A month on from Mental Health Awareness week, we here take a look at why youth work should be a part of the solution.
During the adolescent years and the transition to adulthood there are many instances that can contribute to poor mental health and emotional wellbeing including; exam pressures, worries about future education, and various transitions between life stages and social groups; for example, those that happen between primary and secondary school and between education and employment.
That these happen alongside major stages in neurological development often means there is much instability within the ‘individual self’ of a young person, and their lived experiences. As such, ‘mental health disorders in young people are surprisingly common. Those most frequent in the teenage years include anxiety and depression, eating disorders, conduct disorder (serious antisocial behaviour), attention deficit and hyperactivity disorder (ADHD) and self-harm. This age also witnesses the early emergence of rarer psychotic disorders such as schizophrenia (…). In fact, half of all lifetime cases of psychiatric disorders start by age 14 and three quarters by age 24.’[1]
Continuing the growing recognition of the need to tackle this, the NHS Long Term Plan has a much greater focus on the health of children and young people than previous plans with recognition of specific shortfalls in mental health services, a need for youth participation in service design and delivery, and a commitment to greater service periods up to 25 years old to prevent often harmful transitions between young people and adult’s services. However, adolescents and young adults continue to be under-represented within the overall plan, and there is little on early intervention.
Currently, much policy related to young people’s health and wellbeing is delivered within statutory services, specifically the NHS and schools. For example, the Green Paper on Transforming Young Children and Young People’s Mental Health Provision has little scope for other areas in which young people may come into contact with services.[2] This despite the fact that respondents to the consultation were split between whether schools and colleges (25% of respondents) or charities / non-governmental organisations (24% of respondents) [should] take the lead on setting up teams.[3]
Yet, importantly there is recognition within the Long Term Plan that there is a need for extra early intervention.
It is noticeable from Scottish data that a large share of health spending on children occurs in the community. In England, this type of spending is poorly measured, leading to the 2014 Health Select Committee recommending that the government conduct an ‘audit’ of low-level mental health provision for children. This has never happened, meaning we have an absence of national data on community provision.
As many of these services tend not to address acute health problems, they are also likely to be more vulnerable to cuts,[4] despite young people themselves often favouring this kind of approach when implementing health policies in ‘youth-friendly services that understand the specific needs of young people’.[5]
Even without this data, there is recognition of a shortfall of such services, with the government starting to roll out counselling support in schools. Over the next five years the NHS will fund new Mental Health Support Teams working in schools and colleges, which will be rolled out to between one-fifth and a quarter of the country by the end of 2023; currently there is no timeline for the other 80%; yet in 2015 it was estimated that only around one-quarter of children and young people who needed support from mental health services could access them.[6]
However, a recent Education Select Committee, Forgotten Children, emphasised the importance of such mental health care provision outside of school settings also to reach those most in need.[7] This is more important when we consider that:
- There has been a 40% increase in permanently excluded children in the last 3 years.
- There are at least 48,000 pupils educated outside of mainstream education and special schools.[8]
It is likely that these numbers are far higher, as there are also many hidden from official data, who are being ‘home-educated’, or ‘off-rolled’.[9] Of those outside of the mainstream school system, 50% are likely to have been recognised as having social, emotional and mental health needs, as opposed to just 2% of the general population.[10]
Schools are, at present, unable to cope with the levels of mental health issues they face and increasingly are referring pupils to Child and Adolescent Mental Health Services (CAMHS),[11] but somewhere between one quarter to one third of these referrals are unsuccessful.[12] The most common reason for referrals not being accepted is due to ‘mistakes in the referral process’; suggesting bureaucratic and administrative complications may be denying or delaying these essential services for many, and compounding prevalent needs.[13]
For successful referrals the average waiting time for assessment had dropped from 39 days in 2015-16 to 33 days in 2016-17 and for treatment from 67 to 56 days. Clearly some progress has been made, but nowhere near quickly enough; the average wait for treatment from referral is at 90 days.
Whilst commissioning of CAMHS has moved on significantly in recent years with more innovative approaches being used, the opportunity to use relational youth work to help young people in need of these specialist services are considerable as it often complements alternative therapies and acute services. For example, by encouraging young people to attend appointments and providing support in a less formal environment then school (which is often a root cause of poor mental health), youth work has been used with great success to address many psychologically based issues, such as obesity, substance misuse, self-harming, eating disorders and other body image issues. Crucially support can begin whilst the CAMHS waiting time is ongoing.
The consequences of not providing early intervention and of delayed support are potentially severe, as a study in Scotland has shown, which shows a positive correlation between incidences of non-suicidal self-harm and later prevalence of suicide attempts, especially amongst females, and those who are NEET.[14] The connection between long waiting times and increased chances of self-harm were also made in a Care Quality Commission (CQC) report last year.[15]
There are therefore clearly gaps in the current system with regards to early intervention and support throughout the process from referral to treatment, and these are gaps which schools alone cannot be expected to fill. Of course, schools are an essential part of services to young people (and alongside health services are the two largest areas of public spend), but this should not be considered as a sufficient ‘universal’ level of provision as 85% of a young person’s waking hours in school life are spent outside of school.[16]
it is therefore promising that the Long Term Plan also recognises greater need of community interventions.
The economic benefits of community based work is shown in the Children’s Commissioner Report on Vulnerability, which states the following costs:[17]
- Child in Tier 4 mental health services – £61k per admission
Children who receiving acute community support:
- Tier 3 mental health support – £2,338 per referral
Effective and well-evidenced programmes to address behavioural problems can be delivered for around £1,000 per child in a group setting, as can a course of counselling for mental or emotional difficulties.[18]
However, whilst for mental health the presenting issues naturally require external support, in many other policy areas, a high importance is placed on the personal responsibility of young people and families to make positive changes. This approach would also benefit from greater focus on community-based youth services.
For example, the approach to tackle diet and physical activity in the 2015 Childhood Obesity Plan (updated 2016) places the onus on children and young people to engage with physical activity – including in schools.[19] Yet, the extent to which this will succeed is questionable without providing the support that may be needed. Unfortunately, for many young people the family do not provide this support;[20] and this is again where a community centred approach is necessary.
There is, therefore, across all health-related areas a clearly identifiable need within policy to find youth-centred and community-based solutions outside of the school environment to provide support and activity that focusses on wellbeing as a whole (so as not to be stigmatising), and this is also a want of young people.
For lower-level support and earlier prevention of emerging mental health the decline in youth services has likely had a large effect on the escalating levels of poor mental health – this cannot yet be proved as a causal link, but there is significant anecdotal data to suggest that young people often attribute good mental health and wellbeing outcomes to youth work.
However, increasing the number of community-based youth services is not enough in itself; for youth services to be at their most effective they need to be well resourced over a long-term to allow young people to access them regularly in order for a trusted relationship with a youth worker to be built. Youth workers also need to be supported in relevant mental health training; the most often voiced ‘need’ by youth workers in the recent APPG inquiry into youth work was for greater training in areas of mental health support for young people.[21]
Referencing
[1] Hagell et. al, Key Data on Young People (2017), p. 104.
[2] Department of Health & Social Care and Department for Education, Government Response to the Consultation on ‘Transforming Children and Young People’s Mental Health Provision: A Green Paper’ and Next Steps (HM Government, 2018)
[3] Transforming, p. 24.
[4] Children’s Commissioner, Public Spending on Children in England: 2000 to 2020 (2018), p. 52.
[5] RCPCH, What do Young People Want to Be Improved as Part of the NHS Long Term Plan? (2019). Available at; https://www.rcpch.ac.uk/sites/default/files/2019-01/cyp_voice_pack.pdf
[6] NAO, Improving Children and Young People’s Mental Health Services (2018).
[7] Education Select Committee, Forgotten Children (2018). Available at; https://publications.parliament.uk/pa/cm201719/cmselect/cmeduc/342/342.pdf
[8] IPPR, Making the Difference: Breaking the Link Between School Exclusion and Social Exclusion (2017).
[9] Children’s Commissioner, Skipping School: Invisible Children – How Children Disappear from England’s Schools (2019). Available at; https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/02/cco-skipping-school-invisible-children-feb-2019.pdf
[10] Making the Difference, p. 16.
[11] https://www.nspcc.org.uk/what-we-do/news-opinion/one-third-increase-in-school-referrals-for-mental-health-treatment/
[12] See; Ibid., And; Emily Frith, Access and Waiting Times in Children and Young People’s Mental Health Services (EPI: 2017).
[13] Access and Waiting Times, p. 5.
[14] https://www.cambridge.org/core/services/aop-cambridge-core/content/view/D711AD4AFA2E25CB941814D6EDF90656/S2056472418000145a.pdf/suicide_attempts_and_nonsuicidal_selfharm_national_prevalence_study_of_young_adults.pdf [accessed 15th May 2018]
[15] https://www.theguardian.com/society/2017/oct/20/children-waiting-up-to-18-months-for-mental-health-treatment-cqc [accessed 16th May 2018]
[16] House of Commons Education Committee, Services for Young People: Third Report of the Session 2010-12 (2011), p. 3.
[17] All figures quoted and referenced in; Children’s Commissioner, Vulnerability Report 2018: Overview (2018). p. 11. Available at; https://www.childrenscommissioner.gov.uk/wp-content/uploads/2018/07/Childrens-Commissioner-Vulnerability-Report-2018-Overview-Document-1.pdf
[18] Ibid. p. 12.
[19] HM Government, Childhood Obesity: A Plan for Action (2016).
[20] Children’s Commissioner, Vulnerability Report 2018 (2018).
[21] APPG on Youth Affairs, Youth Work Inquiry: Final Report including Recommendations and Summary (2019). See also: YMCA, What Matters Most: A Report Setting out Young People’s Views about Today’s Key Public Policy Issues (2016), esp. pp. 9–10