Issue 17: The SEND Practitioner

The SEND Practitioner

Issue 17
Children and young people’s
mental health

September/October 2016
With Anne Longfield OBE
and Sarah Norris

In this issue

  • Anne Longfield OBE (Children’s Commissioner for England) discusses the state of the nation’s child and adolescent mental health services (CAMHS) via: CAMHS cuts, SEN general annual grant (GAG) funding, demographics, exclusions, legal aid, and the post-Brexit landscape. Read more…
  • Sarah Norris (senior educational psychologist (EP)) explores the particular challenges facing professionals who support children and young people with social, emotional and mental health (SEMH) difficulties. Read more…

Editorial

In 1954, Pearl S. Buck, author and winner of the Pulitzer Prize and the Nobel Prize in Literature, wrote that “the test of a civilization is the way that it cares for its helpless members”. Her moving words echoed similar sentiments expressed by Samuel Johnson and Mahatma Gandhi many decades earlier. Sentiments that, at their very heart, frame the state of a nation’s health, not in terms of its financial or cultural wealth, but in respect of the welfare of its most vulnerable citizens.

Children and young people with mental health difficulties are one of those vulnerable groups who face a range of challenges in a country grappling with funding constraints, legislative reforms and post-Brexit uncertainties. With so many big questions dominating the headlines it is, perhaps, easy to get preoccupied with their impact on us and forget that the most vulnerable members of our society tend to be most affected when times are tough.

With this in mind, I was really pleased to speak to the Children’s Commissioner for England, to get a better sense of the real and pressing problems facing children and young people with mental health difficulties. The fact that Anne works so closely with young people, in pursuit of her statutory duty to champion, safeguard and promote their rights, means that she is uniquely placed to comment. To get the practitioner’s viewpoint, I was also grateful for the opportunity to speak to our very own Sarah Norris. Sarah is a talented and respected senior educational psychologist and an expert in this important area.

I do hope that you find this issue useful and that, in some small way, it helps you in your practice. At this moment, children and young people face such a myriad of mental health challenges that SEND practitioners are in a powerful position to enable some of this country’s most vulnerable individuals to thrive.

Thank you for continuing to read and engage with this publication over the past two years. I very much appreciate your invaluable input and look forward to speaking to some more high-profile experts in subsequent issues. As ever, please do let me know your thoughts, comments or suggestions.

Kind regards,

Edward Farrow
Editor
edward@realgroup.co.uk

PS: As above, if you do not currently subscribe to this publication, but would like to receive it in your inbox, please do sign up. Also, if you want to receive the latest updates on SEN and The SEND Practitionerfollow us on Twitter.

Table of contents

A Q&A with Anne Longfield OBE on children and young people’s mental health

A Q&A with Sarah Norris on the challenges facing SEND professionals who support children with SEMH difficulties

NB: These links have now been optimised so that they take you straight through to The SEND Practitioner via your browser.

A Q&A with Anne Longfield OBE on children and young people’s mental health

1. In light of the recent heightened awareness around mental health issues and young people, how do you feel that schools should go about raising the awareness of mental health with children and their families without unduly alarming those people?

“Over the last year I have been talking about children’s access to mental health support; this is something that many young people have raised with me while I have been in post. Indeed, some of the advisory group of children I work with produced a report with a particular emphasis on improved access to advice and support around the school. Children and young people have always made it clear that they struggle to know where to go and want to have places where they can get informal advice and test out the particular level of difficulty that they think they have. They aren’t keen to go to a GP, partly due to stigma and partly due to anxieties around diagnosis.

“We’re therefore really keen to have more informal support in and around schools – which is there in various forms but can be inconsistent. On the one hand, while many young people talked very positively about their access to school counsellors; on the other, some parents spoke of how useful it would be to have more information for them in and around schools. On top of this, both parents and children felt that GPs could come into schools more. Instead of waiting for children to see them, and the related anxieties and barriers that visiting a GP can catalyse, perhaps GPs might be able to break down those barriers by going into the schools themselves.

“This isn’t about the school becoming a lead provider, but as a trusted, safe place where children go every day, each school is in a really unique position to enhance the well-being aspects of their work. So, we’re really keen to look at and encourage schools to take a whole-school approach to well-being and really intent on raising awareness to ensure that children and adults in schools can interact and respond. This, for example, could be a school nurse. In fact, we’ve got a piece of research coming out this month about school nurses.

“In the most recent research that we carried out on CAMHS services, over one quarter of children were unable to get an appointment when they were referred to a specialist. More worryingly, 14% of children deemed to have a life-threatening mental health condition had to wait up to six months for an appointment with a mental health specialist – often, with no help in the meantime. And, in many areas, if they did get an appointment and failed to turn up twice, then they were automatically struck off the waiting list. We know that it’s an imperfect system and there are massive inconsistencies across the country. Some areas are doing very well and lots of young people do get very good support, but many are also missing out.”

2. As you mentioned, with CAMHS cuts, children are increasingly suffering from stress. What dialogue are you having with CAMHS commissioners about improving the access to these services to young people?

“The responses that we received showed a real variety of levels of access around the country. While some areas are clearly doing it well (with waiting lists of 14 days), others are clearly struggling (with waiting lists of 200 days).

“The questions are:

  • Why is there such a difference?
  • What makes a good service?
  • What’s leading to the delay for those on a long waiting list?

“I’ve seen some excellent examples of areas that are really looking at a radically different approach for children and young people as part of the Future in Mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing policy. I’ve been impressed by what I’ve seen to date from Birmingham – who put together a very integrated system, which has access points in physical drop-in centres, and a ‘no wrong door’ approach that allows young people to come in at various levels and go up and down.

“It is a much more consumer-based response that guarantees a quick turnaround and tracks each young person’s journey to ensure a positive outcome. And this is so vital because, whatever we do, we simply must make sure that we track and keep in touch with those children who are waiting for a more specialist response. Because one of the key things that young people said in the Lightning Review: Access to Child and Adolescent Mental Health Services, May 2016, was that, if a child was on a six-month waiting list, it would be much better for them to have someone to talk to during that time.

“There are some areas that are looking at an inside-out approach, which differs from the kind of mental health support that we know is needed. Now, clearly, this includes CAMHS, but it’s also very much linked to preventive services; and it’s also got great potential for peer-on-peer support. I don’t think that we need to necessarily think that it’s just about making sure that we’ve got more high-end services for high-end needs – as important as that is. In fact, I think that, for children, it’s actually much more about keeping that flow.

“And, again, one thing that particularly comes to the fore with the Lightning Review research: is that when children and young people go to GPs, there is a significant gap between what GPs think outstrips their ability to respond and the level/threshold at which CAMHS are willing to offer/support. And why does this gap exist? Because there are children and young people who need more help than their GP can give, but they haven’t reached the CAMHS threshold, so they can’t access additional services. Clearly, with all of this in mind, there needs to be a much more holistic response.

“Of course, in your question, you also mention that children are increasingly suffering from stress. You know, in the case of the Lightning Review, I wasn’t keen to shout ‘crisis’, because a lot of children and young people were getting lots of very good support – and it’s important to stress that. But, also, it’s vital to consider that there are no clear indicators to suggest that levels of support are causing more stress – although anecdotally you will of course hear more stories.

“Obviously, we’re aware that kids are growing up in a very complicated world. There is a lot of pressure on them via social media and a huge pressure for them to conform re: popularity, the way they look, and the accessories that they have in life. Clearly, day-to-day living for children and young people is a much more complicated and stressful world than it might have been a decade ago – before the vast majority had smartphones in their hands. Now, I am not saying that children and young people having smartphones is a bad thing – we’re putting a lot of energy into looking at how we can, you know, maximise the potential of them having access to the digital world – but, of course, they are a factor.”

It’s the flipside of being a digital native isn’t it?

“It is, and we’re all part of this world, but the challenges that face you if you’re a teenager are significant and difficult for us to identify with. As a young person, you’re trying to work out both the world around you and your place in the world and, all the while, you’ve got a rigid kind of voyeuristic lens called social media, which may help you to view the world but will also, to a much sharper extent, measure your world in a very different, idealised, way – one that can be very difficult to live up to.”

3. NHS England stated that an additional £1.4bn has been allocated to help CAMHS expand. In March of this year, however, the Mental Health Network stated that it had seen “no significant investment” in psychiatric services. Despite this polarisation, it’s generally accepted that CAMHS provision is a bit of a postcode lottery, with some children reaching crisis-point before they get help. What’s your take on this and what have you done/can you do to tackle this?

“I think that this programme has a good future. It is a force for good, very positive and well-thought-out. It’s about long-term change and £1.4bn of funding is clearly significant and welcome. In addition to this, the move to look at how the conversation happens locally, the assessments around need, and the plans and response to those assessments are all a good thing.

“Having said that, I think that, clearly, there are immediate needs that simply aren’t being met – some of which may be around the fact that the benefits of Future in Mind haven’t yet trickled down. Of course, while quite a bit of time and money has been invested in planning for the future, such a commitment is not going to lead to instant results. Consider the Birmingham example that I mentioned earlier, where the whole-system scale of required change is seismic to say the least. Add to this the increasing need in some areas due to a raft of pressures and you have a very difficult situation. In short, it’s a big ask.

“I will be doing everything that I can to highlight the areas where I think that more urgent action is needed – and certainly access to CAMHS for those with life-threatening conditions is one of the areas that we must prioritise. I am also keen to help people look at how services can be transformed in ways that actually place the needs of children at the centre. For, while that might seem to be a really obvious comment, if we truly place the needs of children at the heart of all we do, then we will actually have to restructure how everything happens. Why? Because we’ll have to refocus by looking at things from the viewpoint of a young person who needs to get easy access to a service. For example: they might not feel comfortable talking about some of these things and they most probably won’t respond well to traditional appointment letters, so we have to adapt to meet their needs. This is because kids say that they prefer phone calls and texts, not just traditional letters. And they want to be involved in a dialogue and tend to shy away from a top-down formal letter that we, as adults, would most likely be more at home with.

“So, it really does require a complete rethink around how services are delivered and it also needs the involvement of more partners who haven’t considered this to be their core area before. Obviously, while well-being, health and mental health are very much a part of each school’s day job, there are other active partners who can be placed in the mix. Take those who are involved in early education and nurseries; they probably won’t consider young children with mental health difficulties to be part of their core business. If you’re looking at long-term prevention, however; if you’re looking at an inclusive service throughout the life course of a child; then nurseries are, in fact, critically important – they talk to parents, they have access to children, and they have a very strong role to play.

“It’s a really big ask, because it’s about long-term change. However, as with any journey, simple first steps are necessary to reach a gateway to transformation. I know that additional investment is needed to make this happen, but I hope that this will lead to long-term savings. Ultimately, we will know that we have succeeded when children become aware of the range of people on tap to help them and when open dialogue with a broad church of people and professionals around their health and well-being becomes the norm.”

4. In March 2014, before your tenure, in the first year of the School Exclusions Inquiry, you found that a boy of black/Caribbean heritage eligible for FSM was “168 times more likely to be excluded” from school than a white British girl without SEN from an affluent family. In line with this, you also found that children with SEN were “nine times more likely to be permanently excluded from school than those without SEN”. What’s the landscape like now and what impact are you having on it?

“This inquiry was undertaken by my predecessor. It had a good impact at the time and I think that it was a really important piece of work that has led to some changes. I intend to follow up on the issues around exclusions going forward – although it’s not something that I’ve focused on in my first year.

“In the last few months, however, I’ve looked at exclusions for Gypsy and Roma Traveller children. Interestingly, they not only have very high levels of exclusion and SEN, but have mental health issues too. So, while the majority of these exclusions revolve around the behaviour of these children in their schools; the level of bullying, unreported bullying and reported mental health concerns that exacerbate such exclusions are also very high. What I’ve been particularly excited by, though (and this is something that I want to share), is that there are very good examples of schools and local authority areas taking a very positive and proactive approach.

“I’ve heard from a head teacher in Blackpool who has set out a very positive whole-school approach to minimise exclusions. She’s worked with parents to identify issues and resolve them; and she’s set out clear principles that make it very clear that the focus will be on reducing/removing exclusions by working with parents to resolve each situation. And, at the same time, in the case of Sheffield local authority for example, we should know that they have instituted a whole-school and whole-authority policy that has reduced exclusions via a more positive and proactive partnership with parents and community groups that nurtures inclusion and support.

“So, as you can see, I am particularly keen to make real progress in these areas. To do this effectively, though, important research will need to be carried out to identify exactly where these exclusions are happening. Moreover, we will also need to highlight particularly good examples, where schools and local authorities are taking a more positive and proactive approach by working closely with pupils, partners and parents.”

5. The legal aid changes have had a huge impact and in 2014 your Child Rights Impact Assessment saw only 57 cases being granted exceptional funding compared with the Ministry of Justice’s 3,700 projection. What’s the situation now and what’s been your approach to this?

“I don’t have the updated figures on this, but I am of course looking at this on a case by case basis. At the end of July, for example, there was a ruling by the Supreme Court following a case that I intervened in with the Law Society. Ultimately, our successful case confirmed that the Lord Chancellor didn’t have the power to remove the right to legal aid from a group of unaccompanied asylum seekers.

“It’s something that I’m going to be looking at going forward but on a case by case basis. This is because the policies from government are pretty definite in these areas. So, with this in mind, one really has to look at where one can make change. If there are areas where parents/practitioners are identifying major gaps, then I’d be glad to hear from them.”

6. How are schools supposed to support children and young people with SEN appropriately when funding’s being reduced? One of our readers has seen her borough reduce funding by 15% when it doesn’t already cover the cost of support – as it doesn’t take costs into account? In light of this, schools have to use a larger proportion of the SEN GAG funding to ensure that quality first teaching takes place. What would you advise our readers to do in this catch 22?

“As I’ve alluded to in my previous answers around whole-school system change: it’s about consistent and coherent partnership, identifying needs and encouraging schools to embrace local dialogue. This is because the reforms are all based on the pressing need for collaboration and dialogue between partners. And this is particularly the case here: where as many partners as possible need to come together to do something really positive. Within that, there are new partnerships being forged between health agencies, health funding, local authorities and schools. While schools clearly want to do all they can with their own budgets, there is a broader responsibility for different partners to collaborate, pool their budgets and look at how they can provide the support needed.

“Clearly, various funding streams will filter through from Future in Mind, local authorities, clinical commissioning groups and the NHS. However, whatever funding streams are on tap, I would really encourage schools to actively take what they know to the table and, through dialogue with collaboration partners, really show how they can offer the support that’s needed. This neatly dovetails with Future in Mind, with its real emphasis on prevention and early support.

“While, of course, we do need to strengthen CAMHS, to ensure that they’re delivering Future in Mind effectively across the country, it is vital that we recognise that these elements are part of a broader strategy that revolves around prevention. And, you know, you’re not going to be able to provide effective preventive support without engaging schools. So, in essence, it’s about really cultivating a two-way dialogue between schools and health to ensure that children get better support.

“I also think that, in terms of public health more generally, young people are very keen to learn how they can use their online presence to offer peer-to-peer support. One thing that young people say with alacrity is: ‘wouldn’t it be great if we could actually learn more about how to offer each other support when we think that problems are developing’. That’s not to offer peer-to-peer as a substitute for more expensive support, but actually to suggest it as a measure that complements the existing support. But, however we couch and optimise this, the more problems that we can find and identify early on, the better the outcomes will be. Combining a mixture of the traditional support mechanisms with newer peer-to-peer approaches will help us on our way.

“Clearly, the person who posed this question demonstrates a real commitment to the provision of support in their school and concomitant worries about provision due to ongoing budget cuts. Given all of this, I would say that it’s more vital than ever that teachers harness their knowledge and passion to ensure that they bring others into this urgent dialogue. Because, ultimately, those responsible for delivering Future in Mind will be very keen to engage with proactive schools.”

7. When set against the possibility of strong economic post-Brexit headwinds, CAMHS and legal aid cuts, SEND reform uncertainties and inconsistencies in provision; can your organisation have a sustained impact on children and young people’s outcomes and life chances without long-term increases in government funding in real terms across the education sector?

“By now, you might have noticed that I’m a bit of an optimist. So, I find that a bit of a pessimistic question. Of course, there are some issues around finances which provide challenges. However, on balance, I really do believe that there is an opportunity to rethink how we provide services for children in a different way; one that delivers important support in innovative ways that differs from that which we’ve done before.

“On the one hand, it is of course about the reform of services (which includes the reform of SEND and mental health support that I spoke about earlier); on the other, it’s also about understanding the outcomes for children and the things that drive their poor outcomes. Over the next three years, to really tackle this, I will not only develop a data set which highlights the real needs of vulnerable children; but will also shine a spotlight and place a policy focus on those children currently in need who have particularly poor outcomes, but aren’t deemed to be high enough of a risk to get child protection or to be in care. By doing this, by having this clear focus, I believe that we can really gain a better understanding that not only drives policy engagement but also obtains more investment for these children and young people.”

About Anne Longfield OBE

Anne was appointed Children’s Commissioner for England in March 2015. As Children’s Commissioner she has legal responsibility for representing the views and interests of the nation’s 12 million children to the decision-makers who can make a difference to their lives. She must also promote and protect their rights and in particular, focus on vulnerable groups of children.

Anne is a leading figure in the children’s sector, with over 30 years’ experience of, and expertise in, shaping the national policy agenda and delivering services to children and families. She is passionate about championing children’s interests and improving their lives and has led numerous high-profile national campaigns, inquiries and research programmes that have resulted in positive change for children.

Prior to becoming Children’s Commissioner, Anne was chief executive of a national children’s charity. She has also spent time advising the government on children and family policy in the Prime Minister’s Strategy Unit at Cabinet Office.

Find out more about the Children’s Commissioner for England.

A Q&A with Sarah Norris on the challenges facing SEND professionals who support children with SEMH difficulties

1. As a highly respected senior educational psychologist practising in the field of mental health, what are the particular challenges that you see in your day-to-day and how do you help children and young people to overcome them?

“I think that the challenges for CAMHS are around resources and funding without a doubt and it is these prevailing winds that call for a flexible and adaptable approach that can really meet the needs of the populations served by CAMHS. The mental health landscape has changed considerably over the years and we have got a lot better at recognising and tracking these changes. In turn, we now have a much better idea of the mental health needs of children and young people and, more particularly, the vulnerable groups who are more likely to experience mental health difficulties. While this is positive, we must ensure that we continue to develop services that are responsive to these needs. How do we do this? First, we need to be clear about the localised population and their needs and, second, we must also commission services that meet these needs at a local level.

“It’s been a privilege to have worked with some exceptional CAMHS practitioners over the years. And while they have tirelessly promoted and supported young people’s well-being during that time, too often it’s been a shame to witness their creativity and knowledge of what really works for each young person go to waste in a system of constraints. The fact that the system is organised by narratives around risk, overshadows treatment and support. In my view, a shift in focus from a medicalised model that allocates assessment and diagnostic resources, to a system that focuses on conceptualising need and delivering support, would mitigate these difficulties and enable easier access for all. I also believe that there is a powerful case for the identification of mental health disorders to not be a prerequisite for the delivery of effective mental health interventions.

“I think that we’ve come a long way towards breaking down some of the stigma around mental health. We are much more aware of what good and poor mental health looks like and we are really starting to think about how to support our young people. Despite this, we must get much better at working together and alongside families. Good mental health is everyone’s responsibility: the individuals, schools, parents, GPs and other professionals; and, in my experience, it is often the holistic systems of people and organisations around our young people who support their well-being most effectively.

“Ultimately, it’s about moving away from this one-size-fits-all model of ‘referrals’, ‘waiting times’ and ‘experts’ and bringing it back to shared responsibilities in a system that is really centred around each young person. Only by taking such a holistic approach can we really get the full picture/the joined-up view about what is helping or contributing to the concern. For it is this full picture that will also enable us to work out whether what we are seeing is a normal response to an extreme situation, or something else, and respond accordingly.”

2. The Association of Teachers and Lecturers (ATL) has stated that “the majority of education staff say that there has been a rise in the number of children with social, emotional, behavioural or mental health problems”. Is this something that you have experienced and, if so, how might SEND professionals be able to deal with this?

“I am not sure that there has been an actual rise or a real increase in numbers. However, my perception is that we have become more aware of what social, emotional and mental health (SEMH) difficulties are and how to identify them in schools. The number often banded about is that ten per cent of children and young people (between five to 16 years of age) have a clinically diagnosable mental health problem, while 70% of children and adolescents who experience mental health problems have not had appropriate interventions at a sufficiently early age.

“In my experience, while SEND professionals have become more adept at identifying SEMH difficulties, we have a long way to go in regard to thinking about the provisions that are in place to support these young people once a concern has been raised. Reduced CAMHS funding streams mean that many services have become retracted and specialised and only offer an intervention when mental health needs are at a critical or life-threatening stage. To tackle this, we need to ensure that SEND practitioners support young people at an earlier stage.

“By and large, as I alluded to in my previous answer, the current system allocates access to mental health resources based on need. I think that we need to shift the focus to support and encourage our young people to take responsibility for their own psychological well-being. How? By teaching them self-awareness and reflective thinking skills and introducing them to effective approaches such as mindfulness and cognitive behavioural therapy.

“There is sufficient evidence to suggest that these approaches can have a significant impact on young people’s well-being and can particularly help children and young people with depression and anxiety. Moreover, such methods could potentially be rolled out across a school and curriculum, so that the pupils in a particular school have the skills to draw upon if and when they need them. For, when push comes to shove, the time to learn such useful skills is when we are psychologically well, not at the point when things have started to go wrong.

“Finally, we must also realise the vital need for schools to be provided with greater access to advice, support and training around SEMH difficulties. Only by making such provision available, will we be able to properly support each child and young person, their families, parents and carers.”

Sarah Norris’s recent paper and tutorial work

Towards the end of last year, Sarah co-wrote ‘A Family Consultation Service: Single session intervention to build the mental health and wellbeing of children and their families’ in the British Psychological Society’s Educational & Child Psychology journal (Volume 32, Number 4, December 2015).

She is also a tutor on our Certificate of Competence in Educational Testing (CCET), Certificate in Psychometric Testing, Assessment and Access Arrangements (CPT3A), and Social, Emotional and Mental Health Difficulties modules.

3. Given all of the changes in education, at the time of writing (or asking), what is the EP’s essential role in mental health and how can EPs best support families without a need for diagnosis or lengthy treatments?

“There is an explicit and linear link between children’s mental health and well-being and their ability to achieve and do well in school. EPs are particularly knowledgeable in the fields of child development, school systems and contexts, and have skills and training in consultation approaches. EPs are, in fact, increasingly working in school settings with a mental health remit, using a wide variety of psychotherapeutic approaches, such as: cognitive behaviour therapy, eye movement desensitisation and reprocessing, human givens therapy, motivational interviewing, personal construct counselling, solution-focused brief therapy and therapeutic stories.

“At my last service, we developed an intervention that was based on the elements that I have just mentioned and the principles of early intervention and process via psychological consultations with families. During these consultations, we discussed their concerns and guided them through reflective processes to support the finding of alternative solutions and ways forward. These interventions were time limited (usually one session of one hour with two therapists in a room to support collaboration and reflection). They were aimed at early intervention for young people who would not reach the criteria for CAMHS involvement.

“In light of this, because of the absence of the need for a particular diagnosis, we were able to meet families with a huge range of presenting needs. This type of approach turned out to be particularly successful, with the majority of families reporting positive change after just one session, and not needing to be referred.”

4. Finally, you’re a tutor on three of our modules: CCET, CPT3A and social, emotional and mental health difficulties. What can they offer SEND practitioners?

“These modules can really help SEND practitioners to increase their knowledge and apply that knowledge to their unique practical context. On the one hand, CCET, through good assessment practice, will provide them with really robust tools that enable them to make good judgements about how a child is progressing and the next steps that they need to take to enhance their progress. On the other, our two modules on social, emotional and mental health difficulties will enable our delegates to fully update their practice and improve their professional development as reflective, research-led practitioners. Moreover, and equally as importantly, all of these modules are continuously updated to reflect ongoing legislative shifts and changes. Which is rather a vital feature, when practitioners are facing so much change.”

About Sarah Norris

Sarah has been a senior educational psychologist with us for over two years and has over 13 years’ experience working within a local authority. She has worked extensively with schools and young people with a range of SEN and across all age ranges. Most recently, Sarah has specialised in the field of mental health and young people with social and emotional needs. She has a diploma in solution-focused practice, has worked therapeutically supporting young people, and developed, delivered and managed an early intervention-based approach with a mental health service in her previous local authority role.

If you have any questions, or there is anything that you would like us to feature in future issues, please edward@realgroup.co.uk.

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