Children and young people’s mental health services

Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.1 | 2014 16 CHILDREN AND YOUNG PEOPLE’S MENTAL HEALTH SERVICES By: Riittakerttu Kaltiala-Heino, Rose Crowley and Sebastian Kraemer Summary: Child and adolescent mental health disorders are common and contribute excessively to the disease burden in developmental years. They impair quality of life and acquisition of social, educational and vocational skills and threaten economic productivity and social cohesion. Consequences are seen and effective prevention and treatment takes place not only in health but also in the social, educational and criminal justice systems. There is wide variation across Europe in funding of child and adolescent mental health services as well as in training and availability of services and experts. Early interventions to prevent these disorders need to be applied systematically, and the effect of interventions needs to be evaluated across sectors. Keywords: Mental Health, Mental Disorders, Children, Adolescents Riittakerttu Kaltiala-Heino is Professor of Adolescent Psychiatry, University of Tampere and Tampere University Hospital, Tampere, Finland. Rose Crowley is Paediatrician, London Specialty School of Paediatrics and Honorary Research Fellow, London School of Hygiene and Tropical Medicine, London, UK. Sebastian Kraemer is Honorary Consultant, Tavistock Clinic and Consultant Child and Adolescent Psychiatrist, Whittington Hospital, London, UK. Email: merihe@uta.fi Introduction Emotional or behavioural disorders affect one in five young people, and mental health conditions are a major contributor to the disease burden in childhood and adolescence. 1 Issues range from young children with emotional disorders to adolescents with psychosis or those who self-harm or misuse substances. The detection and management of such a variety of disorders requires the integration of paediatric and psychiatric input with education and welfare services. Mental disorders directly impair quality of life and threaten the acquisition of social, educational and vocational skills during crucial periods of childhood and adolescent development. This has lifelong consequences for individuals and, on a wider scale, threatens countries’ economic productivity and social cohesion. The majority of major adult mental health disorders have their roots and onset during childhood and adolescence. Failure to address these disorders results in significant costs to the health, social and criminal justice systems in adult life, which could be avoided by effective prevention and treatment. 1 What is mental health? Mental health is more than the absence of a mental illness. The World Health Organization (WHO) defines it as ‘a state of well-being in which the individual realises 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’. 2 This makes it difficult to compare countries’ spending on mental health, as health services per se account for only a small proportion of efforts to tackle broader societal forces (poverty, Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.1 | 2014 17 social exclusion etc.) known to increase children’s risk of developing mental health disorders. A great deal of such conditions in children and young people is concealed behind social problems, such as crime, drug abuse, homelessness, violence, educational failure and bullying. These phenomena are, in turn, strongly associated with early disruption or breakdown in attachments with parents and other caregivers. Workforce and funding The provision of a comprehensive child mental health service requires, firstly, adequate numbers of suitably trained specialist providers (like child psychiatrists and psychologists); and secondly, sufficient skills among those most likely to first detect the disorders (such as paediatricians, GPs, teachers and social workers). There is great variation across Europe in training and availability of specialists in child and adolescent (C&A) psychiatry, and in mental health- related training of paediatricians and primary care physicians. Comparing the budget available for child mental health services between countries is complicated by wide variation in funding streams. In many countries, mental health service budgets are decided independently at regional or federal level from their general allocation for health care, with surprisingly little aggregate data available. Analysing spending within the health service will also fail to take into account the varying proportions of education and social care budgets that are spent on preventive programmes for child mental health. Significant numbers of projects are funded by non- governmental organisations, frequently with little coordination between these and various government sectors. Despite these limitations, the worrying conclusion from the WHO ATLAS survey was that, globally, ‘there is a universal absence of parity between adult and child mental health services’. 3 In 25 countries from the WHO European Region, only 77% had any specific programme for child mental health, and for 29% of countries, out-of- pocket payments were still the second most common means of financing mental health care. Assessing the challenges: needs and trends The most significant mental health disorders in children and adolescents include depressive and anxiety disorders, post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), autism spectrum and conduct disorders, and from adolescence onwards, substance use, eating disorders and psychosis. Little methodologically-sound, comparable information is available on detailed epidemiology of mental disorders among European children and adolescents. At the severe end, suicide rates among young people are available for most European countries in the WHO mortality database, with suicide being the third leading cause of death worldwide among those aged fifteen to nineteen. Even if mortality rates also include deaths from overdose and anorexia nervosa, they may still underestimate the impact of mental ill health, as disorders also increase risk- taking behaviour and accidental injury. Service use figures will underestimate the problem, as many disorders will go unrecognised or untreated, for reasons related to stigma, economic barriers, gaps in service provision and inconsistent referral pathways. 1 Surveys among young people, parents and teachers can give a more comprehensive picture, including untreated and sub threshold disorders. Examples of large European surveys are Child and Adolescent Self – harm in Europe, 4 the WHO HBSC survey, the National Health Interview and Examination Survey in Germany, and the School Health Promotion Survey in Finland. Inequality is a major contributor to young people’s mental health disorders, 5 as are familial problems and traumatising experiences. Children who are taken into care by child welfare authorities and immigrant children form special risk groups. Variation over time in these risk factors may influence mental health epidemiology in children and adolescents. Child mental health care: the European experience The ‘Child Health Services and Systems in Europe’ (CHSSE) questionnaire explored differences and similarities in services for child and adolescent mental disorders through case vignettes. Six key areas of variation and some examples of good practice were highlighted. Professionals and services The respondents to CHSSE identified those primarily responsible for treatment of C&A mental health disorders as being psychiatrists (4 countries), paediatricians (2), combination of the two (2) and psychologists/social workers (1). In the UK, the patient’s condition partly determines this; many behavioural disorders fall within the remit of community paediatricians, while affective or psychotic disorders would be managed by C&A psychiatrists. In Finland, patient age is the major determinant: child psychiatrists provide care for pre-pubertal children and adolescent psychiatrists for those aged 13 to 18 (in outpatient care up to 21). There is great variation in who manages adolescent substance misuse, from child psychiatrists or adult psychiatrists specialised in substance abuse to paediatricians. In Italy, adolescent substance abuse is a subset of adolescent medicine; in France and Finland, it is treated as a part of substance abuse in general (adult services); in Austria, there is a combination of the two. In Poland, patients under-16 are admitted to children’s wards and those who are older to specific toxicology wards for adults. It is unlikely that the overall health needs of adolescents at varying stages of development will be met by being seen wholly within adult services. Inpatient care A particular challenge in caring for children and adolescents is lack of suitable inpatient facilities. Many young people are treated for psychiatric conditions in less than ideal settings, such as adult psychiatric units or general paediatric wards. In Finland, legislation stipulates that adolescent psychiatric inpatient care should be separate from that of adults, while in France there are designated beds for adolescents in adult psychiatric wards. Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.1 | 2014 18 In Scotland, there has been a drive to strengthen existing inpatient adolescent facilities, in response to a 2004 report on psychiatric inpatient facilities. 6 In this respect, psychiatry was earlier to recognise the importance of dedicated adolescent units than other paediatric specialties. In the UK, there is greater political pressure to keep under-18s out of adult psychiatric wards than there is to provide comprehensive mental health care in paediatric settings, where many young people in crisis alongside those with chronic or unexplained medical conditions are likely to be admitted. 7 Pathways to care CHSSE highlighted the importance not only of primary care physicians but of education and social services in identifying and referring C&A mental health disorders, particularly Attention Deficit Hyperactivity Disorder (ADHD). Delays between problem recognition and specialist assessment are common, predominantly due to a lack of available specialist services. In Norway, the child is guaranteed to be seen within ten days by a C&A psychiatrist, and treatment initiated within 90 days if a preliminary ICD-10 diagnosis is reached. In Finland, the Ministry of Health and Social Affairs developed priority rating tools for all specialties in 2004, to guarantee equal access to specialist level services across the country. In C&A psychiatry, patients presenting with disorders with severity scoring over a defined cut-off are guaranteed assessment within six weeks from referral, then treatment within three months. In England, NICE has produced guidance on the referral and management of depression, ADHD, autistic spectrum and conduct disorders with a four-tier hierarchy of referral, ranging from primary care to extremely specialised services. Age range Age boundaries between C&A and adult services form three distinct problems in Europe. Firstly, a gap is created in services when C&A services only treat up to 16 years but adult services refuse to admit under 18 year olds. Secondly, even if adult services should treat all conditions from age 18, they may have limited skills in some typical C&A mental health disorders, such as ADHD, autistic spectrum disorders or even eating disorders. Thirdly, as few young people actually transition to independent living at age 16 – 18, adolescent psychiatric services might better meet the psychological needs of 18 – 23 year olds than adult services. Early intervention services Ante – and perinatal factors, such as maternal depression, anxiety and psychosocial stress, negatively influence children’s development and mental health. 8 This damage could be prevented with coordinated ante – and postnatal care between maternity, primary care and mental health workers. A positive development was identified from Finland where maternity and child health clinics are increasingly being modified to become ‘family welfare clinics’ (preventive services with emphasis on family welfare, the father’s role, and psychosocial factors in addition to children’s physical health), in parallel with similar extension of school health examinations to emphasise ‘psychosocial wellbeing of the child and her/his family’. Future challenges There is a need to promote child mental health knowledge within paediatrics, primary care, education and welfare services. Treatment approaches combining specialist level services with primary care and paediatric care could then be established. It is of outmost importance to determine whether the established usefulness of community treatment in adult mental health will be replicated in the paediatric population. To date, there is scant evidence from randomised controlled trials (RTCs) to judge whether better outpatient care could reduce the need for inpatient care in C&A psychiatry. 9 In the absence of RCT data, prospective multicentre audits should be carried out. School – based programmes are likely to prove of particular importance, reaching a far greater proportion of the population than any intervention based within child psychiatry. One systematic review identified 28 school-based programmes that reduced depressive symptoms. 10 Another systematic review supported the use of parent training and child social skills training to prevent conduct disorder and universal school-based cognitive behavioural therapy programmes to reduce anxiety. 11 The effect of policies in many sectors on C&A mental well-being needs to be recognised. For example, paid parental leave in the first year of life not only reduces child mortality 12 but also promotes child development and mental health. Integrated perinatal prevention remains patchy and without powerful champions 13 but a number of recent policy documents embed mental health provision firmly within broader social policy and emphasise the importance of school health. These include the 2007 WHO Forum ‘Social cohesion for mental well – being among adolescents’, the ‘Mental Health Action Plan for Europe’, and the ‘European Pact on Mental Health and Well – being. The lack of existing comparative data in the region was addressed by the Child and Adolescent Mental Health in the Expanded European Union (CAMHEE) project, 14 which collated information on existing services, identifying examples of best practice, and establishing knowledge networks to share them. Economic evaluation of interventions needs to take into account long-term savings not only to the health service, but also to the education, social services and criminal justice systems. Social return on investment (SROI) analyses delineate the significant benefits to the child, family and state, across all sectors, that prevention and effective intervention for children’s mental health can provide. References 1 Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. The Lancet 2007;369(9569):1302 – 13. 2 WHO. Mental Health web page, 2014. At: http:// www.who.int/topics/mental_health/en/ 3 WHO. Atlas: child and adolescent mental health resources: global concerns, implications for the future. Geneva: WHO, 2005. At: http://apps.who.int/ iris/bitstream/10665/43307/1/9241563044_eng.pdf Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.1 | 2014 19 4 Scoliers G, Portzky G, Madge N, et al. Reasons for adolescent deliberate self-harm: a cry of pain and/or a cry for help? Findings from the child and adolescent self-harm in Europe (CASE) study. Social Psychiatry and Psychiatric Epidemiology 2009;44(8):601 – 7. 5 Wilkinson R, Pickett K. The Spirit Level. London: Penguin, 2010. 6 Child Health Support Group. Inpatient Working Group – Psychiatric Inpatient Services. Edinburgh: Scottish Executive, 2005. At: http://www.scotland. gov.uk/Resource/Doc/35596/0012563.pdf 7 Woodgate M, Garralda M. Paediatric liaison work by child and adolescent mental health services. Child and Adolescent Mental Health 2006;11:19 – 24. 8 Henderson J, Redshaw M. Anxiety in the perinatal period: antenatal and postnatal influences and women’s experience of care. Journal of Reproductive and Infant Psychology 2013;3(5):465 – 8. 9 Shepperd S, Doll H, Gowers S, et al. Health care services instead of admission to hospital for young people or children with mental health problems. Cochrane Summaries 2009. At: http://summaries. cochrane.org/CD006410/ 10 Calear AL, Christensen H. Systematic review of school – based prevention and early intervention programs for depression. Journal of Adolescence 2010;33(3):429 – 38. 11 Waddell C, Hua JM, Garland OM, Peters RD, McEwan K. Preventing mental disorders in children: a systematic review to inform policy- making. Canadian Journal of Public Health 2007;98(3):166 – 73. 12 Tanaka S. Parental leave and child health across OECD countries. Economic Journal 2005;115(501):F7 – 28. 13 Myors KA, Schmied V, Johnson M, Cleary M. Collaboration and integrated services for perinatal mental health: an integrative review. Child and Adolescent Mental Health 2013;18:1 – 10. 14 Braddick F, Carral V, Jenkins R, Jané-Llopis E. Child and Adolescent Mental Health in Europe: Infrastructures, Policy and Programmes. Luxembourg: European Communities, 2009. At: http://ec.europa.eu/health/ph_determinants/ life_style/mental/docs/camhee_infrastructures.pdf Introduction Children are not just small adults. Yet when they need medicine they are often treated as if they were, given drugs tested only on adults and without any additional evaluation. 1 Typically, the only concession is to scale down the dose to take account of the child’s smaller body size. However, children differ in many ways beyond size; differences in metabolic pathways or delays in development of the receptors on cells to which drugs bind mean that a drug may have very different effects in a child, in some cases leading to serious adverse consequences. For the same reasons, it may not be clear what the correct dosage should be, a situation not helped by the use of arbitrary divisions in guidance based on age. Moreover, adverse reactions are substantially under-reported. 2 A further problem arises because of the way that medicines are formulated. Obviously, very young children cannot use inhalers and may not be able to take tablets. Yet the way that the medicine is produced may have implications, in some cases poorly understood, for its stability and bioavailability*. This poses a dilemma for paediatricians. Should they just make an arbitrary decision about what to use, in what dosage, based on rules of thumb? Or should they withhold a potentially life-saving treatment because it has not been evaluated formally for use in children? In practice they tend to do the former, engaging in what is termed off-label prescribing. Yet, when they do so, surveys indicate that a majority have concerns about the safety of what they are prescribing, even though they also believe that their decisions are the inevitable consequence of the situation they are faced with. 3 * Bioavailability concerns drug absorption, specifically the fraction of an administered dose of unchanged drug that reaches the circulation. PRESCRIBING FOR CHILDREN By: Martin McKee Summary: Every day, children throughout Europe are given medicines that have only been evaluated on adults, even though their effects and side effects may differ considerably and, in some cases, the children may be exposed to considerable risk. There are many challenges in evaluating medicines in children. These have been addressed by measures, initially in the USA but subsequently in the EU, that incentives manufacturers to evaluate the use of their drugs in children, with valuable extensions on patent life. However, so far, the response from industry has been quite limited. Keywords: Children, Paediatric, Medicines, Safety, Clinical Trials Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine and Research Director, European Observatory on Health Systems and Policies, United Kingdom. Email: martin.mckee@lshtm.ac.uk