09 Nov Children’s mental wellbeing in a time of stress
What can we do to prevent molehills turning into mountains when overwhelmed and depleted specialist mental health services are unable to act rapidly enough to keep children safe and well?
Facing a crisis in specialist mental health provision, concerned professionals inside and outside medicine are doing their creative best to offer something concrete to children and young people who are struggling to keep well while trapped on long waiting lists.
One response is social prescribing by GPs, pointing children and young people towards activities including dancing, gardening and surfing which may be helpful.
As reported in the Guardian; “children as young as five who suffer from anxiety are to be prescribed cognitive behavioural therapy apps on the NHS via mobile phones, tablets and computers. The National Institute for Health and Care Excellence …. has conditionally recommended digital CBT for use in the health service to help children and young people with symptoms of mild to moderate anxiety. Draft guidance released for consultation on Friday says the technologies can be used with support from a mental health professional, while further evidence is generated to check if the benefits they offer are realised in practice.”
Another report, by the National Institute for Health and Care Research (NIHR), reveals GPs prescribing antidepressants for children from 11 years old. National Institute for Health and Care Excellence (NICE) guidance says that under 18s can be prescribed antidepressants, but only after assessment by a psychiatrist and only in conjunction with talking therapy. The report links this unauthorised response with the long waiting times for treatment by NHS child and adolescent mental health services, and states;
“No antidepressants are licensed in the UK for anxiety in children and teenagers under 18 years, except for obsessive compulsive disorder. Yet both specialists [psychiatrists] and GPs prescribe them. Thousands of children and teenagers in the UK are taking antidepressants for depression and anxiety. The numbers continue to rise and many have not seen a specialist.”
The Royal College of GPs council chair, Prof Martin Marshall, said: “….GPs are highly trained prescribers and there may be instances where a GP believes it is appropriate and in the best interests of a young patient to prescribe medication for a mental health condition, particularly if they are having difficulties accessing specialist services.”
Olly Parker, of Young Minds charity, said the NIHR figures were “yet another alarming sign of the crisis in young people’s mental health” adding: “Record numbers are trying to access support but finding the options are limited. Medication can play an important role in helping a young person manage their mental health but should never be a substitute for other treatments like talking therapies or CAMHS. Long-waiting times and high thresholds for treatment mean that GPs are in a difficult position because they want to help young people but there is a lack of easily accessible treatment options.”
These responses stand on diagnosis of disorder and a matched intervention, with GPs put in the almost impossible position of needing to do something, even if it lies at the edge of their professional scope, when they are face-to-face with their patient. When mental health specialists are required to diagnose illness, the problem of long waiting times returns. And diagnosis itself is not a settled issue in the mental health field. Commenting recently Dr Tara Porter, a highly experienced CAMHS psychologist, offers a way ahead: “Services are organised by diagnosis, but medical psychiatric diagnoses are not a perfect science even for adults, let alone for developing children and adolescents, whose stress responses are subject to change. A child who struggles to concentrate and is feeling pressure about schoolwork, for example, may on some days feel sad and low and on others anxious and worried, and may use both self-harming and not eating as strategies to cope.
Government investment in mental health, such as it is, has focused on mental health support teams employing education mental health practitioners, who are generally new graduates given minimal training, on low salaries. They are using these positions to start their careers before moving on after a year or so. This is a major design flaw: it takes time for distressed children and adolescents to trust adults, and it is that trusting relationship which allows them to heal and take therapeutic advice. An adult may arrive to therapy primed and ready to accept advice, but adolescents are more sceptical about adults’ opinions, and successful therapy with this population requires earning their respect before they will listen. Making these relationships is the challenge (and the joy) of CAMHS work. It is less likely to happen if education mental health practitioners move on after a year.
Good mental health for children and adolescents requires positive, long-term relationships with adults who care and value them. Ideally, this happens in the home, but can additionally or alternatively happen in communities, schools, youth clubs, sports grounds and dance troupes. Mental health services are a last resort. But what I do know is that kids become disenfranchised from society without links to positive adult role models and interests that engage them.”
Which leads straight into my suggestion of a different, non-medical, pre-diagnostic response to the need for structured, relationship-based support for children and young people, in their schools – a first resort, where the kind of positive, long-term relationships with adults who care about them already exist. It requires a shift in mindset, first put in train in 1980 by Dr Martin Seligman with his introduction of the new field of Positive Psychology and by psychotherapists Steve de Shazar and Insoo Kim Berg with their development of Solution Focused Brief Therapy. It means looking for hope, success and resourcefulness in situations where these can be only too easily sidelined by their opposites.
My offer is Solutions Focused Coaching, an application of Solution Focused Brief Therapy. Training staff in the approach enables schools to build their own independent, structured capability to provide an effective early response, improving children’s mental well-being, engagement and achievement. What makes it such a good fit with schools’ existing framework is that it’s educational, future focused and matches children’s natural tendency towards realistic optimism, all features that are key to wellbeing, engagement and achievement in school.
Solutions Focused Coaching – it works and it’s working. A useful addition to what we can do to treat molehills for what they are; small bumps in the road, not barriers to a better future.