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Children and Young People's Mental Health: A Framework for Promotion, Prevention and Care

3. BASIC ASSUMPTIONS

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

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

3.2 The Framework also adopts the following as basic assumptions, derived from the SNAP report on Child and Adolescent Mental Health:

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

When is a young person not a young person?

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

3.4 It can also have a number of disadvantages. Needs may or may not change with age and so young people with very similar needs who are of marginally different ages can be offered very different services. It also runs the risk of creating discontinuities in service provision at times of important transition, e.g. from school to other settings, from care settings to independent living and so on.

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

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

3.5 In practice, those commissioning mental health services for children and young people should consider the mental health needs of all young people in a community under the age of 18. They should also consider the needs of those with significant mental health needs who, on reaching 18, will continue to have significant mental health needs.

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

• Young people with complex problems may remain involved with the child care system beyond their 18th birthday. Young people who are looked after by a local authority may remain in the care system until they are 19 years old and in some circumstances, until they are 21 years old. Where liaison arrangements with child and adolescent mental health services are established for younger clients, it would seem arbitrary and unhelpful to exclude these older young people while they remain in these settings.
• Some forms of severe mental illness can begin in teenage years and persist into adult life. Service developments in relation to such young people, for example with early onset psychosis, should incorporate care pathways which avoid arbitrary disruption of treatment arrangements based on age.

Underlying principles

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

Inequalities

3.8 Like adult mental health, the mental health of children and young people is affected by the circumstances in which they live. Local work on inequalities therefore needs to provide the overall context for work on mental health issues. This needs to sit alongside work in local areas to improve the lives of children in general, but especially those who may be more vulnerable to mental health problems due to their birth/life circumstances e.g. those who are looked after or accommodated, those who have a learning and/or physical disability, those who have been or are at risk of abuse, and those who are from homeless families or who are homeless. (This is not an exhaustive list!)

Accessibility and diversity

3.9 Services for children and young people need to be provided in accessible and imaginative formats. Walk the Talk²⁴ has already published a resource pack²⁵ to provide advice on developing appropriate and accessible health services for young people. It is based on the premise that relevant people + relevant places + relevant times = relevant services. In developing services for children and young people, the following need to be considered:

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

3.10 The voluntary sector has considerable experience and skill in providing accessible services for children and young people, and can offer valuable assistance in considering and addressing some of these issues.

3.11 Clear and transparent transport policies are vital in ensuring that children, young people and their families are able to access services, and in particular, specialist services which may not be available locally. With this in mind, NHS Boards and local authorities should develop or review transport policies and provide information for children, young people and their carers about the assistance they can expect with travel and/or accommodation costs when they need to use mental health services.

Participation and involvement

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

3.13 The United Nations Convention on the Rights of the Child (UNCRC)²⁶ underpins the legislative and cultural progress in involving children and young people in making decisions. In particular, Article 12 of the UNCRC gives children the right to express their views freely in all matters affecting them and states that these views will be given due regard. The UNCRC was ratified by Great Britain in 1991 and in Scotland, the Children (Scotland) Act 1995 incorporated its principles by giving children a right to express their views on a range of decisions which affect them.

3.14 The ability of children and young people to participate in the life of their community is linked to their perception of how safe they feel to become involved. The Children and Young People's Charter²⁷ is written from the perspective of children and young people and was developed through talking to children and young people who have experienced the need to be protected and supported - but it outlines how any child or young person facing difficulties could expect to be treated to enable them to feel safe. It states that "As children and young people, we have a right to be protected and be safe from harm from others. When we have difficulties or problems we expect you to:

3.15 Children and young people will benefit from the resources of their communities when they feel that their views are respected and their perspectives valued. Some of the key competencies in the forthcoming children and young people's mental health Competency Framework²⁸ emphasise the importance of understanding where children and young people are coming from and how life events may have impacted on them. These include:

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

3.16 The participation and involvement of children, young people and their parents in the processes to take forward local implementation of the SNAP report²⁹, using this Framework, is a fundamental underlying principle. Local areas will be expected to demonstrate how they are ensuring this.

Evidence-based services

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

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

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

• "Occur early in the problem cycle and preferably early in age.
• Involve familiar people or people who will be able to empower parents and work in partnership with professionals (e.g. health visitors or trained volunteers).
• Are intensive and sustainable over a period of time.
• Are multifaceted, incorporating several interventions (e.g. to both parents and child; focusing on health, education and parent training).
• Incorporate interventions of proven effectiveness." (page 52)

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

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

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

Building on existing structures

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

Consent

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

3.23 Valid legal consent comprises three elements³⁰:

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

3.24 In Scotland³¹, a person of or over the age of 16 years is presumed to be competent to give valid legal consent to medical treatment. A person under the age of 16 years has the legal capacity to consent on her or his own behalf where, in the opinion of the attending practitioner, she or he is capable of understanding the nature and possible consequences of the procedure or treatment.

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

Confidentiality

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

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

3.27 Information should only be shared between agencies on a 'need to know' basis with those immediately involved in the child/young person's care. The Scottish Executive has recently published guidance³² for health workers about sharing information about children who may be at risk of abuse or neglect.

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