people and those at risk of poor outcomes. This section aims to summarise the commentary on gaps from members of the Expert group which was convened to support the Health needs assessment refresh (HNA 2014). Three Expert Group meetings were held (one in Dec 2013 and two in Jan 2014). The numbering is this Appendix refers to the numbering in the Local need for CAMHS section
4.2. Education
The Health Visitor Implementation Plan 2011–15: a call to action (Department of Health, 2011)62 is
leading to an increase in the number of health visitors employed in Surrey and this will lead to an increase in the number of 2.5 year checks being carried out. Children’s centres have a key role in supporting families with young children including their emotional wellbeing and mental health needs. The need for joint working has been identified and emotional health is a top priority. Joint planning is already taking place to ensure that all children, especially vulnerable children are accessing services. The Health Visiting service is a universal service but provides additional support for vulnerable children. The aim is that most children will be in early year’s settings or engaged with Health Visiting and Children’s Centre services. Children under 5 years are rarely seen by specialist CAMHS as it is envisaged that emotional wellbeing and mental health support for these children will be addressed by health visitors and children’s centres.
Children who are identified with emotional wellbeing and mental health needs in early years and primary school settings may be offered access to a nurture programme. This may support the management of behaviours which could potentially lead to FTEs if not addressed. There are 9 cluster nurture groups for infant children who do not have a statement for BESD as part of the early intervention strategy. Referrals can go straight to the group although schools are advised first discuss the need with their educational psychologist and/or behaviour support service to check what strategies may already be in place. In addition some schools have developed their own in- house nurture groups.
There is concern about children who may not be statemented i.e. those with high functioning autism, ADHD, or dyspraxia as this is identified as a key area and there is a lack of identified support.
Table 8 shows the number of pupils on roll in Short Stay schools (SSS) as 56 however, this is believed to be incorrect and could be significantly higher which may have implications for the mental health support needs of these young people. It is thought that the 2009 figure was
cumulative across the year whereas the number of 56 was a snapshot on one day, however, this information is still being checked. SSS have access to PMHW.
Schools are increasingly using a restorative justice approach and managed moves to reduce/ prevent exclusion (e.g. centres in schools - Ash Manor, Salesian (The Pier) and The Cottage). However, FTEs for persistent disruptive behaviour remain high. There are also more FTEs at the primary age range due to the rising number of children with complex needs that schools are dealing with. This is also linked to the numbers of children in PRUs and SSSs.
Access to Education is dealing with more pupils across all areas in Surrey including those at risk of permanent exclusion. The number of children accessing this service in December 2013 was in excess of 150 pupils. The total number of pupils engaged with Access to Education in 2012/13 was 197 and Medical Access to Education engaged with 91 pupils in 2012/13.
Support for schools includes:
Nurture groups working with children’s centres with the ‘Ready for School’ programme TaMHS and CAMHS
Involvement of behaviour support specialists in the Short Stay Schools and Pupil Referral Units Alternative learning provision in secondary schools
Behaviour support provides specialist input for identified children at risk of exclusion Education Welfare works with parents and families
Babcock 4S with PSHE responsibility
However, there is a need for the development of a TAMHS style approach for staff in Further Education Colleges (16-18 years) to reduce the number of young people dropping out due to emotional wellbeing and mental health needs and becoming not in employment education or training (NEET).
Table 11 highlights a small number of children with FTEs for sexual misconduct with 11 pupils in secondary schools and 3 in primary and/or special schools. The sexual misconduct related incidents may be due to influences and understanding outside school and may include use of inappropriate language. Parents will be informed and the Behaviour support team and educational psychologists may be involved. Children with sexually harmful behaviours may be referred to ACT; this Service also provides training to schools. Sex and Relationship Education provides an
opportunity for learning in this area and is a responsibility for all schools including academies and free schools.
Table 11 also shows that the bullying rate has decreased but does not include the rising numbers of incidents of cyber bullying which has significant implications for emotional wellbeing and mental health of children. There is a gap in the recording of incidents of cyber bullying and in how schools can best respond to this at present. However a multi-agency e-safety sub group (of the Surrey Safeguarding Children Board) chaired by the Education Safeguarding Adviser is developing an action plan to address all on-line behaviour including training and awareness raising for staff, teachers and other professionals. In addition all schools are required to have an anti-bullying policy which will incorporate cyber bullying and an e-safety policy to address any online issues in school. Table 13 shows that the number of pupils with EASL has increased since 2008 throughout Surrey and shows an increase in Arabic, Bengali, Chinese, French, Hindu, Gujarati, Italian, Malay, Nepali, Panjabi, Polish, Portuguese, Spanish, Tagalog/Filipino, Tamil and Urdu. The highest increase is in Polish speaking children. There is a gap in identifying, assessing and responding to the potential emotional wellbeing and mental health needs of these children whose families may not access services or support. The community based language programmes which teach English at weekends for pupils and parents in schools, youth and church facilities may provide an access point for children and their parents in these communities. There is no coherent picture about this at present but it will form part of the local offer. The Surrey Minority Ethnic Forum is another potential forum for engagement with families of pupils with EASL and Asylum Seeking Children and their families.
The main route for addressing the emotional wellbeing and mental health of children and young people is through school however, the potential emotional wellbeing and mental health needs of children not in schools such as school refusers and children missing from education is unknown. The HOPE service offers support for some children who are not in education employment or training.
4.3 Health
As part of the SEN reforms, behaviour emotional and social difficulties will be re-categorised as social emotional and behavioural in Surrey under the Children and Families Care Bill. A joint commissioning and tripartite panel for Education Health and Care Plans is being considered. New
NHS legislation will require all adults with learning disabilities to be registered with a GP and to have a health care assessment and this will be extended to children next year.
There is a gap for children in hospital regarding the emotional wellbeing and mental health component or need, for example a child may be diagnosed with diabetes or other long-term conditions but their emotional wellbeing implications may not be identified or considered.
In terms of parents with mental health needs, Section 3.5.2 highlights the impact of poor parental mental health and poor parenting skills in the increased onset of emotional/conduct disorder in childhood. There is a gap in identifying parents and undertaking early intervention with the children concerned and there is a need to improve co working between AMHS and CAMHS. There is also a gap in the data locally for parents with perinatal alcohol problems however a specialist fetal alcohol service is provided by SABP.
Data for under 16 year olds for self harm is likely to be more accurate as they have to be routinely admitted under NICE guidelines. Self harm is rising. Educational psychologists have undertaken work with schools and held a self harm conference to raise awareness. There is anecdotal evidence from services for young people that levels of self harm are increasing. Impact of social media is significant and there are implications for service responses. Secondary schools are finding the number of issues they need to include in PSHE challenging and there is limited capacity to incorporate further areas of need. There is a gap for young people (and parents) who need faster, instant access to support e.g. 24/7 online and information about alternative positive coping mechanisms to self harm. Self help resources are available but need better communication.
The is a gap in the data on the number of children and young people accessing A & E for incidents relating to self harm and other emotional wellbeing and mental health needs.
There is a gap in identification, assessment and service delivery for the emotional wellbeing and mental health needs of children who are overweight or obese and their families and for children receiving CAMHS support to be referred to appropriate weight management support.
Section 4.9 shows that there were 79 child referrals from SABP Children and Young People Service from Jan – Dec 2013 into AMHS or IAPT. The Care Programme Approach planning is affected by lack of attendance by CAMHS workers and clinicians which results in inconsistent or uninformed handover arrangements of young people from CAMHS to AMHS.
There will also be young people who do not meet the thresholds for AMHS who will require ongoing support but the number is unknown. There is a further gap for this group with no relapse prevention plan or signposting to where they can access additional help if needed. The Mindful service for 16-25 year olds does signpost however service capacity is limited.
4.4 Children and young people who are vulnerable or at risk
Table 33 shows the number of unborn children in Surrey by CIN and CP and the numbers of new cases in the previous month. The highest number of cases are in NW and NE Surrey and current provision capacity is limited. As this data has only recently started to be collected, it is important to monitor to determine whether this is an emerging trend.
There is limited capacity in the PIMH and the You and Your baby service to support families with attachment issues and for those young parents who are in care or care leavers. There needs to be an increased capacity in these services. A perinatal service is needed for mothers who may
become mentally ill during this time or for those with existing mental illness which may relapse or deteriorate. In addition more parenting programmes are needed particularly for parents of children with disabilities or with teenagers.
The approach to assessing the needs of carers is very ad-hoc currently, partly due to the lack of standardised documentation. There are forms in Surrey Children’s Service for Parent Carers (SCS626A) and Young Carers Assessment (SCS200). A joined up approach similar to the Early Help model (Surrey Family Support programme has set criteria) has been suggested. An improved family approach is needed as there will be a family focus in the single plan. There is a gap in the routine and consistent assessment of the needs of parent carers and a lack of knowledge about information concerning support available to them (e.g. Carers Breaks information/the £500 grant for every GP to make Early Intervention payments for carers) to aid signposting. Parent
assessments should be carried out under the Children Act with assessment on first contact with the aim to maintain sustainability of their caring role. There is also a need for training in services in this area. There is a gap in data concerning the number of assessments carried out by CAMHS and other services.
There is a dedicated 14 -24 worker for Young Carers who offers resilience training and referral on to CAMHS with the young person’s consent. There is a need to recognise the potential for young carers to become NEET as many young carers are nine grades lower with attainment than their peers not in caring roles.
All schools have a dedicated person to identify young carers but information sharing can be a challenge. Health assessment of the whole family, including parents and siblings, should take place to raise awareness of any caring role potential of young people. SABP now has a Young Carer’s strategy.
Young Carers want positive coping mechanisms and to develop their resilience. There is a need for open access emotional wellbeing and mental health support e.g. online counselling and/or drop-ins, which should be developed on a co-design basis to prevent this cohort from potentially needing to access CAMHS. Carer champions within services are also suggested, similar to the model used by YSS with champions in each team within borough or district.
Section 4.4 highlights the age of 11-16 as a critical period for LGBTQ young people when they may be subject to discrimination in society such as hate crime, violence, bullying and verbal abuse and homophobic bullying in schools. However, there is a gap in the data and service for this cohort. CAMHS East Systemic Psychotherapist is working with an increasing number of young people who present with gender identity questioning. CAMHS are looking at how to develop practice for this group of marginalised young people as there is definite gap in targeted services with very limited gender variance support locally. CAMHS can work with the emotional wellbeing and mental health element for those young people who are identified and receiving assessment of their needs but there is a bottle neck for further intervention and support and a gap in capacity.
Table 38 summarises the number of refugee and asylum seeking children in Surrey and their country of origin and highlights the countries with the highest number as Afghanistan, Eritrea, Iran and Syria. There is a gap in the identification and assessment of their emotional wellbeing and mental health needs and this is a challenging area as many of the children concerned may not understand the concepts of emotional wellbeing and mental health. There are implications for emotional wellbeing and mental health linked to legal status as there is the potential for self harm and suicide attempts for those at risk of deportation. More work is needed to better understand the needs of this cohort of young people.
There is a gap in the data for children from the GRT community in Surrey and therefore in identifying and assessing the emotional wellbeing and mental health needs and any service
intervention required. Section 4.4.3 shows the estimated number of GRT children in Surrey schools and highlights that being a Young Carer is more common for young people in this community. CAMHS have links with GRT outreach liaison workers and YSS have a GRT worker however details regarding this were not available at the time of this needs assessment.
Section 4.4.12 highlights the gaps in service and support for recently adopted young people and suggests a huge unmet emotional wellbeing and mental health need for young people
experiencing self harm, very low self esteem, extreme anger management, inability to regulate and sensory problems. Reactive Attachment Disorder (RAD) is becoming more prevalent with
increasing numbers of children affected who may present as having ASD and there is a gap in the effective preparation for pre-adoptive parents in relation to RAD and the availability of professional support for the child. There is a gap in post adoption support with increasing numbers experiencing trauma, loss and attachment issues following family or placement breakdown with a significant impact on the family and some young people experiencing secondary rejection
Stigma associated with mental health has been identified as a major issue by young people and other stakeholders and may reinforce the reluctance of individuals and their families to ask for help and support for fear of other people’s negative reactions. The No labels service works to address this in the YSS and CAMHS Youth Advisers (CYA) have undertaken some work through the CYA in schools programme but there is a gap in campaigns to address stigma. However, Time for Change Surrey includes children and young people representation on the steering group and CYA have been part of the training delivery. There are initial plans (subject to securing funding) for further roll out including:
Coordinating ongoing CYA activity in schools with creative arts based approaches through performance of the play ‘Breaking Point’ (specifically for young people and illustrates a young man’s experience of mental health problems)
CYA involvement in further training on mental health awareness for appropriate groups such as youth workers and colleges
Making the role of mental health ambassador more appealing for young people by re-designing the leaflet and getting young people on board to tell their stories
CYA to be part of human libraries and primary care training.
East Surrey Domestic Abuse Service (ESDAS) is the only domestic abuse service working with children through an identified worker and there is therefore a different service delivery arrangement in SW, NE and NW Surrey.
The draft Joint Emotional Wellbeing and Mental Health Commissioning Strategy consultation findings have highlighted further needs and service issues which have been reflected in the recommendations.
APPENDIX 2