The Impact of Child Mental Health Services and NICE

The scale of mental health problems in the young is enormous, of 5-19 year olds 1 in 8 have a mental disorder, and 1 in 20 two or more disorders [The Mental Health of Children and Young People in England (2017). NHS Digital November 2018)]. With a quarter of 11-16 year olds with a disorder self-harming or attempting suicide. Nobody doubts the the importance of reaching out to young people with mental health needs. As a consequence there has been a massive expansion of IAPT services to children and adolescents [ Ludlow, C., Hurn, R., & Lansdell, S. (2020). A Current Review of the Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) Program: Perspectives on Developing an Accessible Workforce. Adolescent health, medicine and therapeutics, 11, 21–28. https://doi.org/10.2147/AHMT.S196492] with an intended extra 1700 Children and Young Persons IAPT workers by 2021. But there is a paucity of evidence on the effectiveness of this outreach.

Meanwhile NICE have just issued proposed guidance on ensuring the mental wellbeing of pupils. But the only clear advise in its’ summary ‘Social, emotional and mental wellbeing in primary and secondary education: NICE guideline DRAFT (January 2022)’, is to ask schools to consider Mindfulness for all pupils! The focus is on enhancing children’s wellbeing and on strategies that improve their scores on wellbeing measures.  But this is of doubtful relevance to the dire state some children are in.

There is evidence that half of children get over their problems within 12 months without active intervention                 [ Leikanger, E., & Larsson, B. (2012). One-year stability, change and incidence in anxiety symptoms among early adolescents in the general population. European child & adolescent psychiatry, 21(9), 493–501. https://doi.org/10.1007/s00787-012-0284-7]. So any intervention has to do better than this. But I could find no evidence of this. NICE in the proposed Summary guidance writes:

‘The committee discussed evidence on delivering targeted support for children and young people in secondary and further education who have been identified as needing mental health support (for example, because of symptoms of depression.The committee had low confidence in the findings of the quantitative evidence, even though there were quite a lot of studies. There was some better evidence from qualitative studies about the acceptability of targeted support, and the committee had more confidence in these findings. These studies included individual or group interventions or counselling that were delivered by school specialists (suchas school counsellors) or external specialists (such as psychologists)’. [p27 of Conclusions] and added that the same considerations likely apply to primary school children. 

The above paragraph from NICE is confusing, from a methodological point of view quantitative evidence is superior to qualitative evidence [see Cochrane Review BMJ 2011;343:d5928 doi: 10.1136/bmj.d5928 ‘Randomised trials, and systematic reviews of such trials, provide the most reliable evidence about the effects of healthcare interventions’].

A treatment may be acceptable but that tells nothing as to whether it makes a real world difference. 

The proposed Guidance is an abstraction, when I think of recent cases I have encountered:

  1. A secondary school teacher distraught at the continuing sexual innuendos of boys, which resonated with the sense of threat she felt following a serious sexual assault by an adult male. One senior teacher was supportive another not, yet the toxic behaviour continued.
  2. An 11 year old with separation anxiety disorder and a mild phobia about travelling by car, neither of which had been identified or treated by the therapist. School considered she had no academic or behavioural problems but she reported that she ‘hated school’.  The therapy sessions allegedly addressed her ‘anxieties’.
  3. A 13 year old who had missed a lot of schooling because of uncomfortable headaches/disorientation. The therapeutic focus had been on trying to relax. There had been no consideration that she may have a health anxiety problem
  4. An 8 year old girl with separation anxiety disorder who had been given EMDR, switching from negative to positive thoughts at the sound of a beep. The therapy was ineffective and delivered despite no evidence for the efficacy of EMDR for separation anxiety disorder.
  5. A 9 year old boy distraught at spending part of the week with his mother (who had a record of drug addiction) and part with his father. He desperately wanted to be with his father but the social worker and school took the mothers view. The school considered that the child may have ADHD when more plausibly he was distracted by the toxic atmosphere in his mothers home and her boyfriend’s behaviour.

This Guidance would have made no difference at all to any of these cases. The proposed Guidance lacks a real world feel. There is no credible mechanism by which targeting emotional wellbeing, impacts depression, anxiety disorders, separation anxiety disorder, or conduct disorders. Further it is not proven that targeting emotional wellbeing prevents these disorders. Moneys are better spent targeting established disorders than tilting at the windmill of emotional wellbeing, with nebulous targets, such as increasing academic resilience.

As far as we can, we must answer the question ‘which treatment works best, for which child, in which circumstances?’. Answering this requires specificity about treatment, diagnosis and the child’s social context.

Dr Mike Scott

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