The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care

1. Introduction

1.1 In the autumn of 2000, the Scottish Executive commissioned a needs assessment of the mental health of Scotland's children and young people. The resulting Scottish Needs Assessment Programme ( SNAP) Report on Child and Adolescent Mental Health² was published in 2003 and was well received. This was in large part due to the meticulous review process, which involved those working in the field of children's and young people's mental health and wider children's services in the development of the recommendations. In addition, and importantly, the views of children and young people themselves shaped the final document.

1.2 The report made 10 broad recommendations. Some have implications at a national level; some for local strategic planning; and others for local practice. This Framework is intended to support local planning and practice and should be used in an inter-agency way and within the integrated children's services planning context.

1.3 The SNAP report emphasised that all agencies and organisations have a role in supporting the mental health of children and young people. It highlighted the need to address the whole continuum of mental health - from mental health promotion, through preventing mental illness, to supporting, treating and caring for those children and young people experiencing mental health difficulties of all ranges of complexity and severity. It also suggested that mental health promotion should underpin all work with children and young people, even when they are mentally unwell and accessing specialist mental health services. This approach is represented in figure 1 below.

Figure 1: Adapted from Mrazek and Haggerty (1993), via Barry (2001)³.

1.4 This is a complex matrix which needs to take account of:

• The life stages of children and young people
• The settings/places where young people live their lives
• The range of people and organisations who come into contact with children and young people
• The continuum of mental health to mental ill-health
• Underlying principles such as inequalities, accessibility and participation

Framework development

1.5 Since publication of the SNAP report, the Scottish Executive has been working with its expert advisory Children and Young People's Health Support Group ⁴ and with HeadsUpScotland ⁵ to promote children's and young people's mental health in Scotland, and ensure better delivery of mental health services for those who need them. Following discussion with the Child Health Commissioners ⁶ in August 2003, the Children and Young People's Health Support Group agreed to develop a framework to assist local health, education and social work services in planning and delivering integrated approaches to children's and young people's mental health across the continuum of promotion, prevention and care. A Child and Adolescent Mental Health ( CAMH) Development Group ⁷ was established in 2002, to draw on the expertise of colleagues from NHS services, education, social work and the voluntary sector in taking this work forward.

1.6 As part of the development process, over 200 delegates from a range of disciplines attended a SNAP Into Action conference in March 2004. Working in small groups, participants considered roles and interventions in a range of scenarios, all of which had a mental health element. Around 30 young people were involved in the event following a SNAP follow-up event which had been arranged specifically for young people earlier in the month.

1.7 During the development of the Framework, a separate working group gave detailed consideration to the size, configuration and commissioning arrangements for psychiatric inpatient services for children and young people in Scotland. The Inpatient Working Group's recommendations ⁸ were published in December 2004, and complement and inform this Framework.

Consultation

1.8 A draft Framework was published in December 2004 for a three-month consultation. In addition to the written consultation, Penumbra ⁹ was commissioned by HeadsUpScotland to undertake some focussed consultation with children, young people and parents. In parallel, YoungMinds ¹⁰ and the Scottish Development Centre for Mental Health ¹¹ were commissioned to consult with local agencies whilst also offering support in using the Framework to guide service planning. Summary reports of these local discussions were submitted for consideration with other consultation responses.

1.9 In total, 102 consultation responses were received from a broad range of agencies and disciplines. The vast majority welcomed the Framework and considered it to be helpful in clarifying expectations and as a planning tool. Many respondents provided helpful comments and suggestions for strengthening the Framework, and these have been taken on board wherever possible.

1.10 A report of the consultation analysis is published concurrently with this finalised version of the Framework and is available on the Scottish Executive website ¹².

Who is the Framework for?

1.11 Everyone working with and caring for children and young people can contribute to their mental health and wellbeing, and many already do so. Local Authorities, for example, have the power to promote community wellbeing and can provide many opportunities through the Community Planning processes to create conditions which support good mental health for our children and young people. Some professionals have a specific "mental health" role, whilst others, such as teachers, make a valuable contribution implicitly, as part of another role. The Framework is therefore for everyone who has a responsibility for children and young people. It is also for professionals who work in adult services, who have a responsibility to consider the needs of any children that their clients have.

1.12 Although the draft Framework had acknowledged the range of activities, agencies and partners involved in supporting children's and young people's mental health and wellbeing, it was presented from an NHS perspective. Respondents to the consultation gave a strong message that they wanted a multi-agency Framework with multi-agency ownership and responsibility for delivery. This finalised version of the Framework is intended to be a multi-agency document. It is about a shared vision for children's and young people's mental health and wellbeing, and it is about joint leadership, planning and delivery. The Framework should therefore be owned and implemented through integrated children's services planning processes, and within the context of Community Planning.

How to use the Framework

1.13 The Framework expands on the Framework for Mental Health Services in Scotland¹³. It also contributes to delivery of the National Programme for Improving Mental Health and Wellbeing ¹⁴ Action Plan ¹⁵. It is intended to be used by local agencies as a planning and audit tool, to identify goals and milestones for continuous improvement in the delivery of services and approaches to support and improve the mental health of children and young people in Scotland. In essence, it is intended to promote and shape coherent, interagency planning.

1.14 The Framework does not set out a prescriptive formula for addressing the mental health needs of children and young people. One size does not fit all. What the Framework does, is outline the elements of an integrated approach to children's and young people's mental health and wellbeing across a range of settings. Much that is described within this Framework is already happening somewhere in Scotland, and in due course, HeadsUpScotland will be establishing an accessible library of practice examples on its website.

1.15 The Framework begins by identifying the service elements, actions and lead partners in universal children's services - in the early years, in the school years, and in the community. Subsequent sections highlight actions required by targeted services, such as social work and NHS specialist child and adolescent mental health services, for those children and young people with additional and specific needs.

1.16 None of the service elements, activities or partners included in the tables of this Framework is listed in any particular order of importance or priority. Lead partners are indicative only - there is a much wider network of partners who should be consulted as appropriate, and these are listed in Annex 1. The involvement of children, young people, parents and carers is assumed.

Achieving change

1.17 The Framework is expected to be taken forward through integrated children's services planning structures. Accordingly, specific actions with associated timescales should be identified, agreed and included within the integrated children's services plans for each area. Agencies should consider and agree a resource framework for realising the Framework, including the extent to which existing funding sources - both mainstream and specific - can be used.

1.18 In order to help the implementation process, YoungMinds and the Scottish Development Centre for Mental Health ( SDC) have already been working with local areas in using the Framework to identify what already exists, where there are gaps and what action is required.

1.19 All of the elements outlined in the Framework are expected to exist within local services by 2015. This will be a challenging timescale, in some areas more than others. However, with effective planning and appropriate prioritisation, much can be achieved over the next 10 years.

Workforce issues

1.20 Workforce shortages present a key barrier in achieving change, and this is acknowledged. In the context of the SNAP report, and recognising the significant workforce issues relating to child and adolescent mental health, the Scottish Executive established a Child and Adolescent Mental Health ( CAMH) Workforce Group to identify ways in which to build capacity for promotion, prevention, care and treatment within the children's services workforce across a range of agencies. That Group has been considering workforce planning for:

• Inpatient and intensive mental health services for children and young people
• Community based specialist mental health services for children and young people
• Building "mental health capacity" across the network of children's services

1.21 The CAMH Workforce Group will be reporting concurrently with publication of this Framework with recommendations for future workforce requirements and how these can be met.

1.22 In the meantime, some workforce development activity has already been taken forward with £1m funding from the Scottish Executive over 2004-06. HeadsUpScotland has managed use of the funding to support training and development, offering a positive use of short-term investment to improve capacity and ensure longer term benefit. The funding has been used to support and commission:

• Children's and young people's inpatient nurse training and development
• Training for those working with vulnerable children and young people
• An increase in specialist skill capacity
• Service redesign

1.23 The content of the training commissioned from this funding, has been informed by the CAMH competency framework¹⁶ which was published by NHS Education for Scotland in 2004 for all those involved in supporting children, young people and families.

Accountability and monitoring

1.24 The Framework is intended as a self-assessment tool to support service planning and continuous improvement. It is not intended to be used as a monitoring tool, though it is designed so that it might be used in this way at a local level.

1.25 At a national level, the delivery of effective services and approaches to meet the mental health needs of children and young people across promotion, prevention and care will be monitored through integrated children's services plans, Joint Health Improvement Plans, and through the Joint Local Implementation Planning mechanisms relating to the Mental Health (Care & Treatment) (Scotland) Act 2003. In reviewing these plans, the Scottish Executive will expect to see clear evidence of planning for, and progress on, implementation of this Framework. In this context, responsibility for ensuring delivery of this Framework rests with both NHS and local authority Chief Executives.

1.26 The involvement of children, young people and their families should feed into the relevant planning processes. The Child Health Commissioners are expected to take the lead in ensuring this happens.

1.27 The Scottish Executive guidance on integrated children's services planning ¹⁷ lists the current performance indicators that the Scottish Executive and NHSScotland use to monitor progress in improving the health of children and young people. The Scottish Executive is working to rationalise existing quality improvement and accountability arrangements across services for children and young people. Revised and more focussed national indicators will be published for consultation in 2005, as part of a quality improvement framework for services for children, young people and their families. The Scottish Executive will also consult on arrangements for integrated inspection of children's services in 2005.