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

3. Basic Principles

SNAP report principles

3.1 The Framework adopts the following as basic principles, derived from the SNAPReport on Child and Adolescent Mental Health:

• Mental health promotion for children and young people should be an underpinning principle for all who come into contact with children and young people, whether they are well or unwell.
• Work on prevention of mental ill health, treatment and care for childrens and young people's mental health should be needs led.
• Mental health promotion, illness prevention, treatment and care for children and young people should have the rights of children and young people as a core value.
• Mental health should be mainstreamed within children's services.
• Improving the mental health of children and young people requires a co-ordinated and coherent combination of health promotion, prevention work and intervention and care services.
• Children's services should operate as intelligent networks - that is, services engaged with one another in ways that encourage development and adaptation to changing need, circumstance and evidence.

An integrated and holistic approach

3.2 The Framework fits within and endorses the vision for an integrated approach to children's services planning and delivery set out in For Scotland's Children, which assumes a holistic approach with the child at the centre. For Scotland's Children has already identified the key elements that need to be in place for effective integrated work. Though we do not propose to repeat the elements in full, they include the need for:

• A shared vision and common purpose amongst partners, focussing on child-centred outcomes
• Planning processes which address both universal and targeted services and pathways between them
• Clarity amongst partners about roles and responsibilities, in service planning and delivery
• A commitment to improve operational practices and develop new and different approaches
• Open and transparent financial management systems
• Agreed policies and practice on information sharing and client confidentiality
• A commitment to multi-agency staff training
• An ongoing, integrated approach to monitoring and evaluation, linked to service planning
• The involvement of service users in planning and evaluation

3.3 Good health involves the whole child, their physical, social and emotional wellbeing as well as the context and settings that they find themselves in. The different aspects of a child or young person's life should not, therefore, be considered in isolation. In this context, there needs to be broad consideration of the influences on mental health and wellbeing, and associated health promotion activities.

3.4 Physical activity can influence social and emotional wellbeing as well as physical health. Body image issues which can affect eating habits can often be helped by being physically active, and taking an integrated approach to healthy eating and physical activity will support young people to have a greater understanding of their bodies and the need for a balanced lifestyle. Evidence also shows that low confidence or self-esteem, stress and anxiety and body image are closely linked to willingness to participate in physical activity. It is important to work with children and young people to find out what they perceive as barriers to being physically active and support them in overcoming these. Being physically active can improve emotional wellbeing, help with anxiety, depression and low self-esteem and may even contribute to preventing such problems developing. This requires integration with local leisure and recreation policies and services.

3.5 The development of Health Promoting Schools in Scotland provides an important focus for partnership working and integration. The Health Promoting School incorporates and integrates daily physical activity (through Active Schools) with a whole school approach to nutrition and health (through Hungry For Success) within an ethos of positive mental wellbeing. The Scottish Health Promoting Schools Unit provides support and guidance to local authorities to help the development of all schools in Scotland as Health Promoting Schools.

Partnership working

3.6 Implementation of the Framework requires a multi-agency approach and strong local partnerships. Effective partnerships help overcome traditional boundaries between service sectors and contribute to positive interpersonal relationships at an individual level. They also create networks of individuals who can provide valuable advice, information and contacts. Good partnership working can also stimulate further developments in and amongst partner agencies.

3.7 During the consultation process, some respondents requested some guidance on establishing strong local partnerships. Though we have already referred to the elements of integrated working (above), it is worth highlighting the foundations of effective partnerships, which require:

• Clear, shared objectives
• A realistic plan and timetable for reaching these objectives
• Commitment from the partners to take the partnership's work into account within their mainstream activities
• A clear framework of responsibilities and accountability
• A high level of trust between partners
• Realistic ways of measuring the partnership's achievements

3.8 Successful partnerships depend on establishing clarity about aims, types of intervention and intended outcomes, and resources, as well as a shared understanding of processes and outcome measures. Agencies from different sectors often work with different models or types of intervention. A transparent process of establishing what assumptions are being made will help avoid misunderstandings and ensure appropriate referral to appropriate services.

3.9 Barriers to change can be lowered by:

• Careful planning of the actions needed to secure the necessary agreement to change
• Persuading stakeholders outside or on the edge of the partnership's active membership of the case for change (by involving them in devising solutions, or in joint training, for example)
• Testing new service delivery models in pilot projects
• Devising mechanisms to equalise the organisational gains and losses that can sometimes result from breaking out of a vicious circle

3.10 There are several toolkits available that can be used by local areas to support the process of developing their partnerships. The ourpartnership website ⁴⁴ provides access to documents and information which give guidance on best practice for partnership working between the voluntary and public sectors in a variety of contexts.

Terminology

3.11 Although the way that we view mental health issues is changing in Scotland, there remains a great deal of confusion about terminology. Different sectors and agencies use terminology differently and sometimes, we can be referring to the same issues in different ways. The SNAP report discusses the issue of terminology in some detail and gives some important messages about the concept of language from the perspective of children and young people. This Framework endorses the approach taken in the SNAP report.

3.12 The term "mental health" is therefore used to describe more than an absence of illness, and includes a notion of wellbeing. This Framework adopts the World Health Organization description of mental health as, "a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community"⁴⁵.

3.13 The language around mental health problems is perhaps more complex with different agencies variously referring to mental disorder, mental illness, emotional and behavioural difficulties, challenging behaviour, and psychological problems. Like the SNAP report, this Framework uses the term "mental health problems" to describe difficulties in living, learning and relating which are expressed in terms of troublesome emotions or behaviours, as well as more explicit psychological or psychiatric problems. The complexity and severity of these difficulties determine the level of specialised intervention and support that they require.

3.14 In terms of terminology, the key message from the SNAP report is that local agencies and practitioners need to, "engage in discussion about their differences, with a view to developing shared accounts of the young person's needs".

When is a young person not a young person?

3.15 For pragmatic reasons, agencies and services commonly adopt age as a way of indicating the range and limits of the services they offer. This has the advantage of being simple, clear and readily communicated. It can work well where a range of good services is available, where these are comparable at both sides of the age limit, and where services work constructively together.

3.16 It can also have a number of disadvantages. Needs may or may not change with age and so young people with very similar needs who are of marginally different ages can be offered very different services. It also runs the risk of creating discontinuities in service provision at times of important transition (see below). There is a particular risk of young people between the ages of 16 and 18 "falling between stools" if services for young people and services for adults do not agree their respective referral criteria.

3.17 The Framework notes some important developments in health policy in relation to age:

• The Mental Health (Care and Treatment) (Scotland) Act 2003, which makes it clear that all those under the age of 18, when admitted to hospital by reason of mental health difficulties, are to be treated in settings which are appropriate to their developmental stage.
• The recent service review in NHS Scotland ⁴⁶, chaired by Professor David Kerr, which made recommendations for improving the quality of children's services, including the adoption of 16 years as a pragmatic upper boundary for children's health services.

3.18 In practice, those commissioning mental health services for children and young people should consider the mental health needs of all young people in a community under the age of 18, in keeping with the provisions of the Children (Scotland) Act 1995. They should also consider the needs of those with significant mental health needs who, on reaching 18, will continue to have significant mental health needs. For example:

• Some forms of severe mental illness can begin in teenage years and persist into adult life. Service developments in relation to such young people, for example with early onset psychosis or eating disorders, should incorporate care pathways which avoid arbitrary disruption of treatment arrangements based on age.
• Similarly there are those young people with severe developmental disorders, including those with autistic spectrum disorder and some of those with attention deficit hyperactivity disorder, who gain benefit from mental health services and will require mental health care which continues when they reach the age of 18.

3.19 In terms of services developed and provided, pragmatic but flexible use of 18th birthday may be regarded as a reasonable referral guideline for new referrals to mainstream child and adolescent mental health services. However, meeting the mental health needs of vulnerable children and young people will often require particular care and flexibility. In these circumstances, well designed care pathways, supported by locally agreed protocols, may supersede the usual arrangement.

3.20 Young people with complex problems may remain involved with the child care system beyond their 18th birthday. Young people looked after by a local authority may remain in the child care system until they are 19 years old, and in some circumstances, until they are 21 years old. Similarly, offenders are considered "young" until the age of 21. Where liaison arrangements with child and adolescent mental health services are established for younger clients, it would seem arbitrary and unhelpful to exclude these older young people while they remain in these settings.

Transitions

3.21 Children and young people are more vulnerable to mental health problems at times of important change in their lives, for example when they are transferring from primary to secondary school, from school to other settings, from care settings to independent living, and between services for young people and those for adults. Careful and early planning is required across agencies and boundaries, to minimise distress for children and young people and, where appropriate, ensure continuity of care. Careful planning is particularly important where transitions involve a child or young person with additional support needs, including mental health problems.

3.22 Young people with mental health problems may face additional transitions when:

• Moving between hospital-based services, such as inpatient or day patient care, and community-based care
• Moving between child and adolescent mental health services when these are organised separately for children and for young people
• Moving between child and adolescent mental health services if they change home address
• Moving from child and adolescent mental health services to adult mental health services

3.23 These require careful management, across agencies and services and between practitioners, to ensure continuity of treatment and care and to prevent any adverse impact on the child or young person's condition.

Underlying principles

3.24 There are a number of underlying principles and themes which need to be taken into account in all thinking about the mental health of children and young people. These are, however, difficult to thread through the document without making it over-complex to use. Local implementation processes should, however, ensure that the following are considered.

Inequalities

3.25 Like adult mental health, the mental health of children and young people is affected by the circumstances in which they live. Inequalities span social, economic, and geographic factors as well as discriminatory practices towards certain groups and the way in which services are provided. Inequalities significantly amplify both the risk and the impact of mental health problems. This needs to be reflected in local work on inequalities.

3.26 Local authorities and community planning partnerships provide the optimum context for addressing these wider issues. This needs to sit alongside work in local areas to improve the lives of children in general, as well as targeted work with those who may be more vulnerable to mental health problems due to their birth/life circumstances, e.g. those who are looked after or accommodated, those who have a learning and/or physical disability, those who have been or are at risk of abuse, and those who have experienced living with domestic abuse or homelessness. (This is not an exhaustive list and more is said about children and young people requiring additional and specific supports in Section 7 of the Framework.)

Accessibility and diversity

3.27 Services for children and young people need to be provided in accessible and imaginative formats. Walk the Talk⁴⁷ has already published a resource pack ⁴⁸ to provide advice on developing appropriate and accessible health services for young people. It is based on the premise that relevant people + relevant places + relevant times = relevant services. In developing services for children and young people, the following need to be considered:

• Where are children and young people in the locality?
• What times are they there?
• Are there buildings lying unused in the evenings that could be used?
• Are there local out-of-hours services already available that could be built upon?
• Are there other delivery methods that are familiar to children and young people? (E.g. text messaging, web-based information, outreach work with community learning development workers.)
• How will children and young people who have particular difficulties/vulnerabilities access services?
• How will children and young people from ethnic minorities access the services - are there existing local networks?
• What networks and contact mechanisms exist for disabled children and young people?
• Are there local advocacy services which could contribute to this process?

3.28 The voluntary sector has considerable experience and skill in providing accessible services for children and young people, and can offer valuable assistance in considering and addressing some of these issues, including the place and value of outreach/street work.

3.29 The arts sector provides a wide range of creative opportunities, and these are increasingly being regarded as having the potential to be utilised not only to deliver key messages on mental health to young people, but also as inclusive participatory processes based on the principles of participation and involvement as outlined above. These participatory practices - located within schools, community centres, arts organisations, etc. - offer ways in which the principles of health promotion can be delivered "in action" through activities which have traditionally been successful in engaging young people from a range of backgrounds, including those who are "hard to reach".

3.30 Clear, joined-up transport policies are vital in ensuring that children, young people and their families are able to access services, particularly specialist services, which may not be available locally. With this in mind, NHS Boards and local authorities (and regional transport partnerships) should develop or review transport policies to facilitate access to health care. The Scottish Executive is keen to see the development and enhancement of joined-up working at local and regional level to develop transport approaches which ensure:

• The availability of transport for those with differing needs
• Clear, consistent and well-understood service eligibility and costs
• Seamless and efficient interaction between services

3.31 Agencies should work together to ensure that clear and comprehensible information is provided for children, young people and their carers about the transport services that are available and any available assistance with travel and/or accommodation costs when they need to use mental health services.

Participation and involvement

3.32 The participation of children and young people was highlighted as the first of three core themes in the main SNAP report - "… recognising the right of children and young people to be heard and their capacity to play a full part in thinking about mental health and in influencing the arrangements that we make to improve mental health".

3.33 The United Nations Convention on the Rights of the Child ( UNCRC) ⁴⁹ underpins the legislative and cultural progress in involving children and young people in making decisions. In particular, Article 12 of the UNCRC gives children the right to express their views freely in all matters affecting them and states that these views will be given due regard. The UNCRC was ratified by Great Britain in 1991 and in Scotland, the Children (Scotland) Act 1995 incorporated its principles by giving children a right to express their views on a range of decisions which affect them.

3.34 The ability of children and young people to participate in the life of their community is linked to their perception of how safe they feel to become involved. The Children and Young People's Charter ⁵⁰ is written from the perspective of children and young people and was developed through talking to children and young people who have experienced the need to be protected and supported - but it outlines how any child or young person facing difficulties could expect to be treated to enable them to feel safe. It states that, "As children and young people, we have a right to be protected and be safe from harm from others. When we have difficulties or problems we expect you to:

• Get to know us
• Be responsible to us
• Speak with us
• Think about our lives as a whole
• Listen to us
• Think carefully about how you use information about us
• Take us seriously
• Put us in touch with the right people
• Involve us
• Use your power to help
• Respect our privacy
• Make things happen when they should."
• Help us be safe

3.35 Children and young people will benefit from the resources of their communities when they feel that their views are respected and their perspectives valued. Some of the key competencies in the children's and young people's mental health competency framework ⁵¹ emphasise the importance of understanding where children and young people are coming from and how life events may have impacted on them. These include:

• Values, approach, and attitudes
• Resilience and capacity building
• Understanding of family functioning and systemic approaches
• Impact of poverty, domestic abuse, parental drug/alcohol/health problems
• Impact of loss/trauma/abuse
• Experiences of bullying and harassment
• Difficulties in communication

3.36 The participation and involvement of children, young people and their parents in the processes to take forward local implementation of the SNAP report ⁵², using this Framework, is a fundamental underlying principle. Local areas will be expected to demonstrate how they are ensuring this.

Evidence-based services

3.37 This document has already highlighted good communication and meaningful participation as important factors in the delivery of better services. But it is also important that agencies, services and teams have arrangements in place which allow them to ensure that the services, programmes and interventions which they provide are as effective as they can be. This is not without its challenges, as the SNAP report indicated:

"Much of the evidence is derived from the treatment of children with single conditions, while most children presenting to child and adolescent mental health services have several co-existing mental health problems. Not all treatment methods have been evaluated, nor are there effective treatments for the whole range of mental health difficulties which children and young people experience. Further research is needed both to identify effective intervention methods and to test the feasibility of translating them into everyday practice settings." ( page 53)

3.38 However, as the SNAP report also highlights, several themes emerge in literature and studies, indicating that effective programmes:

• Occur early in the problem cycle and preferably early in age
• Involve familiar people or people who will be able to empower parents and work in partnership with professionals ( e.g. health visitors or trained volunteers)
• Are intensive and sustainable over a period of time
• Are multifaceted, incorporating several interventions ( e.g. to both parents and child; focussing on health, education and parent training)
• Incorporate interventions of proven effectiveness

3.39 In practice, this means that services should offer interventions which are:

• Developed in light of the best available evidence
• Delivered by staff who are appropriately trained, supervised and supported
• Offered in an appropriate place by the most appropriate person
• Monitored through appropriate, explicit governance arrangements
• The subject of consultation with service users in relation to acceptability and effectiveness

3.40 New interventions or services which are developed to address needs which had previously gone unmet or unrecognised, will need to be evaluated by arrangements established in advance and incorporated in the developmental process.

Building on existing structures

3.41 Links with other local services and systems are assumed, e.g. working with schools, any existing Healthy Living Centres, Childcare Partnerships, the Children's Hearings System, community health projects, domestic abuse fora, community safety partnerships, youth and community initiatives, Choose Life initiatives, etc. The Framework is not about creating new structures, but building on what already exists.

Consent

3.42 Consent is central to the relationship within which a health service is offered. Any person receiving a health service in Scotland, or giving consent on behalf of another, does so of their own free will, with a clear understanding of the reasons as to their involvement and the likely outcome. Interventions within the health service are not generally carried out without consent. The exceptions to this rule are to be found in few, generally well recognised circumstances, which will usually have been tested and established in a legal setting.

3.43 Valid legal consent comprises three elements ⁵³:

• The person being invited to give consent must be capable of consenting (legally competent)
• The consent must be freely given
• The person consenting must be suitably informed

3.44 In Scotland ⁵⁴, a person of, or over, the age of 16 years is presumed to be competent to give valid legal consent to medical treatment. A person under the age of 16 years has the legal capacity to consent on her or his own behalf where, in the opinion of the attending practitioner, she or he is capable of understanding the nature and possible consequences of the procedure or treatment.

3.45 Whilst it is good practice to investigate the possibility of shared decision making and consensus, and important as the views of persons with parental responsibility are, the decision of a competent child or young person to accept (or refuse) treatment cannot be set aside.

Confidentiality

3.46 A child or young person under the age of 16 who is deemed capable of giving consent has the same right to confidentiality as an adult. This can mean that someone working with a young person will maintain their privacy even when a parent, carer or other professional requests information. Only in certain circumstances should confidentiality be broken. These include:

• When the safety of the child or young person, or the safety of another child or young person is at risk
• When the child or young person gives consent for professionals to share information
• When colleagues talk with one another within supervision or consultation

3.47 Confidentiality should not be a barrier to effective communication with families and carers. Often, carers can be given information in general terms without breaching confidentiality. Similarly, the concerns of carers can be heard whilst maintaining the privacy of the child. Where confidentiality is an issue, every effort should be made to negotiate with the young person about what information can and cannot be shared.

3.48 The Scottish Executive has published guidance ⁵⁵ for health workers about sharing information about children who may be at risk of abuse or neglect. Practice should be informed by these guidelines, and supported by access to advice and supervision.