0-25 models and transitions: the scale of need Dr Bernadka Dubicka chair faculty C&A psychiatry RCPsych honorary reader University of Manchester consultant Pennine Care Foundation Trust, Manchester London 2019

EU Milestones study Signorini EJCAP 2018 25-49% CAMHS YP will need transitioning ~1/3 AMHS users under 30 yrs with previous contact with CAMHS Only Denmark & UK have transition policies/guidelines UK YP concerns: eligibility, culture, lack connections between CAMHS/AMH, AMH competencies

Preschool children (2 to 4 year olds) One in eighteen (5.5%) preschool children had a mental disorder. (SLIDE 11 of Summary Report) This survey also included preschool children (2-4 year olds) for the first time Early childhood is an important phase for children, where a child develops language and other social skills. This survey interviewed parents of preschool children and found one in eighteen preschool children experienced difficulties with their mental health. These figures are classed as experimental statistics, as they have used an adapted version of the Development and Well-Being Assessment to be age appropriate for parents of 2 to 4 year olds. Whilst it’s helpful produce headline findings, it is important to delve deeper into how the mental health of children and young people differed by age and sex. Background info (if needed) Specific disorders: Oppositional defiant disorder 1.9%. Autism spectrum disorder (ASD): 1.4% Other disorders of specific relevance to this age group sleeping (1.3%) feeding (0.8%) disorders The prevalence of mental disorders for two to four year-olds in England has been surveyed for the first time so these figures are experimental statistics. Source: NHS Digital. 2 to 4 year olds identified with any mental disorder, England.

Learning disability: importance of early detection 4.5x more likely to have MH disorder EU: neurodevelopmental disorders most frequent diagnostic group (up to 81%) in CAMHS (Signorini, 2017, Lancet Psych) Institute Health Equity 2018: 40% LD not diagnosed in childhood Die 15-20 years before general population

NHS Digital prevalence survey 2018 Emotional disorders, 1999 to 2017 The increase since 2004 in emotional disorders is evident in both boys and girls. In boys, from 4.2% in 1999 and 3.3% in 2004 to 5.6% in 2017. And in girls, from 4.4% in 1999 and 4.5% in 2004 to 6.1% in 2017. Source: NHS Digital. 5 to 15 year olds identified with a mental disorder, England.

Prince’s Trust Macquarie Youth Index 2018 2,194 respondents,16 to 25 years happiness & confidence dropped to lowest levels since 2009 61% regularly feel stressed 1/4 regularly feel hopeless those who don’t feel in control of their lives increased from 28% (2017) to 39%

15.4% of 17 to 19 year olds had ever self-harmed or attempted suicide (SLIDE 24 of Summary Report) Overall, 15.4% of 17 to 19 year olds reported having ever self harmed or attempted suicide. Rates were twice as high in girls (21.5%) as boys (9.7%). Rates of self-harm and attempted suicide in 17 to 19 year olds were five times higher in those with a mental disorder (46.8%) than in those without (9.0%). These associations were evident in both boys and girls. One in two (52.7%) 17 to 19 year old girls and one in three (34.1%) 17 to 19 year old boys with a disorder had ever self-harmed or attempted suicide.

Differences between boys and girls Differences were also found between boys and girls. For preschool children and primary school aged children, boys were more likely than girls to have a mental disorder. Primary school aged boys were nearly twice and likely as girls to have a mental disorder. When children reached secondary school age, boys and girls had similar rates of mental disorders. When children become young adults, one in four young women experienced a mental disorder. In comparison, one in 10 young men had a mental disorder. Background info: Why young women higher: The reasons for this are likely due to a complex interaction of biological and lifestyle factors, however the extent of influence of different factors remains unclear (NHS Choices, 2016). Source: NHS Digital. 2 to 19 year olds identified with any mental disorder, England.

Sexual Identity (14 to 19 year olds) Young people who identified as lesbian, gay, bisexual or as another non-heterosexual sexual identity were more likely to have a mental disorder (SLIDE 16 of Summary Report) This survey also asked children aged 14 to 19 about their sexual identity. We found one in ten children aged 14 to 19 identified as a non-heterosexual identity (that is, gay/lesbian, bisexual or another sexual identity). And in relation to mental health, we found young people who identified as lesbian, gay, bisexual or with an other sexual identity were more likely to have a mental disorder (34.9%) than those who identified as heterosexual (13.2%). Source: NHS Digital. 14 to 19 year olds identified with any mental disorder, England.

Social and Family Context (5 to 19 year olds) Children with a mental disorder were more likely to live in a family that struggles to function well, as well as where a parent struggles with poor mental health. (SLIDE 18 of Summary Report) This survey also collected information on a range of social and family indicators. These can be found in the topic repots published today. Highlighting two of these factors: Children with a mental disorder are more likely to live in a family that struggles to function well. For example, families who do not get on well together or struggle to understand each other) Mental disorders in children were associated with parental mental health. For example, children who have a parent who struggles with their mental health were more likely to have a disorder themselves. There will be many reasons for this: unhealthy family dynamics or poor parental mental health may contribute to mental disorders in children, However families, and in particular parents, dealing with the needs of a child with poor mental health may struggle to cope. In either case, the findings of this report will be a valuable resource for policy makers and service providers working not only with children, but also with their families and schools. Source: NHS Digital. 5 to 19 year olds identified with any mental disorder, England.

Exclusion from school One boy in ten with a disorder had been excluded from school One child in twenty with a hyperactivity or behavioural disorder had been excluded on three or more occasions. (SLIDE 25 of Summary Report) Boys with a disorder (9.9%) were more likely than girls with a disorder (2.4%) to be excluded from school. One boy in ten with a disorder had been excluded, around half of whom had been excluded multiple times. One child in twenty with a hyperactivity or behavioural disorder had been excluded on three or more occasions.

Prevalence of Neurodisability for YP in custody Hughes, Williams and Chitsabesan, 2012 Neurodevelopmental disorder Reported prevalence rates amongst young people in custody Reported prevalence rates amongst young people in the general population Learning disabilities 23 - 32% 2 - 4% Dyslexia 43 - 57% 10% Communication disorders 60 - 90% 5 - 7% Attention deficit hyperactivity disorder 12% 1.7 – 5% Autistic spectrum disorder 2.3 – 30% 0.6 – 1.2% Traumatic brain injury 65.1 - 72.1% 5 - 24% Epilepsy 0.7 – 0.8% 0.45 – 1% Foetal alcohol syndrome 10.9 - 11.7% 0.1 – 5%

76% suicides male male to female ratio: 2.6:1 in those aged 15-19 3.7:1 in those aged 20 and over Source: Suicide by Children and Young People (2017) National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

Recruitment and Retention Only 1/4 CYP with MH disorder treated in UK (NHS digital 2018) 10 yr plan: 100% of those in need 0-25 yrs Green paper requires doubling workforce If aim to treat 100% disorder, 6-fold increase needed (based on past figures and to 18) CAP all grades, incl trainees, England 2009-18

RCPsych activities Training, values, recruitment, QI

0-25 RCPsych position paper in progress No one model Services need to be age appropriate with staff trained in the developmental needs of each age group (infants, children, adolescents, young adults), & training on developmental disorders CYP centred, accessible, values driven with patient choice and shared decision making ‘think family’ ‘think systems’ Quality, evidence and outcomes driven Build on good current practice with considered implementation, lessons learned Flexible Needs must be matched by resource

Where next? Build on recent progress NHSE Long Term Plan: 18-25 services & offer for 0-25 yr olds: integrated approach (‘iThrive’); student mental health services Trained, supported workforce + resource + values + meaningful participation Levers e.g. CQUIN STPs/LTPs: incl service users Peer reviews and outcomes e.g. Benchmarking Network, RCPsych Quality Improvement Network Research e.g. EU MILESTONES study (Singh)

Thank you: Questions Bernadka.Dubicka@manchester.ac.uk