Why 'low level' mental health problems require a sophisticated service response

The Children’s Commissioner’s latest report Early Access to Mental Health Support provides further evidence that children suffering anxiety, depression and other mental health conditions face a postcode lottery when seeking treatment. 

The report brings a welcome and timely focus on preventive and early intervention services for treating problems like anxiety and depression or eating disorders.

These services, which the report calls “low-level”, have often been funded by local authorities, or jointly with the NHS, and have been particularly hard hit by funding cuts. 

While the total reported spend on “low-level” mental health services across all areas in England increased by 17 per cent in real term between 2016-17 and 2018-19, nearly 60 per cent of local authorities saw a real-term fall suggesting wide disparities in the funding and prioritisation of service to meet the needs of children, young people and families.

In this respect, the government’s emphasis on child and adolescent mental health in the NHS long term-plan is very welcome, including the investment in mental health support teams in schools which will seek to fill some of the gaps in early intervention services.

The Children’s Commissioner’s report mirrors the experience of frontline NHS child and adolescent psychotherapists and also reflects the Association of Child Psychotherapists’ own research.

Providing children and families early on with an experience of being helped and taken seriously can help them access services later on if more severe problems emerge

Providing children and families early on with an experience of being helped and taken seriously can help them access services later on if more severe problems emerge. A first experience of being attended to, that they remember and can make use of again, is important for families. 

However, we do have some concerns about the use of the phrase “low-level” in relation to the difficulties that are being seen in community and primary care services.

Many children and young people seen in the community will have complex needs and complicated networks of care that require skill and experience to manage.

Symptoms of depression, anxiety and eating disorder should not be taken on face value. “Mild” presenting symptoms, whether emotional, relational or behavioural, may mask some very troubling underlying problems. 

A seemingly straightforward symptom or behaviour, such as self-harm, risk-taking, conduct problems or a less visible withdrawal into oneself, may mask or be an indicator of highly complex and entrenched states of mind with multiple causes and manifestations.

If these needs are not met with effective early intervention then difficulties can quickly escalate with serious costs for the individual, their family and in terms of the impact on schools, accident and emergency and inpatient care.  

The government are rightly tackling these difficulties through increased spending and the long-term plan for the NHS and need to ensure that all parts of the country address the inequity of access to early intervention and also to the specialist services that are needed to support primary care and to treat those children with serious and long-standing mental health problems. 

Integrate care

The iThrivemodel is being adopted in many localities as an approach to integrating care across health, social care, education and the voluntary sector and recommends that health input to the initial “Getting Advice” quadrant, “should involve some of our most experienced workforce, to provide experienced decision making about how best to help people in this group and to help determine whose needs can be met by this approach.” 

Those working in the mental health field know that this type of work can often be highly demanding even for experienced staff with the support of a full multidisciplinary team behind them. 

An over-simplistic view of childhood mental illness risks not only a mismatch between what is offered and what is needed, but also a heavy burden of stress and burn-out on a workforce that finds the task to be significantly more difficult and disturbing than their training, and the support structures around them, allows for.  

As a society, as our understanding of child development and psychology develops, there is increasing recognition of the complexity of mental distress which is often linked to adverse childhood experiences, abuse, trauma and also to parental mental health problems, domestic violence and substance abuse. 

What is now needed is to map this evidence of the range and depth of need in the community onto available service provision

Clearly the best course of action is the prevention of harm occurring in the first place including through intervention in the early years of life and we need to redouble our preventive efforts. This is not always possible so we also need effective services to support children and families when difficulties arise. 

The recent data published by NHS Digital provides the best picture we have ever had of the prevalence of mental illness in children and young people. What is now needed is to map this evidence of the range and depth of need in the community onto available service provision. 

This should lead to a realistic assessment of what services are required, and what skills and competences are required of the workforce in those services, in order to meet the recognised need. This would include the capacity of specialist services to supervise and consult to primary and community staff.

This should be included in the LTP implementation plan and the accompanying workforce plan. Otherwise we are putting forward solutions, and making investments, without a clear understanding of the impact and whether we are correctly aligning provision to need. 

A misalignment between the recognised needs of children and young people and the solutions offered may lead to unintended consequences and failures within the system, to the detriment of children and young people and their families.