Understanding and responding to children and young people’s mental health challenges

In 2015, the Future in Mind report (DH and NHS England, 2015) provided recommendations on how to improve CYPMHS and £1.5 billion of additional investment for CYP mental health provision was provided over a five year period. Subsequently, the Five Year Forward View for Mental Health was produced (Mental Health Taskforce, 2016) and in 2017 its recommendations were formulated into a series of planned reforms to improve CYP mental health. These included new support for schools to improve links with NHS, a review of CAMHS by the Care Quality Commission (CQC) and the Transforming children and Young people’s mental health provision: a green paper (DH and DfE, 2017). Key proposals contained in the green paper included the identification of a designated senior lead for mental health (DSLMH) and the establishment of school based mental health support teams (MHSTs) to work with NHS CYP mental health staff and provide extra capacity for early intervention and ongoing help.

Alongside these policy initiatives, the CQC published its final report Are we listening? (CQC, 2018) which found that the quality of mental health services for CYP were varied across England; that there were problems around access amid growing demand; that there was a lack of coordination between the different services; and outlined the pressures on staff and a lack of resources.

All these developments, concerns and recommendations were crystallised in the NHS long term plan (NHS England, 2019) which included a commitment to improve access to mental health treatment for 70,000 more children and young people.

Further measures in the plan included a commitment that:

• funding for CYP mental health will grow faster than both overall NHS funding and mental health funding
• there will be continued investment to improve access to community mental health services - an estimated 345,000 CYP will be able to access these services by 2023/24
• extra investment for eating disorders services would be provided
• the NHS would fund new MHSTs in schools and colleges
• the current 0-18 year service models would be extended to create a comprehensive offer for 0-25 year olds.

In September 2018 the Northern Ireland Commissioner for Children and Young People (NICCY) launched its Still waiting - a rights based review of mental health services and support for children and young people in Northern Ireland (NICCY, 2018). The review assessed the adequacy and effectiveness of mental health services for children and young people, highlighted good practice and identified barriers which prevent them from fully realising their right to the highest attainable standard of mental health. In October 2019, the Department of Health produced a draft action plan to enhance mental health services and support for children and young people. The recommendations included flexible treatment options, support for adults working with children and young people, and moving from child to adult services. NICCY is now monitoring implementation of the plan.

In Northern Ireland, the Health and Social Care Board and the Public Health Agency launched its care pathway for children and young people coming into CAMHS in 2018: Working together: a pathway for children and young people through CAMHS. The pathway outlines what should be expected when referred for treatment and provides a summary of clinical advice for all sectors of the service derived from evidence-based practice. It also includes information about accessing support before, during, and after treatment. The regional CAMHS pathway is accompanied by the publication Welcome to child and adolescent mental health services: a guide for you, which gives children and young people and their families or other carers information about CAMHS.

The Scottish government and the Convention of Scottish Local Authorities (COSLA) have identified mental wellbeing as one of six shared public health priorities for Scotland. In Scotland, the Getting it right for every child (GIRFEC) principles have applied to children and young people’s services to ensure they receive the right help, at the right time, from the right people. In addition, GIRFEC stresses the importance of care planning and collaboration between professionals as the required standard for delivery of children’s services in Scotland. Children’s mental health services are now widely run by integrated joint boards (IJBs) or are in the process of being integrated.

The Mental Health Foundation’s 2016 review of mental health services made a series of recommendations which informed the Scottish government’s Mental health strategy 2017-2027.

These recommendations included:

• a focus on prevention and early intervention
• addressing regional variations in services
• the need to tackle stigma and address Scotland’s high suicide rates compared to other UK countries
• greater workforce investment.

The strategy also included a commitment to audit CAMHS rejected referrals, which was undertaken by the mental health charity SAMH & ISD Scotland in 2018 and the creation of a taskforce that published its final recommendations in July 2019. These are now being implemented by a programme board, of which RCN Scotland is a member.

In February 2020 a new service specification for CAMHS was published and NHS boards are working on implementing this as part of their post COVID-19 remobilisation. An independent review into mental health law in Scotland has also been commissioned and, although focused on legislation which mainly affects adult mental health services, its findings will have implications for children and young people too.

Launched in 2015, Together for children and young people (T4CYP) designated children and young people’s emotional and mental health as a priority. With cross cabinet commitment, this multiagency service improvement programme aims to consider ways to reshape, remodel and refocus the emotional and mental health services provided for children and young people in Wales. The original four year programme has been extended into 2021, and the workstreams involve reviewing the roles of community and specialist CAMH services.

In light of concerns about the increase in the prevalence of mental health problems among children and young people, in 2018 the National Assembly for Wales Children, Young People and Education Committee published its Mind over matter report. Identifying that a step change was needed in emotional and mental health support for children and young people in Wales, the report advised the Welsh government to make this a stated national priority and called for a stronger emphasis on early intervention and building emotional resilience. It also recommended embedding mental health into the new school curriculum and ensuring that schools are supported by other services.

In recent years new data has emerged about the prevalence of mental health disorders (NHS Digital, 2018), indicating that mental health issues in children and young people are more prevalent than previously thought. The 2018 report found that 12.8% (1-in-8) of those aged 5-19 had at least one mental disorder, an increase on the previously estimated 1-in-10 prevalence. Other key developments that have changed the landscape for nursing staff in caring for children and young people with mental health issues since 2014 include:

• a growing awareness of the impact of social media on CYP mental health and wellbeing
• the rise of mental health issues for transgender and LBGTQ+ young people
• the concept of ‘parity of esteem’
• the impact of COVID 19 on young people’s mental health and on mental health service provision.

Children and young people with mental health issues may present at health facilities with a range of other non-mental health issues. It is incumbent on any nurse - not just those located in community, school or specialist mental health services - to be aware, sensitive to, and empathetic of these mental health issues. This updated document brings all nurses up to date with this rapidly developing and changing aspect of health care.

This document outlines the common mental health problems that practitioners may need to identify in various community or hospital settings, including GP practices, school nursing services, looked after children, community children’s nursing, accident and emergency departments, outpatient services, acute children’s wards, and youth offending services. It provides basic information on the knowledge and skills nurses will need in order to recognise and care for children and young people who present with possible mental health problems. It also supports the philosophy of the Royal Colleges of GPs (RCGP), Paediatrics and Child Health (RCPCH), and Psychiatrists (RCPsych) that young people’s mental health is everyone’s business (MHF, 2018).

This document also contains references and signposts organisations and websites that nurses may find useful for developing their knowledge. It can also be linked to the following NHS Knowledge and Skills Framework (KSF) dimensions:

• HWB1 (promotion of health and wellbeing and prevention of adverse effects on health and wellbeing)
• HWB3 (protection of health and wellbeing)
• HWB4 (enablement to address health and wellbeing needs)
• HWB6 (assessment and treatment planning)
• HWB7 (interventions and treatments).

Further information can be obtained from Skills For Health. 

While a simplified version of the original KSF is now in operation, NHS employers still prefer to utilise the original KSF dimensions as described above.

A nationwide prevalence study of a large sample of 9,117 children and young people aged 5-19 living in England indicated that at any one time 1-in-8 children (12.8%) have a mental health disorder, in other words, a diagnosable condition recognised as such by the World Health Organisation (NHS Digital, 2018). Disorders were grouped into four types: emotional (for example, anxiety, depression); behavioural (for example, disruptive behaviour); hyperactive (for example, ADHD); and other less common disorders (for example, autism). For the first time the study also provided statistics for pre-schoolchildren aged 2-4.

However, nurses need to be mindful that any process that categorises CYP by identifying a mental health condition for them, while helpful in many ways, also has drawbacks as these classifications are oversimplifications of the vast continuum of human behaviours. In particular young people’s behaviours and emotions change rapidly, and their presentation may just be a normal phase of growing up. Additionally, it is clear that there are a range of different kinds of social experiences there are linked to health, particularly those in childhood years (known as ACEs – adverse childhood experiences). The task for nurses is to recognise that each young person is unique and likely to have individual, family and community determinants that can affect their development. Clinicians should describe these set of circumstances as opposed to medicalising or pathologising the young person. Several authors have examined the difficulties that may arise from applying diagnostic criteria in an unthinking way (Khoury et al., 2014, Clark et al., 2017). Misdiagnosis can also be a problem if it results in inappropriate or incorrect interventions.

The NHS nationwide study found that:

• conditions are more common in older children especially teenage girls
• amongst younger children, boys are almost twice as likely to have a mental health condition compared to girls
• boys are more likely to have conditions which ‘externalise’ symptoms that present as behavioural disorders that mean they are likely to have more contact with police as a result of youth offending, rather than with health services
• girls are more likely to have conditions which are ‘internalised’, such as emotional disorders
• in pre-school children aged 2-4 years, 1-in-18 (5.5%) had a disorder; of these, half were behavioural disorders (mainly oppositional defiant disorder). Autism spectrum was also identified in 1.9% of these very young children.

This data indicates that there has been an increase in mental health condition rates for children and young people over the past decade, rising to 12.8% from 9.7 % in 1999 and 10.1% in 2004. Since these figures provide a snapshot taken at one point in time, the actual number of children who will have a condition at some point in their childhood will be far greater than the 1-in-8 indicated in the study. All of which highlights the pressing need for specialised clinical services.

Additionally, support at a lower level is required for those children with emerging conditions who have not reached the required clinical threshold, or who have needs across health and social domains where the aggregated impact can lead to significant difficulties or periods of crisis. For example, children and young people who have emotional/behavioural challenges in a difficult family/social context are often not seen by statutory CAMHS services but will be seen by nurses in other settings such as LAC medicals, A&E, and health visitors for younger ones.

The picture in Scotland is very similar. A literature review undertaken by the Scottish government in 2018 identified a decline in the mental wellbeing of adolescents across a number of indicators, particularly among teenage girls.

The Scottish adolescent lifestyle and substance use survey (SALSUS, 2018) found an increase in the proportion of 15 year old girls reporting high levels of emotional and behavioural difficulties in the last decade. In 2015, nearly 4-in-10 (39%) of 15 year old girls had a borderline or abnormal total difficulties score, compared to 31% in 2006. Among 15 year old boys, 22% had a borderline or abnormal total difficulties score in 2006, compared to 28% in 2015. The findings of the Health behaviours in school-aged children (HBSC) survey reveal that nearly a quarter of Scottish adolescents (23%) experienced two or more psychological complaints within the past week, with difficulty sleeping being particularly common. The proportion of 13 year olds, and particularly 15 year old girls, reporting psychological health complaints has increased substantially since 2006 (Currie et al., 2015).

The reasons for these increases in England and Scotland over the past 15 years as described above are multifactorial and require further investigation, but the explosive increase in the use of social media and peer group influence over this time scale are likely to be particularly important factors. Furthermore, young people are nowadays more keen to destigmatise their mental health issues and are more willing to identify and speak about their problems ; celebrities and other role models are coming forward to publicise and raise awareness of mental health issues; and “parity of esteem” within the health system has rightly provided an opportunity for appropriate attention to be given to mental health issues. All these factors may have contributed to the rise in reported numbers of young people with mental health difficulties. The Covid pandemic is also likely to have worsened the picture.

In Northern Ireland, the Children’s Commissioner’s review (NICCY, 2015) found more than 20% of young people suffer significant mental health problems by the time they reach 18 of age. The Northern Ireland youth wellbeing prevalence survey provided data on more than 3,000 children and young people and more than 2,800 parents and found that 1-in-8 children and young people (12.6%) had an emotional disorder such as anxiety or depression.

Studies of adult populations indicate that Northern Ireland (NI) has 25% higher rates of common mental health disorders than England, Scotland, or Wales (Bunting et al., 2020). Indicators for poor mental health include disproportionately higher rates of suicide in NI within under 18s compared to other parts of the UK, increasing anti-depressant prescription rates for 0-19 year olds, increasing self-harm rates for 0-18 year olds and self-reported poor emotional wellbeing.

More detail on the prevalence of specific mental health conditions is provided in Section 4.

It is crucial that wherever services are provided for children and young people, the environment must be appropriate to meet their holistic needs. Children and young people should not be cared for in an adult environment, and care settings should be made confidential and child/young person friendly.

Individual nurses, midwives and health visitors have a responsibility to ensure that a child or young person is only admitted where necessary, and if required, to an area that is conducive to meeting their specific needs. Services should be combined to provide integrated provision across all health care sectors and must include local provision initiatives that will give rural communities access to these services.

In particular, greater attention needs to be given to how those aged 16-18 make the transition to adult services. There is emerging evidence that providing youth mental health services increases positive health outcomes significantly (Broad et al., 2017). It is therefore important to ensure the development of such services is given serious consideration.

Department of Health (England) policy identified in Future in mind places the mental health needs of children, young people, and their families as an integral part of any children’s service (DH, 2015). All staff should understand how to assess and address the emotional wellbeing of children, be able to identify significant mental health problems, and liaise with the appropriate services in relation to:

• the management of overdoses and deliberate self-harm
• an acute psychiatric crisis
• direct clinical work
• complex cases
• child protection cases
• long term and life-limiting illness
• the death of a child.

Local policies should give clear guidance to practitioners regarding referral and the support available to them. Child and Adolescent Mental Health Services (CAMHS) are the recognised specialised service for supporting children and young people with mental health problems. However, it is not the responsibility of these specialist services alone. Children and young people need to be supported via help in schools and communities (often referred to as lower level services) and other lower level mental health services.

There are local variations in the services provided and differences in referral procedures across the four nations. It is therefore imperative that individual practitioners familiarise themselves with the procedures relevant to their clinical area.

2.3.1. Specialist services for CYP

CAMHS are provided through a network of services organised in four tiers and the roles of the different tiers in England are shown below. Similar arrangement exist in Wales, Scotland and Northern Ireland and references for the other UK nations are given below. It is also important to recognise and understand that how services are designed, developed and delivered changes over time. There are areas within England that are moving away from the Tier model in favour of the Thrive model (Wolpert et.al, 2019),

Tier 1

Services provided by practitioners in universal services (such as early years services, primary care, health visitors, school nurses, teachers, and youth workers) who are non-specialists and who can:

• offer general advice and in certain cases
• provide treatment for less severe problems
• promote mental health
• aid the early identification of problems
• refer to specialist services.

Tier 2

A service provided by specialist individuals such as youth offending teams, primary mental health workers, and school and youth counselling (including social care and education) who offer:

• training and consultation for other professionals
• consultation for families and carers
• outreach to families and children requiring more help and who are unwilling to use specialist services
• assessment, which may trigger further treatment.

Tier 3

A specialist multi-disciplinary service for more severe, complex, or persistent disorders, offering:

• assessment and treatment
• assessment for referrals to Tier 4
• contributions to consultation and training at Tiers 1 and 2
• participation in research and development projects.

Tier 4

These are specialist tertiary services comprised of:

• day units
• highly specialist inpatient and outpatient services.

A 2020 report by Anne Longfield, the Children’s Commissioner for England, found that more than one-third of children who are referred to community CAMHS are not accepted for treatment and waiting times for admission can be up to four months. Additionally, those young people not accepted by CAMHS may have higher rates of behavioural disorders. Over the preceding year the report found that 377, 866 children accessed CAMH Services. Given that 12.8% of children have a diagnosable mental health condition, this equates to over 1 million children who need support overall and, the Commissioner concluded, too few children are getting help. The NHS long term plan (NHS, 2019) contains a commitment to treat 500,000 children by 2024-2025.

Similar concerns have been raised in Scotland, where there has been a 24% increase in the number of rejected referrals for CAMHS services between 2013-2014 and 2017-2018, and over 25% of CYP referred to specialist services wait longer than 18 weeks to start treatment. The government Green paper (2017) commits to providing school mental health support teams (MHSTs), who will be NHS trained, in 20-25% of areas by 2024. Meaning that an additional 80,000 children will be able to get specialist evidence-based interventions through MHSTs (see also Section 2.5). The Scottish government has committed to addressing the increasing pressures on CAMHS services through policy reforms and investment, including increased mental health first aid training in schools, a commitment to ensuring every secondary school has access to a counselling service, and 250 additional school nurses.

In Northern Ireland, the action plan published in 2019 in response to the Still waiting report will see important policy changes in children and young people’s mental health services.

Likewise in Wales, the Welsh assembly’s recommendations in response to the Mind to matter report and the Together for children and young people programme (T4CYP) will transform children’s experiences of mental health care.

2.3.2 Other sources of help and support for children and young people

As only one-third of children with diagnosable mental health conditions are currently treated by NHS mental health services, this leaves about 760,000 children with a significant mental health issue requiring additional support. However, there is no standard model of how this additional lower level of service can be provided.

The Children’s Commissioner (2020) reports that most schools believe that they have an ethos that promotes good mental health. Many provide some form of in-house counselling from within their core budget, but a much lower percentage have a clinical model such as cognitive behavioural therapy (CBT) to support their approach. Children presenting with significant behavioural difficulties within school may not always have their underlying mental health or emotional needs identified at this level and may therefore miss out on this early help support.

Local NHS bodies (CCGs), local authority children’s services and local authority public health teams can all contribute to the provision of lower level help for children. However, the Children’s Commissioner’s report notes that what is available to children is dependent on a number of different people – for example, head teachers, directors of children’s services, local councillors - and so provision can be variable and not joined up.

There is also a significant population of children (perhaps 1 million according to the Children’s Commissioner report) with pre-diagnosable mental health conditions who also need this lower level support. Provision of in-school counselling delivered either 1-to-1 or in groups (for example, group art therapy, group CBT), training on mental health issues and coping strategies and advice to parents/carers, are likely to provide benefit to these types of cases. However, this relies on those young people being in full time education and so may not capture those young people who experience repeated exclusions or who struggle to attend education full time for other reasons. Few services include involving parents /carers in the process.

2.3.3 Involving young people in shaping service provision

There is an expectation that young people will participate in the development and construction of the services that they use and this is intrinsic to the operating framework of the NHS across the UK. This requires creative engagement with children and young people and it may be an opportunity to work across other disciplines such as art, music, and play, which can be useful tools in engaging children and young people’s views. Organisations such as YoungMinds and the Mental Health Foundation have substantial experience in this area and can be a good source of information and advice.

Children are often happy to express their views but will need to be informed and prepared before formal consultations. Bringing their expert patient view to the clinical process, children need to know that their views will be taken on board and understand any limits to their participation, such as restrictions because of health and safety, clinical safety, or costs. Parents, siblings, and carers can also provide a unique contribution from their experience as well as being a representative of the child’s view.

Using technology will allow children to engage through communication channels that are familiar to them, can be made fun, and can allow a degree of privacy to their feedback or evaluation of services.

2.3.4 Parents and carers

Parents whose children have never experienced worries, fears, bullying, sadness, problems with friendships and bereavement are in the minority. Parents of a child that has mental health difficulties are often made to feel it is their fault, and as a result they do not tell anyone. It is common for parents and carers to feel isolated and alone in trying to deal with their child’s problems.

In some instances issues such as family breakdown, poverty and parenting difficulties may have contributed to the child or young person’s problems. However, practitioners should remain non-judgmental in their approach to parents and carers, aiming instead to support and assist them. Several charities offer specific help to parents and carers and knowledge of these organisations can be useful. Details of useful websites can be found in the final section of this document.

2.3.5 Integrated working across and between services

As described in Section 2.3.1, services for children and young people are provided by a variety of health care professionals and agencies. The integration of health and social care services, including some children and young people’s services began in Scotland in 2014. Many integrated joint boards (IJBs) have significantly integrated children’s mental health services, and all place a specific importance on early prevention in this area. To guide further integration, the Framework for community health and social care integrated services was published in 2019.

A whole systems approach is being advocated in many settings, including the SECURE STAIRS reform within the children and young people’s secure estate, and was recommended as essential to the delivery of safe and effective care in the CQC Are we listening? report (CQC, 2018). This includes all agencies working together with the child and family, and ensuring appropriate information is shared in a timely and effective manner.

The GIRFEC (Getting it Right for Every Child) national practice model (Scottish Government, 2016) is an approach to working with and supporting children and young people which emphasises the responsibility of all services working together to ensure all children get appropriate support, by providing a set of indicators of wellbeing. Universal services such as health and education are often the main and first point of contact and often work with a preventative approach, which national policy is driving forward, such as with the National improvement framework and improvement plan 2020 and the Mental health strategy 2017-2027 in Scotland. When a mental health problem is identified, referrals are then made into services such as child and adolescent mental health services or voluntary services.

All those working with children and young people need appropriate education and training, albeit at different levels, in the following areas, and according to the country they practise in:

• child protection (local policy as well as national)
• education on mental health
• the Children’s Act
• mental health legislation
• other legal frameworks such as the Education Act.

Training under the Improving Access to Psychological Therapies (IAPT) programme is also available. The programme began in 2008 and has transformed the treatment of adult anxiety disorders and depression in England (NHS England, 2014).

Clear referral pathways are vital to ensure that services work seamlessly to offer support to children and young people. Supervision and joint working contribute to the level of care given and enable nurses to deliver the appropriate intervention at the right time and to share knowledge and skills. Supervision and consultation may be offered by specialist service providers in Tiers 2, 3 and 4 to those providers in Tier 1. Policy partners and service leads need to work together across services to ensure that early intervention is a core part of services and that when needed there is access to Tiers 2-4 services.

Recently, in respect of using police cells to detain children and young people, changes were made to the Mental Health Act 1983 by the Police and Crime Act 2017. This now bans the use of police cells as a place of safety for the under 18s. Likewise, detaining or admitting young people to adult mental health facilities is an issue of concern.

In addition to the capacity issues for service provision, which were severely stretched during the COVID 19 pandemic in 2020, there are other important issues for CYP mental health provision that need to be addressed in the future.

In March 2018, the Care Quality Commission (CQC, 2018) published its review report of CAMHS entitled Are we listening? The report found that:

• the quality of CYP mental health (MH) services (including those CYP in care) varied across England
• there were problems around access, a lack of coordination, pressure on staff and a lack of resources.

Recommendations made included making CYPMH a national priority, making local organisations work together, and providing training to encourage good mental health and offer basic support to all everyone e that works, volunteers or carers of children and young people (CQC, 2018). These recommendations were taken forward in the government Green paper (2017) (see also Section 2.5).

Additionally, in recent years emerging concerns such as transgender issues, adverse childhood experiences, the role of social media, and parity of esteem will need to be considered in future CYPMH service provision and these are discussed in more detail in Section 3.

Audit Scotland’s 2018 report on CYPMH services concluded that not enough emphasis was being placed on early intervention and that services were complex and fragmented. The report also recommended improvements in data about existing services and the prevalence of mental health issues amongst CYP in Scotland (Audit Scotland, 2018).

In 2015 the Future in mind report (DH, 2015) outlined how CYP mental health care might be improved by 2020. This was followed up by specific plans contained in the NHS Five year forward view for mental health report (2016) and led to publication of Children and young people’s mental health green paper (2017).

The important changes to CYPMH provision that resulted were:

• schools to identify a designated senior lead for mental health
• CYPMH services to identify a link for schools
• government funded mental health support teams (MHSTs) for specific extra capacity for early intervention
• MHSTs to be managed jointly by schools, colleges, and the NHS
• additional service provision for young people with a complex high risk presentation through the implementation of FCAMHS (community based forensic CAMHS) and SECURE STAIRS (a trauma informed whole systems approach to care with the secure estate).

The NHS long term plan (NHS, 2019) supported these improvements in CYPMH provision and committed the government to grow CYPMH spending faster than both overall NHS funding and mental health spending. This continued investment in community mental health services for children and young people estimated that by 2024 an additional 345,000 CYP will be able to access support via NHS specialist services and school MHSTs. Following a 2019 pilot in 225 schools, MHSTs are now being rolled out and will cover 25% of the country by 2023 (1,200 schools). There will also be extra investment in CYP eating disorder services, and a single point of access available 24/7 through the NHS 111 online and phone helpline for children and young people experiencing mental health crisis.

The NHS long term plan also includes measures to extend current service models for those aged 0-18 to cover those aged 0-25, making it possible to extend reach across the mental services for CYP and adults.

The Scottish government’s Mental health strategy 2017-2027 includes an aim to achieve parity between physical and mental health (see below). An independent review into mental health law in Scotland has also been commissioned and although it is focusing on legislation which mainly affects adult mental health services, its findings will have implications for children and young people too. There are also plans to establish a 24/7 crisis service for children and young people, which is being developed by partners and the CYP Mental Health and Wellbeing Programme Board.

The term ‘parity of esteem’ describes the need to value mental and physical health equally. Nursing professionals across the four nations have a crucial role to play in ensuring equality of service delivery across both aspects (RCN, 2019).

Evidence has demonstrated that people with serious poor mental health die 15 to 20 years earlier than the rest of the population (WHO, 2015). Additionally, children who experience a serious or chronic illness are twice as likely to develop emotional disorders (Brady, 2020).

Parity of esteem was enshrined in the Health and Social Care Act 2012. In February 2016, the Five year forward view for mental health (NHS, 2016) made a set of recommendations for the six NHS arm’s length bodies to achieve the ambition of parity of esteem between mental and physical health. The NHS long term plan (NHS, 2019) outlines a programme of service expansion and improvement to deliver this parity. A parity approach enables NHS and local authority health and social care services to provide a holistic response to the individual’s needs, with their physical and mental health needs being treated equally.

Several barriers will need to be overcome to achieve this parity. One of these is stigma arising from either ignorance, prejudice, or discrimination, which can stop people with serious mental health problems getting treated with the same vigour as those with physical illness. Other barriers include inadequate diagnosis (mental health problems are less likely to be diagnosed than physical health conditions), socio-economic factors, and poorer access to services.

There are opportunities for nurses and nursing teams to get involved in this programme of work (RCN, 2019).

While bullying is common, it should always be viewed as unacceptable as it can seriously affect a child or young person’s mental health. Bullying can be physical or psychological. It can take various forms such as teasing, name calling, hitting, kicking, telling nasty stories or social exclusion. Children and young people with neurodevelopmental difficulties (such as autism or a learning disability) are more likely to be bullied but are often less able to disclose this to the appropriate adult (Toseeb et al., 2020).

The YMCA England and Wales’s In your face report (YMCA, 2018) found that half of children aged 11-16 have been bullied about the way they look, with 40% targeted at least once a week. According to the survey, most of the bullying focuses on weight and body shape, which lays bare the devastating effect it can have on victims. More than half (53%) of young people who experienced bullying based on their appearance said they had become anxious as a result and 29% had become depressed; 1-in-10 said they had had suicidal thoughts and 9% that they had self-harmed.

Nurses need to consider the context that young people are engaging with the internet and their motivations for doing so. Professional colleges across the four nations have developed guidance around this issue along with advice to parents and carers (RCPsych, 2020).

There are some signs and symptoms that can indicate a child or young person is being bullied. These include:

• unexplained scratches and bruises
• crying themselves to sleep
• nightmares
• depression
• self-harm
• headaches
• abdominal pain
• fear of walking to or from school
• school refusal or truancy
• poor school performance
• change in behaviour, for example social isolation.

It is important for practitioners to be aware of these signs and to ask a child directly, either alone or with their parents, whether they have been bullied. Questions you can ask include:

• Have you been bullied?
• Has anyone at school been horrible to you?

Be suspicious, even if the child says no. Although the school should deal with the bullying, the child or young person’s emotional or behavioural symptoms may mean referral to a mental health specialist is needed.

There is a growing number of trans young people presenting to mental health services. Trans is an umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth (Stonewall 2019). Gender dysphoria is a term used to describe the psychological and emotional distress which a person feels regarding their assigned gender and their identification with a gender other than that associated with their birth sex.

A review of the mental health of transgender youths (Connolly et al., 2016) found that they have high rates of depression, suicidality, self-harm and eating disorders compared to their non-transgender peers. As is the case with any at risk population, a lot of these young people can also be resilient and not exhibit a high degree of co-morbidity or co-existing problems.

Young people attempting to access specialist health services often experience lengthy waiting times, and treatments have not as yet been subject to high quality research scrutiny. Nurses therefore need to be aware of good practice guidance in this uniquely challenging area.

Those nursing working outside of the mental health field need an improved understanding and the knowledge and skills in reducing the gap and acknowledge the interdependence of good physical and mental health.

Useful guidance has been published in Northern Ireland (Education Authority Northern Ireland, 2020), Scotland (Scottish Government, 2018) and by the charity Stonewall.

There are still many controversies and debates about treatments for gender dysphoria and there is insufficient research to assess their long-term outcomes. At present, treatment options involve a combination of psychological and physical interventions. Before any physical interventions are considered, a comprehensive assessment and exploration of the individual’s psychosocial and family issues should be undertaken by an appropriately trained mental health profession (Butler et al 2018). The Tavistock legal judgement of 2021 has also clarified the question of competence for those under 18 who are seeking to use puberty blockers.

Nurses also need to act as allies by creating a safe space to support children and young people through their journey and allow them to explore their gender identity in a non-judgemental and supportive environment. Services still need to develop supportive pathways and onward referral; useful guidance in this area was published in 2015 by the American Psychological Association.

Adverse childhood experiences (ACEs) are traumatic events that effect children’s growth and development. These include neglect, maltreatment, domestic violence or growing up in a household with adults with mental health problems, criminality or drug and alcohol problems.

A key large scale study of the impact of ACE, conducted in the USA between 1995 and 1997, identified a link between childhood experiences and adult health and wellbeing outcomes. The findings of this research resulted in the development of the ACE Pyramid (CDC, 2016).

The pyramid identifies event stages which may arise in the lifespan (between conception) and death with fewer and fewer individuals being affected at each succeeding stage:

ACE
↓
Disrupted neurodevelopment
↓
Social emotional and cognitive impairment
↓
Adoption of health risk behaviours
↓
Disease, disability and social problems
↓
Death

ACEs are quite common and are not confined to deprived and underprivileged families. In fact young people at risk are a heterogenous group that includes those from middle class families. A strong correlation has been identified between the more ACE experienced and a greater chance of poor outcomes in later life, including dramatically increased risks of physical health problems and poor academic achievement.

For examples, children who experience four or more adversities are twice as likely to binge drink, and eleven times more likely to go on to use crack cocaine or heroin, with consequent impacts upon their mental health (YoungMinds, 2018).

In the early 2000s the National Scientific Council for the Developing Child coined the term toxic stress in relation to how ACEs can affect physiological development (for example, brain architecture) and trigger biological events that can lead to such outcomes (National Scientific Council for the Developing Child, 2014). The effects of excessive activation of the stress response system can have a wear and tear effect on the body. In addition to individual and family factors, there are community and systemic ACEs, such as violence in the child’s community.

Nurses need to be aware of the five principles of trauma informed care: safety, choice, collaboration, trustworthiness and above all empowerment. Nurses in the frontline need to engage with the battle against the toxic stress associated with ACEs in young people.

It is also recognised that people who have experienced significant adversity in childhood are not irreparably damaged. There is a spectrum of potential responses that can mitigate against such risks.

Nurses need to be well versed in the role played by protective factors and understand the practice of trauma-informed care. ACE-based screening and referral is becoming common practice in services. As is the case with all mental health difficulties, the parent/carer can buffer a child from the effects of stress by developing the building blocks of resilience. For further four country advice and information, see:

• England
• Northern Ireland
• Scotland
• Wales

4.1.1 What is good mental health?

Mental health is everyone’s business. As No health without mental health states; “good mental health and resilience are fundamental to our physical health, our relationships, our education, our training, our work and to achieving our potential” (DH, 2011).

According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realizes 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” (WHO, 2004).

The mental health of the child, young person and their family should be an integral part of all children’s services, and not overlooked when a physical health disorder takes priority (DH, 2004). In children and young people, good mental health can be indicated by being able to:

• develop emotionally, creatively, intellectually and spiritually
• initiate, develop and sustain mutually satisfying personal relationships
• face problems, resolve them and learn from them in ways appropriate for the child’s age
• develop a sense of right and wrong
• be confident and assertive
• be aware of others and empathise with them
• enjoy solitude
• play and learn.

(Mental Health Foundation, 2020)

Following the Children’s Health Outcomes Forum report in 2012 in England the DH response included a commitment to: “Improve the mental health of our children and young people by promoting resilience and mental wellbeing and providing early and effective evidence-based treatments for those people who need it” (DH, 2013).

The notion of “wellbeing” has been placed on a statutory footing in Scotland by the Children and Young People (Scotland) Act 2014. Eight indicators of wellbeing are referred to (safe; healthy; achieving; nurtured; active; respected; responsible; included). Scottish government draft guidance defines ‘healthy’ as “having the highest attainable standards of physical and mental health, access to suitable healthcare, and support in learning to make safe, healthy choices.”

4.1.2 What is mental ill health?

It is now common to differentiate between mental health problems and disorders, the former being regarded as less severe. However, mental health problems can be distressing to the child and its family, resulting in their seeking help from a health care professional. Problems may include:

• sleeping difficulties
• eating difficulties
• unhappiness
• bed wetting that does not have a physical cause
• faecal soiling without a physical cause
• over-activity
• tantrums, oppositional and defiant behaviour
• psychosomatic symptoms – for example, abdominal pain without a physical cause.

Mental health disorders include:

• conduct disorders - for example, persistent or extreme defiance, physical and verbal aggression, vandalism, oppositional defiant disorder (ODD)
• emotional - for example, phobias, anxiety, depression, or obsessive compulsive disorder (OCD)
• neurodevelopmental disorders - for example, attention deficit hyperactivity disorder (ADHD) or autistic spectrum disorders (ASD)
• eating disorders - for example pre-school eating problems, anorexia nervosa and bulimia nervosa
• substance misuse problems
• post-traumatic stress disorder
• psychosis
• emotional and unstable personality disorder (EUPD)
• self-harm and suicidal ideas and actions.

Children rarely present with one disorder, for example a conduct disorder along with an emotional disorder. For more information, visit the Royal College of Paediatrics and Child Health (RCPCH) website.

4.1.3 Risk and protective factors

Any child can experience mental health problems and factors relating to a child’s personality, family, socio-economic status, or environment can put some children and young people at greater risk of developing mental health problems than others.

For example, children and young people in special circumstances or those with learning difficulties and/or disabilities can be at greater risk. For these children and their parents or carers, the provision of early intervention may make a significant difference.

Knowledge of the factors that can increase the risk of problems developing or being sustained is important when considering how to improve the mental health of children and young people.

Child risk factors include:

• poverty
• family breakdown
• single parent family
• parental mental ill health
• parental criminality, alcoholism, or substance abuse
• overt parental conflict
• lack of boundaries
• frequent family moves/being homeless
• over protection
• hostile and rejecting relationships
• failure to adapt to the child’s developmental needs
• academic failure
• death and loss, including loss of friendships
• caring for a disabled parent
• school non-attendance.

Family risk factors include:

• learning disability
• abuse
• domestic violence
• prematurity or low birth weight
• difficult temperament
• physical illness
• lack of boundaries
• looked-after children
• lack of attachment to carer
• academic failure
• low self-esteem
• shy, anxious, or difficult temperament
• young offenders
• chronic illness.
• inconsistent discipline
• death/loss.

(Scottish Government, 2020)

External risk factors include:

• school - unclear discipline, failure to recognise children as individuals
• bullying – including cyber bullying
• peer rejection/peer pressure
• school exclusion including school refusal.

It is also valuable to understand the protective factors that can help promote and sustain good mental health.

Protective factors include:

• a good start in life and positive parenting
• being loved and feeling secure
• living in a stable home environment
• parental employment
• good parental mental health
• activities and interests
• positive peer relationships
• emotional resilience and positive thinking
• sense of humour
• full engagement with education
• being female
• good communication and problem solving skills
• capacity to reflect and learn from setbacks.

4.1.4 Promoting good mental health

“Social and emotional wellbeing creates the foundations for healthy behaviours and educational attainment. It also helps prevent behavioural problems (including substance misuse) and mental health problems. That’s why it is important to focus on the social and emotional wellbeing of children and young people.” (NICE, 2013)

All children and young people, and their parents or carers, require access to information and supportive environments to ensure that the child or young person’s mental health is promoted.

“Two key skills are necessary for positive mental health – learning to cope and even prosper in the face of adversity and the ability to create feelings of happiness through healthy, positive means… If children and young people have pleasure, engagement and meaning in life, they are likely to experience happiness, life satisfaction, wellbeing and lead more flourishing lives.” (Ward, 2008)

Good practice towards achieving this includes:

• the ability of frontline staff to access support and advice from specialist child and adolescent mental health services (CAMHS) and other children’s services to aid the early identification and support of those with mental health difficulties - these include social workers, behaviour specialists, educational psychologists. school nurses and specialist support staff
• local protocols for referral
• ensuring that local needs’ assessments identify children in special circumstances – including those who are homeless, seeking asylum, misusing substances, living in young offender settings and those ‘looked after’, not attending school – and that services are in place to meet their needs
• an emphasis on children and young people who are vulnerable to mental health problems and on providing focused, structured, proactive programmes which target risk factors, using a common assessment framework as appropriate
• specific activities such as tackling bullying (including cyber bullying) and increasing awareness of mental health issues
• promoting lifestyles that protect children and young people from mental health problems.

“School nurses are at the cutting edge of modernising ways of conducting assessments and brief interventions with on-line assessments and access to confidential services via websites, social media and text messaging blended with more traditional means of working such as face to face consultations with children, young people and families.” (DH and PHE 2014)

Examples of interventions by school nurses are provided in a separate RCN publication (RCN, 2017a).

4.2.1 Introduction

The prevalence of mental health disorders in children and young people (NHS Digital, 2017) has been summarised in Section 2.2. The following sections present specific information on mental health disorders that are frequently encountered in children in young people.

The list provided is not intended to be definitive and reference to other disorders, causes, help treatment, additional references and case studies can be found at Royal College of Psychiatrists website and in the Public Health England report The mental health of children and young people in England (PHE, 2016).

4.2.2 Anxiety

Anxiety disorders are the most common mental health problem affecting children and young people. These include generalised anxiety disorder (GAD), panic disorder, obsessive -compulsive disorder, social phobia and agoraphobia.

It is estimated that 4.4% of 11-15 year olds and 2.2 % of 5–10 year olds experience this problem (PHE, 2016). Many children have times when they feel frightened about things, and it is a normal part of growing up. Teenagers may be moody and worried about how they look, what other people think of them, and how they get on with people in general, particularly the opposite sex (see the Royal College of Psychiatrists website).

Although there are many possible causes of anxiety, practitioners should be aware of links with street drugs, such as amphetamines, LSD, ecstasy and cocaine; 40% of children and young people have a substance misuse disorder (PHE, 2016).

Anxiety is a sense of worry, apprehension, fear, and distress. Symptoms can be both physical (for example, a headache or nausea) and emotional (feeling nervous or afraid) and the child or young person’s thinking, decision making, learning and concentration can be adversely affected.

Anxiety can lead to depression in later life and suicidal behaviours. In addition, anxiety can lead to physiological changes, such as a raised blood pressure and heart rate, vomiting, pain and diarrhoea. Consequently, persistent and intense anxiety that is disruptive to everyday life requires attention.

Nurses working with children and young people, particularly school nurses, can help by facilitating the child or young person to talk about the cause of their anxiety, teaching relaxation techniques and giving information on further support. It may be necessary to seek a medical assessment.

4.2.3 Self-harm

Self-harm is a descriptive term used to describe a spectrum of behaviours and a universally agreed definition is not easy to find. Self-harm can have very different meanings for individuals and even different meanings for the same individual in different situations. Essential features are that there is a non-fatal outcome, there is no judgement of the underlying motivation, and the behaviours were initiated by the individual to cause harm to self.

Definitions of self-harm vary from short explanations to longer more detailed descriptions. A preferred definition is the one used by in NICE Guidelines (2004 and 2011); “Self-poisoning or injury irrespective of the apparent purpose of the act.”

• The UK has the highest rates of self-harm in Europe.
• Self-harm used to be a rare event in those aged under 12 but is increasing in primary school children.
• Self-harm increases through adolescent years and significant increases have been observed in adolescent girls aged 13-17 years.
• Nearly 20,000 adolescent presentations to hospital services per year (2015) -this compares to 12,944 in 2009/10 and 14,780 in 2012/13.
• 15% of those who present with self-harm will present with further episodes within a year (Hawton et al., 2012).
• The majority are self-harmers are girls aged 12-15; one quarter of girls aged 14 self-harmed in a year compared to in 1-in-10 boys (Children’s Society, 2018).
• The prevalence in adolescent girls is up to five times higher than in boys – but sex ratio decreases in later years.
• Self-harm and its repetition is a marker for completed suicide Those who have self-harmed are 100x more likely than the general population to die by suicide in the following year (PHE, 2106).
• Self-harm accounts for 150,000 attendances per year at A&E (PHE, 2016).
• About 1-in-10 young people will self-harm (PHE, 2016).

Causes

• Self-harm is a complex behaviour influenced by a range of factors that can contribute to difficulty in regulating emotions.
• Adolescent self-harm is the result of complex interactions between interpersonal, social and psychiatric factors.
• An improved understanding of the meaning of self-harm to young people will help to identify appropriate interventions.
• Self-harm is associated with some underlying conditions such as emotionally unstable personality disorder (EUPD), anxiety and depression and can be a symptom of these and other mental health issues.
• For some it may be the result of experimentation and a part of adolescent identity and self-image and a communication of distress.

Risk assessment

The purpose of risk assessment is to identify those at risk of completed suicide and enable risk management strategies, including treatment interventions, to be put in place. Assessment should always include a consideration of any protective factors and an individual’s resilience.

Risk assessment should take place as soon as possible after an incident of self-harm, when the young person is medically fit and parents/carers are available. Risk assessments are often conducted in a paediatric/medical ward or A&E departments. The interview should always involve an assessment of the young person seen on their own and history from parents/carers. For young people under 16 years of age, admission to hospital must be considered for all young people who overdose.

Risk assessments are often conducted in paediatric/medical wards or A&E departments. It is essential to consider protective factors and resilience. These are the aspects of person’s life that may help to reduce the impact of the risks they are facing.

A list of considerations that a risk assessment should cover are shown below (taken from NICE, 2011):

• methods and frequency of current and past self-harm
• current and past suicidal intent
• depressive symptoms and their relationship to self-harm
• any psychiatric illness and its relationship to self-harm
• the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships.

Immediate management of self-harming

Young people frequently self-harm in crisis. Young people may present to A&E or access urgent assessment at CAMHS. There are national variations but young people under 18 years of age will be assessed by CAMHS services. Young people aged 16-18 may be assessed by adult services out of hours but should be treated by a CAMHS or transition mental health team. Some important features for clinical staff to consider when a child or young person is admitted to A&E include:

• understand your role – the role of a doctor/clinician is to assess physical risk and suicide risk and identify treatable mental disorder
• ensure the safety of the young person
• assess for risk of suicide and involve another person such as a parent/carer or member of young persons’ care team
• what is the formulation of why this young person has presented now?
• is the young person safe to discharge/return home; consider the least restrictive care environment; it is important to seek supervision before discharging any young person from A&E
• if discharged, agree a safety plan and if no services involved consider referral, and arrange for a seven day follow-up
• refer for crisis admission if unsafe to discharge - usually there will be a nurse-led crisis team.

Indications for admission to psychiatric bed include:

• evidence of mental disorder which merits expert assessment
• indications for treatment with medication which can only be administered in hospital
• high risk of physical health deterioration or the need for physical health treatment
• continuing risk despite constant supervision in the community
• lack of engagement from the young person or lack of consent warranting mental health act assessment.

Useful information on self-harm can be found in NICE guidelines (2004, 2011) and in a publication by the Royal College of Psychiatrists (2010). These provide basic knowledge and awareness of self-harm in children and young people, with advice about ways staff in children’s services can respond.

4.2.4 Depression

It is estimated that depression arises in one in every 500 children (0.2%) aged 5-10 and 1.4% of those aged 11-16. About 67,000 CYP in England experience depression and it is more common in girls aged 5-16 (PHE, 2016).

However, children and young people are often unwilling to seek help because of the stigma associated with mental health problems (NICE, 2019). Signs and symptoms of depression can include:

• being moody and irritable – easily upset, ‘ratty’ or tearful
• becoming withdrawn – avoiding friends, family, or regular activities
• feeling guilty or bad, being self-critical and self-blaming
• feeling unhappy, miserable, and lonely a lot of the time
• feeling hopeless and wanting to die
• finding it difficult to concentrate
• not looking after their personal appearance
• changes in sleep pattern - sleeping too little or too much
• tiredness and lack of energy
• changes in appetite
• frequent minor health problems, such as headaches or stomach pains.

Some young people may express or escape from their negative feelings and thoughts through acting recklessly – for example, taking drugs, drinking too much, risky sexual behaviour or getting into dangerous situations. Others who are very depressed can become preoccupied with thoughts of death and may attempt suicide or harm themselves. Many children and young people can be helped by someone who is willing to listen to their anxieties, such as a family member. In addition, telephone help lines, such as Childline, YoungMinds and the Samaritans, are useful.

Clear guidance on managing depression is given in the National Institute for Health and Care Excellence (NICE) publication Depression in children and young people: identification and management (NICE, 2019).

Practitioners working in universal services can care for children and young people with mild depression where the following circumstances apply:

• exposure to a single undesirable event, in the absence of other risk factors for depression
• exposure to a recent undesirable life event in the presence of two or more other risk factors, with no evidence of depression and/or self-harm
• exposure to a recent undesirable life event where one or more family members – parents or children – have multiple-risk histories for depression, providing that there is no evidence of depression and/or self-harm in the child/young person
• mild depression, without co-morbidity.

Health care professionals in primary care, schools and other relevant community settings should be trained to detect symptoms of depression and to assess children and young people who may be at risk. This training should include:

• the evaluation of recent and past psychosocial risk factors, such as age, gender, family discord, bullying, and physical, sexual, or emotional abuse
• co-morbidity disorders, including drug and alcohol use, and a history of parental depression
• the natural history of single loss events
• the importance of multiple risk factors
• ethnic and cultural issues
• factors known to be associated with a high risk of depression, including problems such as homelessness, being a refugee or living in an institutional setting

(NICE, 2019).

4.2.5 Substance misuse

NICE guidance (NICE, 2007) defines substance misuse as: “Intoxication by, or regular excessive consumption of and/or dependence on psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances).”

Many young people experiment with illegal substances such as cannabis or ecstasy at some stage, but only a small number are regular users. Other substances used include other hallucinogens, amphetamines, opiates (heroin and cocaine), and prescription only medicines, such as anti-depressants.

In most instances the young person will not seek help for an addiction but will present with other problems. This may include difficulties at school, signs of depression, inappropriate sexual behaviour or because a parent has become worried.

Some clues may indicate excessive drug use:

• changes in attitude or behaviour – for example, lying or stealing
• mood changes
• deterioration in physical health
• sexually transmitted infections.

It is likely that the young person may not see that they have a problem and seldom want to do anything about their substance misuse. It may be the parents who are expressing concern. In the first instance, harm minimisation to reduce the risks may be the best course of action. This involves giving information to the young person and their family, by providing leaflets, websites, and telephone numbers.

Referral to a drug counselling service may be difficult. It will need the young person to be motivated and services are scarce in some areas.

Vulnerable and disadvantaged children and young people are particularly at risk of substance misuse. Influencing factors may include:

• family members who misuse substances
• behavioural, mental, and social problems
• exclusion from school or truancy
• young offenders
• looked-after children
• homelessness
• commercial sex workers
• black and minority ethnic backgrounds.

For these children and young people, NICE recommends the use of screening tools to identify vulnerable and disadvantaged children and young people under 25 years of age who may be at risk of substance abuse:

• common assessment frameworks
• substance abuse subtle screening inventory – adolescent version (SASSI Institute).

For those at risk, referral to professionals with specialist expertise in delivering community based interventions is recommended.

What you can do:

As a universal practitioner working with children and young people who may be misusing substances, you should be able to provide:

• accurate and age appropriate drug and alcohol information, advice, and education
• support, advice and information for parents and carers
• a referral to another service.

The updated NICE guideline (NICE, 2017) covers targeted interventions to prevent misuse of drugs, including illegal drugs, legal highs and prescription-only medicines. It aims to prevent or delay harmful use of drugs in children, young people and adults who are most likely to start using drugs or who are already experimenting or using drugs occasionally. The guideline includes recommendations for providing skills training for children and young people who are vulnerable to drug misuse.

4.2.6 Conduct disorders

Conduct disorders such as defiance, aggression and anti-social behaviour affect nearly 6% of children aged 5-16. Risk factors include being male, coming from a low income family and children with conduct disorders are likely to have poorer outcomes, being twice as likely to leave school with no qualifications, six times more likely to die before the age of 30, and 20 times more likely to end up in prison (PHE, 2016).

“Behavioural disorders such as conduct disorder and oppositional defiant disorder entail more than a child being occasionally naughty, difficult, stubborn or aggressive; the child has to present with a persistent, repetitive pattern of not sticking to the rules or disobeying socially accepted norms.”
Ryan and Pryjmachuk, 2011

In oppositional defiant disorder (ODD), the child or young person has persistently hostile behaviour that is not aggressive or anti-social. Behaviour problems are common complaints and may be difficult to address. Specific issues in young children include tantrums, aggression, and sibling rivalry.

There are a number of risk factors that can lead to antisocial behaviour. These include:

• attention deficit hyperactivity disorder
• specific learning difficulties – for example, reading or language delay
• poor child-rearing practices
• parent-child interactions that contribute to the persistence of the behaviours
• any form of child abuse
• losses that the child views as important
• school and social influences.

Attention deficit hyperactivity disorder (ADHD) affects 1.5% of children aged 5-16 and equates to 18,900 children (PHE, 2016).

NICE guidance (2013, updated in 2017) recommends that conduct disorders need to be assessed by a psychiatrist, clinical psychologist or other professional with the necessary competence in the area of children and young people’s mental health. Where problems start at an early age, the long-term outcome is usually poor, unless the child gets early and effective treatment. There can be a detrimental impact on the whole family.

Management for conduct disorders can include behavioural, cognitive, and psychosocial skills training, play, and music. Parent training and education programmes are also beneficial. NICE recommends the development of group-based programmes with individual programmes as necessary. These programmes are structured and based on principles of social learning theory. Parent training/education programmes should feature 8-12 sessions which are delivered by trained and skilled facilitators, with supervision.

4.2.7 Psychosis/bipolar disorder

Young people often worry that they may be ‘going mad’ when they are feeling stressed, confused or very upset. In fact, worries like this are rarely a sign of mental illness. Psychosis is when an individual’s thoughts are so disturbed that they lose touch with reality. This type of problem can be severe and distressing.

How common is it?

While psychosis and bipolar disorder are relatively rare before the age of 13, there are as many as 40% of men and 23% of women with psychosis diagnosed before the age of 19. Psychoses affect 1.6 to 1.9 per 100,000 children.

What causes psychosis?

A psychotic episode may signal the presence of another underlying illness. Individuals may also experience a psychotic episode after a stressful event, such as losing a close friend or relative. It can also be the result of:

• a physical illness (like a severe infection)
• the use of illegal drugs (like cannabis)
• a severe mental illness (like schizophrenia or bipolar disorder).

Sometimes it is difficult to know what caused the psychotic event. See the Royal College of Psychiatry website for information that has been created for parents and young people.

4.2.8 Eating disorders

Eating disorders can manifest themselves in a variety of ways. The most serious are anorexia and bulimia nervosa and these, along with eating disorder unspecified are a group of illnesses that cause a person to have issues with their body weight and shape which disturbs their everyday diet and attitude to food. Over 750,00 people in the UK have an eating disorder (PHE, 2016).

Obesity or binge eating disorder (BED) is also an eating disorder but this is not usually regarded as a specific mental health problem.

Anorexia nervosa is determined food avoidance resulting in weight loss, or failure to maintain a steady weight gain related to increasing age. The child or young person is preoccupied with their weight and shape and has a distorted body image. While it has traditionally been seen as affecting mostly teenage girls, the incidence in younger children and boys is increasing.

The young person experiencing bulimia nervosa will have recurrent food binges followed by compensatory behaviour, such as vomiting, laxative use, excessive exercise and fasting; 90% of those affected are female (PHE, 2016).

Other types of recognised eating disorders are ARFID (avoidant restrictive food intake disorder) and OSFED (other specified feeding or eating disorder), previously known as EDNOS (eating disorder not otherwise specified).

Eating disorders can cause severe physical and psychiatric problems and occasionally death. Intervention in the early stages of the illness is more likely to be successful. A person with an eating disorder usually keeps their behaviour secret and may deny the problem if confronted. While eventually someone notices or the person realises they need help, this can take months or even years.

Children and young people with an eating disorder will need specialist care and should be referred to a child and adolescent mental health service as soon as possible. Continuing care may be within a children’s setting, where close links with specialists will be needed. Practitioners should acknowledge that many people with eating disorders find it difficult to engage with treatment. They should also recognise the consequent demands and challenges this presents.

It is important for patients and, where appropriate, carers to be provided with education and information on the nature, course, and treatment of eating disorders.

Some core elements of practice can assist in promoting the wellbeing of children and young people. It is important that practitioners base their practice on the needs of children and young people and seek ways to ensure those needs are identified. Young people have described some of the barriers to their effective use of services:

• services are not well known, accessible, responsive or child centred
• particular issues of access to services due to disability, poverty, ethnicity, being in care (looked after) and sexual orientation.

Successful interaction is important for learning the child or young person’s story and for ensuring appropriate care and management. When working with and assessing young people, nurses need to find a way of interacting that is more than having a chat but is not doing therapy. To do this, nurses must be aware of how they are influenced by their personal belief system and that of the environment. Similarly, they should be aware of cultural issues that may influence their care and judgements.

Active listening involves:

• observing and reading non-verbal behaviour – for example, posture, facial expressions, movement, or tone of voice
• listening and understanding verbal messages
• listening to the whole person, in the context of the social settings of life
• tough-minded listening – accepting that a client’s feelings and visions of themselves are valid.

Obstacles to adequate listening include:

• being distracted
• judging the merits of what’s being said, using our own value system.

As a nurse, midwife, health visitor or HCA you are responsible for safeguarding those in your care and you must respond to any safeguarding concerns. Effective safeguarding is underpinned by two key principles:

1. safeguarding is everyone’s responsibility; for services to be effective each professional and organisation should play their full part
2. professionals and organisations must work in partnership to protect children and adults in need.

These two key safeguarding principles are underpinned by the RCN’s eight principles of nursing practice which encourage a proactive and empowering stance that is desirable in the prevention of safeguarding issues. Here are the key stages to follow:

• identify safeguarding concern
• report the concerns – for most nurses, midwives, health visitors and HCAs this will be in conjunction with partner agencies, and you should use organisational and local policies
• participate in enquiries, debriefing and (where appropriate) in developing a protection plan
• reflect on the outcomes and learning.
• you will need to check the relevant statutory guidance and legislation for the country where you work.

The RCN has published a position statement (RCN, 2016) which clarifies the role and responsibilities of the designated nurse for safeguarding children. The need for clarification is essential given the significant loss of expertise nationally and the subsequent challenge to effective succession planning. The role provides safeguarding, child protection expertise and leadership throughout health and multiagency partnerships. The role is distinct and should not be combined with other designated nurse roles or functions, for example vulnerable adults.

Additionally, roles and competencies for health care staff are fully described in an inter collegiate publication (RCN, 2019). This document provides details of knowledge and skills needed by school nurses and CYPMH nurses to recognise potential safeguarding issues in children and families.

For further information visit the RCN Children and Young People’s safeguarding pages.

Consent is decision-specific. Capacity and competence must be assessed. Capacity is presumed for young people over 16 years unless demonstrated that they do not have capacity. For young people under 16, capacity is not presumed. Parents can consent on behalf of their children if the treatment falls within the zone or scope of parental consent. The Mental Capacity Act 2005 applies to young people over the age of 16.

To consent to any treatment a young person must:

• understand the principal benefits, risks and alternatives to the treatment being proposed
• understand the likely consequences of not receiving the treatment being proposed
• retain the above information for long enough to make an informed decision; and
• make a choice that is free from external pressure and secondary gain.

Gillick competence applies to children under 16, who are not subject to the Mental Capacity Act. A Gillick competent child has sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention. Capacity to consent must be assessed for the decision-making scenario presenting, rather than making blanket assumptions related to chronological age (CQC, 2019). A child needs to be assessed whether they have enough understanding to make up their own mind about the benefits and risks of treatment. It should be noted the term Fraser guidelines is also sometimes used in relation to a young person’s consent to treatment, but these guidelines are specific to contraceptive advice.

Children aged 16-17 are presumed to be able to consent for themselves, although it is good practice to involve their parents. Parents or those with parental responsibility may override the refusal of a child of any age up to 18 years. In exceptional circumstances, it may be necessary to seek an order from the court.

In Scotland, the age of legal capacity is 16 years and is regulated by the Age of Legal Capacity (Scotland) Act, 1991. This Act sets out the current position on the legal capacity of children, including giving or withholding consent to treatment. The law is broadly similar to that in England and Wales but with one important difference; parental consent cannot override a refusal of consent by a competent child. Wherever possible, a child or young person should receive treatment for their mental health problem on a consensual basis. This should be either the child’s own consent (where the child is deemed competent to give it) or with consent from a person with parental responsibility and the co-operation of the child (where the child lacks capacity in relation to the decision in question). A trusting relationship with the child can help to achieve this. It is important to take the child’s view into account, even when you may disagree with them (Article 24, UN Convention on the Rights of the Child; UN, 1989).

In Wales, the Welsh Language Act (1993) gives individuals the right to communicate in their language of choice and local procedures will advise practitioners on the actions that will facilitate this. Where the first language of children, young people and their parents/carers is not English, it is important to ensure their understanding, providing interpreting services and/or written material in an appropriate language.

For further information visit the RCN Consent pages.

Article 12 of the United Nations Convention on the Rights of the Child (UN, 1989) enshrines the principle of self-determination. Nurses should treat any information in confidence, unless the young person consents to it being disclosed. However, the nurse also needs to consider the interests of the young person and where there is significant risk; the information will need to be disclosed. Examples of such situations include:

• abuse
• if the young person is likely to harm themselves, or others are at risk from harm
• if the young person may be involved in serious criminal activity.

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. If a decision is made to share information, the young person should be told.

Children and young people have the right to confidentiality. Where children are competent and have capacity to make decisions about the use and disclosure of information they have provided in confidence, their wishes should be respected. In circumstances where the risks of non-disclosure outweigh the risks of disclosure, confidence may be broken. It is good practice to explain these rules to young people who are competent.

Concepts of mental illness and the understanding of the origins of children’s emotional and behavioural difficulties vary across cultures. Nurses need to be sensitive to these differences and ensure they are equipped with the knowledge to work effectively with different groups represented within the community they serve. The publication Positive steps – supporting race equality in mental healthcare (DH England, 2007) gives the following advice:

• Be prepared to develop friendships with everyone. Be politically astute and politically balanced. Don’t get caught up in race politics. If your own ethnicity differs from that of a client or community member, never feel you have to apologise for that difference.
• Never feel you have to justify who you are. Saying things like, ‘I’m not a racist, some of my best friends are black,’ will only undermine your position.
• A white mental health staff worker is no less equipped to provide a culturally responsive service for black and minority ethnic (BAME) clients than a black or Asian staff worker. Competency and commitment will cross all ethnic boundaries.
• Be prepared to stop, reflect and even start again if necessary. Keep the bigger picture in mind; a few setbacks and defeats don’t mean you won’t succeed in the long term.

Additionally, in line with the RCN’s Equality and inclusion strategy: 2017-2020 (RCN, 2017) the nursing profession needs to be emboldened, empowered, and better equipped to face the challenges of the future with the knowledge that equality, inclusion and human rights is an important building block to securing a better future for the art and science of nursing.

Mental health is every nurse’s business. Therefore, all staff working with children need to be trained in how to recognise significant mental health problems and understand how to manage any connected emotional health needs.

Pre-registration nurses receive comprehensive training within a variety of settings with a diverse range of needs including mental health. The NMC set out learning outcome standards which should be obtained by every entry level nurse. It specifically requires nurses to be able to identify risks and needs in relation to psychological health, and to be to implement a plan of care in partnership with clients.

To enable this, it sets out further standards as supported in Directive 2005/36/EC of the European Parliament. These specifically state that; “Theory and practice learning outcomes must take account of the essential physical and mental health needs of all people, including babies, children and young people, pregnant and postnatal women, adults and older people. This includes people with acute and long-term conditions, people requiring end of life care, people with learning disabilities and people with mental health problems.”

To build on this, and to support post-registration nurses, there is a continued need for targeted education and training in order to:

• ensure evidence-based best practice
• continue to promote mental health pre-registration placements
• develop the skills and knowledge of non-specialist child and adolescent workers
• enable post-registration nurses working at Tier 1 and 2 the opportunity for reflective practice and clinical supervision
• enhance the knowledge and skills of specialist child and adolescent mental health workers
• ensure that all nurses working within specialist child and adolescent mental health services have access to clinical supervision
• provide both general and specialist child and adolescent mental health workers with a flexible framework of learning for progression and professional development.

5.7.1 In England and Wales, relevant legislation includes:

5.7.2 Legislation in Scotland includes:

Children (Scotland) Act 1995 – this safeguards children and young people.

Children and Young People (Scotland) Act 2014 – is a broad piece of legislation which introduces a range of reforms to children’s services and puts elements of existing policy on a statutory footing, including a number of GIRFEC principles. The Act requires a plan to be developed for an individual child if they have a wellbeing need which requires a targeted intervention, and also puts the notion of wellbeing on a statutory footing.

Mental Health (Care and Treatment) (Scotland) Act 2003 – this places a responsibility on health boards to provide for children and young people under the age of 18, who are detained under the Act, or admitted to hospital for treatment services accommodation ‘sufficient to meet the particular needs’. It enables people aged 16 or over to appoint a named person of their choice, authorised to make decisions about their care. For children under 16, the named person is their main carer, or in the case of looked after children, the local authority. It also lays out the principle that the welfare of a child with a mental disorder should be paramount in any interventions imposed on a child.

The Mental Health (Scotland) Act 2015 – has amended the 2003 Act above so that applications may be made to a tribunal to remove a child’s named person where they are not acting in the child’s best interest.

The Adults with Incapacity (Scotland) Act 2000 - Part 5, Medical Treatment and Research and the Mental Health (Care and Treatment) (Scotland) Act 2003 – these both provide for delivering health care to people who lack the ability to make treatment decisions for themselves.

The Age of Legal Capacity (Scotland) Act 1991 – this outlines that someone has the capacity to make decisions about consent from the age of 16. However additional safeguards are in place when a person under the age of 18 is receiving treatment in relation to their mental health. Even under the age of 16, a young person may have the legal capacity to make a consent decision on a health care intervention, provided that they are capable of understanding its nature and possible consequences.

5.7.3 Legislation in Northern Ireland includes:

The Mental Health (Northern Ireland) Order 1986 - currently provides the framework for mental health issues. There is no legislation pertaining to mental capacity.

The Bamford Review of Mental Health and Learning Disability (Northern Ireland) - recommended the introduction of a comprehensive legislative framework to include capacity issues and the needs of children and young people. At the time of writing, this legislation was still being developed.

Audit Scotland (2018) Children and young people’s mental health. Available at www.audit-scotland.gov.uk (PDF).

Biagianti B, Quraishi S and Schlosser D (2018) Potential benefits of incorporating peer-to-peer interactions into digital interventions for psychotic disorders: a systematic review, Psychiatric Services 69 (4), pp.377-388.

BOND (2015) Children and young people with learning disabilities – understanding their mental health, Department of Education and YoungMinds, available at www.mentalhealth.org.uk (PDF).

Brady AM (2020) Chronic illness in childhood and early adolescence: a longitudinal exploration of co-occurring mental illness, Development and Psychopathology, 33(3), pp.885-898.

Broad KL, Sandhu VK, Sunderji N and Charach A (2017) Youth experiences of transition from child mental health services to adult mental health services: a qualitative thematic synthesis, BMC Psychiatry, 17, p.380.

Bunting L, McCartan C, Davidson G, Grant A, McBride O, Mulholland C, Murphy C, Schubotz D, Cameron J and Shevli M (2020) The youth wellbeing prevalence survey: the mental health of children and parents in Northern Ireland, Belfast: HSCB. Available at www.hscboard.hscni.net.

Butler G, De Graaf N, Wren B et al (2018) Assessment and support of children and adolescents with gender dysphoria. Archives of Disease in Childhood. 103, 7, 631-636. doi: 10.1136/archdischild-2018-314992

Children’s Society (2018) Good childhood report 2018, cited in The Guardian (29 August 2018). See www.theguardian.com (news article).

Clark LC, Cuthbert B,Lewis- Fernandez, R Narrow WE and Reed GM (2017) Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC) Psychological Science in the Public Interest 8(2) 72–145

Collishaw S, Maughan B, Goodman R and Pickles A (2004) Time trends in adolescent mental health, Journal of Child Psychology and Psychiatry, 45 (8), pp.1350-1362.

Connolly M, Zervos M, Barone C, Johnson C and Joseph C (2016) The mental health of transgender youth: advances in understanding, Journal of Adolescent Health, 59(5), pp.489-495.

CQC (2018) Are we listening? Review of children and young people’s mental health services, Care Quality Commission (Guildford). Available at www.cqc.org.uk (PDF).

CQC (2019) Brief guide: capacity and competence to consent in under 18s, Guildford: Care Quality Commission. Available at www.cqc.org.uk (PDF).

Currie C, van der Sluijs W, Whitehead R, Currie D, Rhodes G, Neville F and Inchley J (2015) Findings from the HSBC 2014 survey in Scotland: health behaviour in school-aged children. A World Health Organization collaborative cross-national study (HSBC) with Glasgow Caledonian University. Available at www.gcu.ac.uk (PDF).

Department of Health (2001) Seeking consent. Working with children, London: DH.

Department of Health (2004a) NHS knowledge and skills framework (NHS KSF) and the development review process, London: DH.

Department of Health (2006) Tackling the health and mental health effects of domestic and sexual violence and abuse, London: DH.

Department of Health (2007) National service framework for children, young people and maternity services. The Mental health and psychological well-being of children and young people, London: DH. Available at http://webarchive.nationalarchives.gov.uk.

Department of Health (2007) The NHS KSF dimensions, levels and indicators (appendix 2), London: DH.

Department of Health (2013) Annual report of the chief medical officer 2012. Our children deserve better: prevention pays, London: DH. Available at www.gov.uk (PDF).

Department of Health (2013) Improving children and young people’s health outcomes: a system wide response, London: DH.

Department of Health (2015) Future in mind: promoting, protecting and improving our children and young people’s mental health and wellbeing, London: DH. Available at www.assets.publishing.service.gov.uk (PDF).

Department of Health and Public Health England (2013) Promoting emotional wellbeing and positive mental health of children and young people, London: DH and PHE. See also the PHE blog by Viv Bennett (online).

Department of Health and Public Health England (2014) Maximising the school nursing contribution to the public health of school-aged children. Guidance to support the commissioning of public health provision for school aged children 5 to 19, London: DH and PHE.

Department of Health Northern Ireland (2020) COVID-19 mental health response plan: annex to the NI mental health action plan, Belfast: DHNI. Available at www.health-ni.gov.uk.

Education Authority Northern Ireland (2020) Supporting transgender young people. Guidance for schools, EOTAS centres, and youth service on supporting transgender young people, Belfast: EANI. Available at www.eani.org.uk (PDF).

European Union (2005) Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications.

Glasper EA and Richardson J (editors) (2006) A textbook of children’s and young people’s nursing, London: Churchill Livingstone Elsevier.

HM Government (2011) Early intervention: The next steps. Available at wwwldwp.gov.uk (PDF).

HM Government (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages.

HM Government (2017) Transforming children and young people’s mental health provision: a green paper, London: DHSC and DoE. Available at www.gov.uk (PDF).

Kelly Y, Zilanawala A, Booker C and Sacker A (2019) Social media use and adolescent mental health: findings from the UK millennium cohort study, The Lancet, Vol 6, pp.59-68.

Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S and Ustun TB (2007) Age of onset of mental disorders: a review of recent literature, Current Opinion in Psychiatry, 20, pp.359–364.

Khoury B, Langer EJ and Pagnini F (2014) The DSM: mindful science or mindless power? A critical review Frontiers in Psychology, 5 Article 602 1-8 doi: 10.3389/fpsyg.2014.00602

Lader D, Singleton N and Meltzer H (2003) Psychiatric morbidity among young offenders in England and Wales, International Review of Psychiatry, 15 (1-2), pp.144-147.

Lough Dennell BL, Anderson G and McDonnell D (2018) Life in Scotland for LGBT young people, LGBT Youth Scotland. Available at www.lgbtyouth.org.uk.

Morgan C, Webb RT, Carr M, Kontopantelis E, Green J, Chew-Graham CA, Kapur N and Ashcroft DM (2017) Incidence, clinical management, and mortality risk following self-harm among children and adolescents: cohort study in primary care, BMJ 2017, 359, j4351.

MH Taskforce (2016) The five year forward view for mental health. A report from the independent Mental Health Taskforce to the NHS in England. Available at www.england.nhs.uk.

National Scientific Council for the Developing Child (2014) Talking about toxic stress: a communications toolkit. Available at www.developingchild.harvard.edu/resources (PDF).

NHS (2019) NHS long term plan. See www.longtermplan.nhs.uk/.

NHS England (2014) CYP IAPT principles in child & adolescent mental health services; values and standards. Delivering with and delivering well. Available at www.england.nhs.uk (PDF).

NHS Digital (2018) Mental health of children and young people in England, 2017. Available at www.digital.nhs.uk (webpage).

National Institute for Health and Care Excellence (2004) Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. NICE clinical guideline 9, London: NICE.

National Institute for Health and Care Excellence (2004) Self-harm in over 8s: short-term management and prevention of recurrence. Clinical guideline [CG16], London: NICE. Available at www.nice.org.uk (webpage).

National Institute for Health and Care Excellence (2007) Quick reference guide. Intervention to reduce substance misuse among vulnerable young people, London: NICE.

National Institute for Health and Care Excellence (2011) Self-harm in over 8s: long-term management. Clinical guideline [CG133], London: NICE. Available at www.nice.org.uk (webpage).

National Institute for Health and Care Excellence (2013) Antisocial behaviour and conduct disorders in children and young people: recognition and management. Clinical guideline [CG158], London: NICE.

National Institute for Health and Care Excellence (2015) Obesity prevention. Clinical guideline [CG43], London: NICE. Available at www.nice.org.uk (webpage).

National Institute for Health and Care Excellence (2017) Drug misuse prevention: targeted interventions NICE guideline [NG64], London: NICE.

National Institute for Health and Care Excellence (2019) Depression in children and young people: identification and management. Guideline [NG134], London: NICE.

Northern Ireland Commissioner for Children and Young People (2018) Still waiting: a rights based review of mental health services and support for children and young people in Northern Ireland, Belfast: NICCY. Available at www.niccy.org (PDF).

Nursing and Midwifery Council (2015 updated 2108) The Code: professional standards of practice and behaviour for nurses, midwives and nursing associates, London: NMC.

Office for National Statistics (2004) The mental health of young people looked after by local authorities in Scotland, Newport: ONS.

Public Health England (2016) The mental health of children and young people in England, London: PHE.

Royal College of Nursing (2010) Restrictive physical intervention and therapeutic holding for children and young people. Guidance for nursing staff, London: RCN. Available at www.rcn.org.uk.

Royal College of Nursing (2014a) Mental health in children and young people An RCN toolkit for nurses who are not mental health specialists, London: RCN. Available at www.rcn.org.uk.

Royal College of Nursing (2014b) Children and young people’s mental health – every nurse’s business RCN guidance for nursing staff, London: RCN. Available at www.rcn.org.uk.

Royal College of Nursing (2016) RCN position statement: the role of the designated nurse for safeguarding children and young people in England, London: RCN. Available at www.rcn.org.uk.

Royal College of Nursing (2017a) An RCN toolkit for school nurses supporting your practice to deliver services for children and young people in educational setting, London: RCN.

Royal College of Nursing (2017b) Courageous about equality and bold about inclusion. Equality and inclusion strategy: 2017-2020, London: RCN. Available at www.rcn.org.uk.

Royal College of Nursing (2019a) Parity of esteem – delivering physical health equality for those with serious mental health needs, London: RCN.

Royal College of Nursing (2019b) Restrictive physical interventions and the clinical holding of children and young people: guidance for nursing staff, London: RCN.

Royal College of Nursing (2019c) Safeguarding children and young people: roles and competencies for health care staff (Fourth edition), London: RCN.

Royal College of Psychiatrists (2010) Self-harm, suicide and risk: helping people who self-harm. Final report of a working group [College report: CR158 June 2010], London: RCPsych.

Royal College of Psychiatrists (2014) Managing self-harm in young people [College report: CR192 October 2014], London: RCPsych.

Royal College of Psychiatrists (2020) Technology use and the mental health of children and young people [College report: CR225 January 2020], London: RCPsych. Available at www.rcpsych.ac.uk (webpage).

Royal Society of Public Health UK (2017) #Statusofmind: social media and young people’s mental health and wellbeing, London: RSPH. Available at www.rsph.org.uk [PDF].

Ryan N and Pryjmachuk S (2011) Helping children with mental health problems, in S Pryjmachuk (ed.) Mental Health Nursing: An Evidence-based Introduction. London: Sage.

SALSUS (2018) Scottish schools adolescent lifestyle and substance use survey (SALSUS): national overview 2018. Available at www.gov.scot/publications (webpage).

Scottish Government (2016) Getting it right for every child (GIRFEC), Edinburgh: SG. Available at www.gov.scot/policies (webpage).

Scottish Government (2017) Mental health strategy 2017-2027: the Scottish Government's approach to mental health from 2017 to 2027 – a 10 year vision, Edinburgh: SG. Available at www.gov.scot/publications (webpage).

Scottish Government (2018) Supporting transgender young people: guidance for schools in Scotland, Edinburgh: SG. Available at www.lgbtyouth.org.uk (PDF).

Scottish Government (2020) Factors affecting children’s mental health and wellbeing: results from the 2015-2017 realigning children's services wellbeing surveys into factors effecting mental health and wellbeing amongst children and young people in Scotland, Edinburgh: SG. Available at www.gov.scot/publications/ (webpage).

Toseeb U, McChesney G, Oldfield J and Wolke D (2020) Sibling bullying in middle childhood is associated with psychosocial difficulties in early adolescence: the case of individuals with autism spectrum disorder, Journal of Autism and Developmental Disorders, 50, pp.1457-1469. Available at www.link.springer.com (webpage).

United Nations (1989) The United Nations convention on the rights of the child, New York City: UN. Available at www.unicef.org.uk (PDF).

United Nations Children’s Fund (2019) UNICEF UK annual report 2019, London: UNICEF UK. Available at www.unicef.org.uk (webpage).

Word Health Organization (2004) Promoting mental health: concepts, emerging evidence, practice (summary report), Geneva: WHO.

Word Health Organization (2015) Premature death among people with severe mental disorders (information sheet), Geneva: WHO. Available at www.who.int (PDF).

YMCA UK (2018) In your face: a report investigating young people’s experiences of appearance-based bullying, London: YMCA UK. Available at www.ymca.org.uk (PDF).

YoungMinds (2018) Childhood adversity, substance misuse and young people's mental health, London: YoungMinds. Available at www.youngminds.org.uk.

Dr Gemma Trainor - RCN Children and Young People’s Staying Healthy Forum Steering Committee member and Senior Lecturer, Liverpool John Moores University, Visiting Lecturer, Kings College, London and formerly Nurse Consultant, NHS CAMHS, Manchester#

With contributions from

Melissa Beaumont - RCN Children and Young People’s Staying Healthy Forum and lead CAMHS nurse health and well-being team

Ross Sanderson - Policy Officer, RCN Scotland

Billie Hughes - Children Services Manager and lead nurse CAMHS, Belfast and South Eastern Trust, Northern Ireland

Dr Euan Hail - RCN Children and Young People’s Staying Healthy Forum Steering Committee member and Consultant Nurse. Visiting Professor, South Wales trustee, Hafal, Associate Professor, School of Medicine, Swansea University

Michelle Eleftheriades - UK Professional Lead for Children and Young People’s Nursing, Royal College of Nursing

Fiona Smith - Former UK Professional Lead for Children and Young People’s Nursing, Royal College of Nursing

Children and Young People with Mental Health Needs, Autism or Learning Disability programme
A new online learning platform from NHS elearning for healthcare, addressing children and young people with mental health needs, autism, or learning disability in acute settings. We have gathered and peer-reviewed existing resources and training modules in one place for easy access.

Childline
Providing a free and confidential telephone service for children.
Helpline: 0800 1111

Childnet International
International non-profit organisation working with others to help make the internet a great and safe place for children.

Children’s Commissioner for England
Championing children and young people in England.

Children’s Commissioner for Northern Ireland
Promoting the rights of children and young people.

The Children’s Society
Works with children and young people who are struggling to cope with the pressures of everyday life.

Children in Scotland
National agency for voluntary, statutory, and professional organisations and individuals working with children and their families in Scotland.

Children in Wales
National umbrella organisation for those working with children and young people in Wales.

Contact a Family
Advice and support for families with disabled children.

Department for Education in England
Responsible for education and children’s services in England.

Department of Education, Northern Ireland
Responsible for education and children’s services in Northern Ireland.

Action for Children
Support of vulnerable children, young people and families.

ADDISS (National Attention Deficit Disorder
Information and Support Service)
Providing people-friendly information and resources about attention deficit hyperactivity disorder to anyone who needs assistance.

Alcoholics Anonymous
For help with drinking problems.
Great Britain National Helpline 0845 769 7555

Beat
Understanding eating disorders, focusing on anorexia and bulimia nervosa and how you can help.

Bullying UK
Find advice on all aspect of bullying including cyber bullying. Help and advice for victims of bullying, parents and schools.

CEOP (Child Exploitation and Online Protection)
Child exploitation and online protection centre.

Children’s Commissioner for Wales
Standing up for children and young people’s rights.

Mental Welfare Commission for Scotland
Ensuring that care, treatment and support are lawful and respecting the rights and promoting the welfare of individuals with mental illness, learning disability and related conditions.

Mind
Mental health charity providing information, advice and training.

MindEd (the online portal of the Royal College of Paediatrics and Child Health)
The MindEd website provides free e-learning to help adults to identify and understand children and young people with mental health issues.

National Treatment Agency for Substance Misuse (now part of Public Health England)
Promoting a balanced and ambitious treatment system and supporting local commissioners by providing high quality information and intelligence about drugs and alcohol.

NHS Health Scotland
Scotland’s Health Improvement Agency.

Northern Ireland Association of Mental Health
The largest and longest established independent charity focusing on mental health and wellbeing services in Northern Ireland.

Public Health Agency in Northern Ireland
The major regional organisation for health protection and health and social wellbeing improvement in Northern Ireland.

Royal College of Psychiatrists
Includes parents and youth information index and case studies, further information and references.

Depression Alliance
Working to relieve and prevent this treatable condition by providing information and support services.

Family Action
Providing a range of services for families with complex needs.

Family Lives
National charity that provides support for all aspects of family life.

Funky Dragon
Children and young people’s assembly for Wales – a peer led organisation.

Health Behaviour in School-aged Children (HBSC)
A World Health Organization collaborative cross-national study.

Health Rights Information Scotland
Providing clear, accurate and up-to-date information about people’s health rights.

The Incredible Years
Preventing and treating young children’s behaviour problems and promoting their social, emotional and academic competence.

Kidscape
Provides advice, training courses and helpful booklets and information about bullying. Anti-bullying helpline for parents: 08451 205 204.

legislation.gov.co.uk
Revised enacted UK legislation.

Mental Health Foundation
A UK mental health research, policy and service improvement charity.

Skills for Health
Contains a core skills framework to support workforce development for the implementation of the national mental health strategy in England.

Self-Harm: Recovery, Advice and Support
Alumina is a free online self-harm support course for those aged 14-19 who are struggling with self-harm.

Triple P (Postive Parenting Program)
An evidence-based parenting program, backed up by more than 30 years of ongoing research.

Research in Practice
Supporting evidence-informed practice with children and families.

Respect Me
Scotland’s anti-bulling service.

The Samaritans
A charity offering confidential, non-judgemental support, 24 hours a day.

Scotland’s Commissioner for Children and Young People
Information for children and young people in Scotland, their parents and the adults who work with them.

Scottish Association for Mental Health
Scotland’s national mental health charity provides mental health social care support and services in primary care, schools and further education and operates a number of programmes including suicide prevention.

The Scottish Government
The responsibilities of the Scottish Government include health, education, justice, rural affairs, housing and transport.

Scottish Government Health and Social Care Directorates
Aiming to help people sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care.

Scottish Intercollegiate Guidelines Network (SIGN)
SIGN develops evidence-based clinical practice guidelines for the NHS in Scotland. SIGN guidelines are derived from a systematic review of the scientific literature and are designed as a vehicle for accelerating the translation of new knowledge into action to meet our aim of reducing variations in practice, and improving patient-important outcomes.

YoungMinds
Committed to improving the emotional wellbeing and mental health of children and young people.

Publication code: 009 969

Review date: October 2023

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This is an RCN practice guidance. Practice guidance are evidence-based consensus
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population in a specific context.

Publication date: October 2022 Review date: October 2025

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