Family group conferencing is good in social care why not in mental health? Empowering FAmilies (JAnet Treasure SLAM) Families are there before during and long after services step back and are the key to long term, lasting recovery.
Therapy needs to be more flexible, personalised and holistic, Emotional focused therapy (Jennifer Danby, SLAM), Cognitive Remedial therapy, (KAte Tanchuria et al). Ive even seen drama based therapy. At the moment there is a tendancy that if CYP doesnt fit CBT or DBT then they are not engaging! The onus is on the practitioner to ensure/work harder to achieve engagement!
Most of all there needs to be a massive real improvement in Mentalhealth care capacity and capacity nationwide.
My daughter age 12 in 2006 suffered a lack of service in S.W. her ED worsened required 2 months in acute paeds before an inpatient ED stay for 6 months 240 miles away,and nothing post discharge. Age 18 in 2012, she relapsed at uni in Hampshire, amazingly self referred but was made to wait 10 months for ED service help. Age 21 crisis and inpatient adult ED unit was recommended in Exeter, but 3 month wait for bed. Its taken 3 years for her to get to a physically healthier place. Now in 2019 doing a masters at Uni in Newcastle she struggles with severe anxiety and OCD but was only offered a 6 week set of sessions!
In 12 years she has never been able to access a service she’s needed yet promises promises have been made, claims of improvement but yet the reality we’ve lived is very different. The point I make is, if as a family we hadnt gone out and sought info:, learnt new skills , I gave up my NHS job, sort my own therapy to cope with supporting her and advocating for her when she was too ill and suicidal to bother, in most cases family will be the only constant, the most motivated, but they do need help, education, enpowering to be a key element of their CYP recovery. Its a resource that comes cheap, just needs harnessing.
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Dear Jacqueline, thank you so much for such comprehensive reflections & for sharing your experiences too – loads to think about, and really helpful constructive challenge about schools issues & family support, thank you, K
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