I have just completed my training post in community paediatrics, where I have seen countless children with behavioural and mental health difficulties. I feel utterly compelled to share the degree to which the service is stretched, and across the country we are failing these children. Admissions to hospital for self harm have increased by 15%, child suicide rates show no sign of declining and horrific deaths, such as children hanging themselves, are increasing.
The typical child I saw came in because their school or their parents wanted to give them a diagnosis like attention deficit and hyperactivity disorder (ADHD) to explain their problems, to medicalise/medicate them. Understandably, their behaviour had become too difficult to manage without extra support, and so people asked us as healthcare professionals to provide it.
But there was no quick fix. Even with a child that had a genuine diagnosis of ADHD, a formal diagnosis would take more than a year and getting an appointment for medication to be prescribed would take even longer. However, a diagnosis wasn’t always going to be helpful, or even accurate. Every child had their unique story, but the underlying causes for most of their behavioural difficulties were infinitely more complex than seemed to be acknowledged, and the time for action to prevent problems arising was long gone by the time they got to clinic.
I want to paint you a typical story from an amalgamation of real experiences I have had with real patients.
It starts with future parents handicapped by life circumstances that were not their fault. Lack of a secure and well paid job, but not through lack of trying. Unfit housing: overcrowded, with the infrastructure breaking down, full of health hazards like mould or mice infestations, lack of space, with little, if any, support. The parents may also have had their own difficulties that amplified the problem: lack of education, their own potentially troubled childhoods, perhaps medical problems, maybe mental health problems, or addictions; the list of potential issues was endless. These people needed support, but were not receiving it, even before having a child.
And then the parents have a child. No doubt one that is genuinely loved. But into what situation is that child born? The fourth largest economy in the world, yet with a quarter of all children born into poverty.
A child brings greater costs to the family, yet any extra employment has to be balanced against the need to love and spend time with their baby. Parents work tirelessly on minimum wage or zero-hour contracts, exhausted and not able to maximise the quality of those precious few moments left for their children. The problems with housing get worse. The family get poorer. The physical and mental health of the parents deteriorate. The strain on the partnership may lead to separation, making the environment even more challenging.
This inevitably affects the child’s physical health. They pick up infections from the home. Even basic things like food get neglected: three million children are left hungry during the school holidays because those children are dependant on the free meals that they get during term time. They are left helpless.
Applying for support is so difficult both practically and psychologically. Families are scared because they don’t want to be labelled as neglecting their children, and they do not necessarily know the best way to put forward their case for help. Even if they do, where are they going to find the time to fill in all the paperwork and to attend all the appointments? Where do they find the services when the National Health Service (NHS) is more overstretched than ever before?
All this strain takes its toll on the child’s well-being and mental health, affecting their behaviour. It’s hard to live in such an environment so challenging, with the school environment often making things worse, not better. With class sizes in school increasing more and more, teachers, through no fault of their own, are able to give less and less attention to those that require extra help. The child, after underperforming at school and not knowing how to cope with their complex social situations, may get bullied or lash out at other children or teachers. I have seen children whose teachers have said:
But then how do you expect the parents to be able to manage? Who taught them how to deal with the complex behaviours of a child with difficulties beyond what trained professionals can manage?
And then the child continues to suffer. Self harm. Even suicide. I will never forget seeing an eight year old girl that still had fresh bruises on her neck from having attempted to hang herself. I spoke to the children’s mental health team every week. They do such good work when they can, but with a third less staff than they need, the commonest response that I hear is an acknowledgement of the child’s problems, but that in the current climate they do not meet the threshold for care, as there are so many other children in more urgent need.
As a doctor I feel so helpless, because I physically see children with mental health problems suffering, yet what I can offer does not match what is needed. It has reached the stage where children are setting up groups in schools to help other children manage their wellbeing: is this really the best we can offer? Children having to support children? I don’t just see it in my medical life. I remember walking back to my car after eating out at a nice restaurant, and finding a teenage boy crying lying under my car. He was lucky that he was crying, otherwise I may have ran him over from not hearing him. I felt compelled to speak to him and then drove him back home. His overwhelming sentiment was that he couldn’t believe that someone would be so nice to him – he was so isolated and depressed. It was so sad that being kind to someone with a mental illness was seen as surprising not the norm.
There is a whole plethora of diagnoses we can label a difficult child with: ADHD, oppositional defiant disorder, conduct disorder, depression, anxiety, post traumatic stress disorder. At best, this accelerates a child getting extra support at school, psychological therapy, financial support, and perhaps medication. But too often none of that is available, and the child is left with a permanent label which medicalises and shines a spotlight on their difficulties but without any real help with getting them better in exchange.
I have looked around the world at other models for managing mental health problems in children to see what is out there. It is so important to find a solution, with 1 in 4 people suffering from a mental health problem, and 75% of mental health problems having started in childhood. Investment in child mental health is investing in the future, and places like Australia have really made things work with Headspace centres which I’ve visited and personally seen how they prioritise early and accessible intervention, tailored to suite the needs of the children. They have provided over 1.5 million services, across 93 centres, making a real difference, and growing rapidly with cross party support.
But the solution is so much more than acute mental health services. The story of this child’s mental health and its risk factors began with socio-economic factors outside of their control. And then housing policy, welfare policy, school policy. With healthcare then expected to deal with the consequences of all the upstream failures. This is why the Royal College of Paediatrics and Child Health advocate that every policy made my government within health and outside of this is looked at through the lens of “Will this harm children?”.
For now though, when seeing such children, I have done what I could, with the limited power that I had. Referring vulnerable children to support services hoping that they will have the resources to accept an extra referral, even as a favour to me. Asking the parents to look after their own wellbeing and find time to see their own GP because it is so difficult to manage it these complex situations on their own. Making people aware of courses available in the private sector to help improve their child’s life, because no equivalent is available in the NHS. Letting them know about free support available through organisations such as the NSPCC, through programmes like Childline (whom I am supporting personally this year by running the London Marathon) which takes up to 50 calls a day from children.
Most of the time, the best thing I have been able to offer is a listening ear: one that can empathise with the suffering of these families. And maybe offer tiny suggestions that may at least be a small part of the solution. I saw a boy that had recently felt suicidal, and when we talked about what made him happy he said that his only outlet for expressing his emotions was singing. So by sitting down with him and his family we identified ways in which he could nurture this through community groups, making it even bigger part of his life. He is now going to attend a choir every Sunday.
The budget for children’s services in the NHS has dropped by 16% nationally, and perhaps even more shockingly this extends to 27% in the poorest areas. Why is there not more of an outcry? We have heard lots of rhetoric about mental health services being prioritised, greater investment, but often money allocated to it in hospital budgets gets redirected to other areas because of perceived greater priorities.
I sat with a mum who burst into tears as I spoke to her about her daughter’s severe mental health problems that were not getting better.
Less than a quarter of mental services needed for children are currently in place. I couldn’t help but let out a momentary cry, knowing the potential path this family could go down.
There is hope and there are solutions. Prioritising child mental health is about more than just rhetoric; it needs to translate into action on the ground like in Australia and other countries that are allocating more of their budget to children’s services. We should demand clearer, practical, local and urgent change, or the dark cloud of preventable mental health problems will continue to engulf us.
Here’s a nice drawing a little girl did for me on my last day of her and her family in the room. It made me smile not just from its content, but also because despite horribly suffering herself, this lovely girl still cared enough to make other people happy.