This position statement outlines the role of paediatricians in supporting children and young people’s (CYP) mental health and includes key policy recommendations.
It is intended to:
- Inform paediatricians about the current mental health landscape
- Describe the role of paediatricians in supporting children’s mental health and wellbeing, alongside the rest of the children’s workforce
- Be aspirational about a future of working in a more integrated way across mental and physical health and achieving a better future for children and young people and the workforce which support them - this includes RCPCH’s national policy calls for improved support, training, and increased capacity across the paediatric workforce
- Outline what the College is doing on CYP mental health, and link to relevant national guidance, resources and legislation.
Childhood mental health problems are common and increasing: almost one in in five (18%) children aged 7-17 has a probable mental disorder, a 50% increase from 12% in 2017.1 While some of this reflects longer-term trends, the COVID-19 pandemic had a stark impact on the mental health of many children and young people across the country.
As former Children’s Commissioner Anne Longfield highlighted, children were “placed at the back of the queue” during the pandemic, with decision makers failing to consider the impact of school closures, social isolation and reduced access to health services. Eighty percent of young people surveyed by Young Minds reported that their mental health was worse because of the COVID-19 pandemic, and two thirds thought it would have a long-term negative impact on their mental health.2
Alongside an increased rate of poor mental health, there have been changes to the type of mental health need reported, with increased complexity and acuity, a rise in the number of younger children reporting difficulties and an increase in rates of self-harm and eating disorders over the last few years.
There is a need for greater investment to increase the capacity of child and adolescent mental health services (CAMHS) for children who need them, and psychiatrists and wider mental health teams play a vital role in supporting children and young people’s mental health. However, it is clear that specialist mental health services cannot be expected to care for every child with any mental health need alone, any more than paediatric secondary care should be required for every child with a physical health complaint. There is a place for all professionals working with children to support their mental wellbeing, recognise and respond well to childhood mental ill health, and refer children to onward support if it is needed.
While paediatricians should not be expected to take on psychiatric roles such as the diagnosis and pharmacological treatment of acute mental illness, child health encompasses both mental and physical wellbeing, and paediatricians are uniquely well placed to play a role in supporting children’s mental health. It has never been more important for paediatricians to recognise that the mental health of our patients is our business.
- Childhood mental health problems are common and increasing: almost one in five (18%) children aged 7-17 now has a probable mental disorder, a 50% increase from one in nine (12%) in 2017.1
- Childhood is the key time to intervene: 50% of lifetime mental health problems are established by the age of 14, and 75% by the age of 25.3
- We are increasingly aware of the importance of good mental health in early childhood, and there are worrying signs this may be worsening. NHS Digital estimate that 5.5% of children aged 2-4 now have one or more mental health conditions.4
- The number of younger children reporting mental health difficulties and seeking support has increased. Childline reported a 29% increase in children aged 5-11 seeking support for their mental health,5 echoing reports from the Care Quality Commission that younger children have started to present with poor mental health over the last few years.6
- There has also been an increase in ‘significant’ mental illness and the number of children and young people experiencing mental health crises. This includes increases in emergency department attendance and hospital admissions due to mental ill health, suicide attempts, self-harm and eating disorders.
- Rates of self-harm remain high for young people, with almost a quarter (24%) of 17-year-olds self-harming each year. Suicide remains the leading cause of death for young people in the UK.7
- Mental health problems are not evenly distributed across society and intersect with other forms of inequality and vulnerability. Children from low-income households, parental mental illness, LGBT+ children and young people, those with special educational needs or disabilities, looked after children, and those in the criminal justice system are all significantly more likely to experience poor mental health. There are also geographical differences, and children and young people in Northern Ireland are around 25% more likely to experience anxiety, depression and ‘psychotic-like experiences’ than children in England, Wales or Scotland.8
- Physical and mental health needs are frequently comorbid in children. Nearly three-quarters of children and young people with a mental illness also have a physical health or developmental problem.4 Having any physical illness increases the likelihood of having a mental illness by 82%.9 This means it is highly likely that many of the children seen in paediatric clinics will have experienced poor mental health or may have a diagnosed or undiagnosed mental illness.
COVID-19, the cost of living crisis, and the wider context
- While some of the increase reflects longer-term trends, the COVID-19 pandemic introduced new challenges and impacted the mental health and wellbeing of many children and young people across the country.
- Eighty percent of young people surveyed by Young Minds said the COVID-19 pandemic had made their mental health worse, while 67% believed that the pandemic would have a long-term negative effect on their mental health.2
- There have been changes to the type of mental health need reported during this time, with a notable increase in complexity and acuity, and an increase in younger children reporting difficulties.10 11 12
- The number of young people completing an urgent referral for eating disorders increased by 141% from 2020 to 2021.13 NHS Providers estimated a 72% increase in CAMHS referrals during the pandemic.14
- Wider societal, economic and environmental factors have also negatively impacted the mental wellbeing of many children.
- Over half (56%) of young people aged 11-25 years old reported that the cost of living crisis was their major worry, with disruptions to daily life, especially related to diet and sleep. Children are also impacted, with 21% of 11-year-olds reporting that money worries had caused them stress, anxiety, unhappiness, or anger.15
- Social disruptions such as bullying, discrimination and national and international conflicts can also impact children and young people's wellbeing.
- ‘Eco-distress’ is an emerging concept that refers to children’s overwhelming or unmanageable feelings of anxiety when they hear about the environmental threats of climate change. A recent survey found that 73% of young people and young adults felt climate crisis was having a negative effect of their mental health.16
Access to services and support
- Problems accessing mental health support are not new, but they have been exacerbated during and since the COVID-19 pandemic. Access to timely support is vital to support children’s mental health and prevent children and young people ending up in crisis, yet 85% of providers say they are now struggling to keep up with demand. 100% of mental health trust leaders said demand for child health services had significantly (80%) or moderately (20%) increased during the pandemic, with 84% saying there had been an increase in waiting times as a result.14
- A review of mental health provision by the Northern Ireland Children’s Commissioner “found a system under significant pressure, finding it different to respond to the scale of need, and the complexity of issues children and young people are presenting”.17
- The number of children seeking mental health support has risen across the whole system, not only for CAMHS but across primary care, online tools such as Kooth and Childline, in education settings, paediatric services, and emergency departments.
- As a result, almost a quarter of a million children in the UK who were referred for mental health services were subsequently denied support.18
- The College’s engagement with children and young people through RCPCH &Us highlighted low levels of trust in mental health services as a result of increased waiting times and thresholds. While we continue to advocate for increased funding for CAMHS, all services working with children have a role to play in supporting their wellbeing and addressing mild to moderate mental health needs.
- Over the last few years, there has been investment to expand mental health provision in education settings across the UK. While education-based support has a limited scope of practice and is focused on early intervention, low level mental health needs and changes to school ethos and culture, it is nevertheless an important part of the wider system of support for children.
- In England, Mental Health Support Teams have been rolled out to a quarter of schools and colleges, with the aim of supporting children and young people with mild to moderate mental health needs such as low mood, anxiety and depression.
- In Wales, CAMHS in-reach teams provide liaison, consultancy, and advice to education settings to equip them to better support students’ mental wellbeing.
- The Scottish government has also invested in education-based mental health support and have committed to ensuring every secondary school has access to counselling services.
What is the role for paediatricians in supporting children’s mental health?
Paediatricians are uniquely well placed to support children’s mental health and can do five key things to play a key role in health promotion, early recognition, onward referrals, and the provision of holistic, joined-up care.
1. Promoting positive mental health and wellbeing in all interactions
- Paediatricians have a powerful role in promoting positive mental health in all their interactions. They should do this by encouraging good sleep, exercise and eating habits, and the importance of play, family, friends, and engagement with education.
2. Early recognition and intervening or referring as appropriate
- A report from the Children’s Commissioner for England found that too many children reach mental health crisis which could have been prevented by earlier intervention from a range of professionals.21 Paediatricians have a key role to play in recognising common signs of poor mental health in their patients and responding well.
- Paediatricians who work with children and young people with long term health conditions, such as epilepsy and diabetes, or with other groups of children who have an increased risk of mental ill health, such as neurodiverse children or looked after children, should consider regular screening for mental health problems.
- Paediatricians should know how to make onward referrals to specialist mental health services when needed. However, there are many children with mild to moderate mental health needs that nevertheless fall below the threshold for CAMHS support. Paediatricians should be aware of and able to signpost to appropriate health, education-based, voluntary sector or online resources available in their local area and nationally.
- All paediatricians should consider their own knowledge and confidence to respond to children’s mental health needs and pursue opportunities for learning and training where there are gaps.
3. Assessing any child or young person by considering the biological, psychological and social factors contributing to their presentation
- Children can present with a range of physical and mental distress that is attributable to a wide range of factors, often undisclosed or unrecognised, which can include adverse events, neurodiversity, family factors including caring responsibilities, bullying, and unhealthy sleep patterns and diets. This distress can manifest in their emotions, behaviours and physical symptoms, many of which present through paediatric services.
- Paediatricians should be able to assess the biological, psychological and social factors contributing to a child’s presentation, and take a child-centred approach. Every complex presentation in children should be considered in a biopsychosocial way. They should feel comfortable explaining the link between mind and body to children and young people and their families.
- Paediatricians should protect young people from the harm of unnecessary investigations and treatments for symptoms when a biopsychosocial assessment suggests there are more appropriate pathways of support.
4. Responding well in inpatient and emergency settings
- While most children and young people with mental health needs should be supported in the community, there are situations where admission to acute paediatric settings may be the most clinically appropriate option due to a lack of safe alternatives.
- Paediatricians working in inpatient and emergency settings should understand the appropriate legislation around mental capacity, and the legal frameworks within which mental illness can be assessed and treated, with and without consent, in the nation within which they work. This includes the Mental Health Act (1983), Children Act (2004) the Mental Capacity Act (2005), and in Scotland, the Mental Health (Scotland) Act (2015), as well as relevant national and local guidance. It is important to recognise that some children and young people may be brought to the hospital as a designated ‘place of safety’ (as set out in Section 136 of the Mental Health Act).
- Paediatricians have a duty to care for children and young people with mental health needs and/or a learning disability or autism in the least restrictive way possible (as per the Mental Health Act and NHS framework for Supporting CYP with mental health needs in acute paediatric settings.) Any use of physical or chemical restraint must be proportional to the risk to self and others, and “the best interests of the child and young person must always be a significant consideration” for clinicians when making decisions (Mental Health Act, 19.5).
- Paediatricians should work with their Trust or Health Board to ensure the physical environment, staffing levels, and necessary training in de-escalation and appropriate restraint are in place to protect children’s rights and safely meet their needs.
- Paediatricians should be aware of trauma-informed models of care and align their practise to reduce any further risk of trauma for children in their care.
- More information about treating a child or young person with mental ill health, including how to assess for capacity (for children) or consent (for young people), the process for decision making, and the approach in emergencies can be found in Chapter 19 of the Mental Health Act (PDF) and supporting guidance. NHS England has published a framework for systems in Supporting children and young people with mental health needs in acute paediatric settings, which includes a series of interactive flowcharts to support decision making.
5. Joint working with mental health teams
- While joint working between paediatric and mental health teams is essential to providing high quality care for children, 38% of paediatric services across the UK said that they did not have an effective joint pathway with CAMHS.22
- Paediatricians should be committed to supporting effective joint working and integrated pathways with mental health services. In addition to local Child and Adolescent Mental Health services, this will include working with mental health teams in education settings, and with voluntary organisations. Paediatricians should seek to work collaboratively, communicate across teams and service boundaries, and pursue joint learning opportunities.
- While there is a crucial role for individual paediatricians to support joint working, join up must be enabled at strategic and operational levels. The coordination of established networks between paediatric emergency medicine, paediatric teams, CAMHS and other emergency and crisis services is needed to better meet the needs of children and young people.
Prevention and protection
- In order to improve children and young people’s mental health and wellbeing, protective factors should be promoted and risk factors minimised. This includes national action to tackle child poverty, improve housing conditions and access to green spaces, and to improve children’s physical health.
- The College is calling for the Government in all four nations to adopt a ‘child health in all policies approach’ and develop a cross-government strategy to improve child health and wellbeing, which considers the role of each department in tackling the causes of ill health and reducing health inequalities.
- Increase funding to expand early mental health support, including funding to expand coverage of Mental Health Support Teams, or national equivalents, to every school and college.
Commissioning, planning and delivering health services
- Increase funding for Child and Adolescent Mental Health Services (CAMHS) to improve access to support, reduce long waits for care, and reduce the number of children who reach crisis while waiting for CAMHS services.
- While it is not the College’s view that every child with a mental health need can be or should be seen by specialist mental health services, it is clear that levels of national spending on children’s mental health services are insufficient and inequitable, particularly when compared to spending on adult mental health services. In England, just 8% of ICB spending on mental health was allocated to children and young people.23 The Northern Ireland Mental Health Strategy commits to spend just 10% of the funding for adult mental health services on CYP provision 24 and the Scottish Government has likewise committed just 1% of the NHS budget to children’s mental health, ten times less than adult mental health provision.25 While these funding arrangements represent slight increases from previous years, they remain significantly below an equitable split based on population demographics or mental health need. Children and young people make up almost a quarter of the population and deserve equitable access to care.
- Health services should be planned around the holistic needs of children and young people. Services should be supported to work together across primary, paediatric, emergency, and mental health teams, and in partnership with social care, education and voluntary organisations.
- Commissioning arrangements should support mental health professionals to work within paediatric teams, and vice versa.
- High quality services for adolescents and young adults are needed, and funding arrangements should allow for developmentally appropriate care to be delivered, rather than reinforce strict age cut offs which can leave young people facing a ‘cliff edge’ of care.
- Implement Mental Health Champion roles in every setting which admits children. In England, the College has called for long term funding of the roles and additional investment to increase the time allocated to the roles to bring them in line with clinical lead roles and named doctors for safeguarding. This model should also be rolled out across Wales, Scotland and Northern Ireland.26
- Improve the design of paediatric wards and emergency settings to ensure they remain fit for purpose and take into account the increase in children and young people presenting with acute mental distress. This should be a priority for the New Hospitals Programme, and there should be additional investment for existing settings to improve their wards and emergency settings. The design of paediatric wards should consider the distinct needs of adolescents, prevent risks such as ligatures, and integrate mental and physical health (as in the Cambridge Children’s Hospital approach.)
- Improve the provision of out of hospital crisis centres for children and young people to provide high quality care closer to home. This includes schemes such as 24/7 peripatetic crisis teams, ‘crisis cafes’ and intensive home treatment teams. This could be funded by reinvesting money saved by decommissioning expensive specialist inpatient mental health beds.
Paediatric education and training
- Children’s mental health and wellbeing should be included within core paediatric training, as reflected in the Progress+ curriculum. Paediatric training must continue to adapt to meet changing population needs, notably the increase in child mental health presentations, and to reflect the growing focus on public health, leadership behaviours, and patient safety.27
- Paediatric Schools should develop activities that encourage postgraduate learning in mental health and embed a thorough understanding of the biopsychosocial approach. The College’s ‘Paediatrician of the Future: Delivering really good training’ guide explores this in more detail.
- Opportunities for joint training between paediatric and child and adolescent psychiatry trainees should be explored.
- The College supports the development and national roll-out of simulation-based, multi-professional training on CYP mental health crisis presentations to increase the confidence and skills of the child health workforce and provide a standardised framework for all professionals to respond well to acute mental health distress. This should cover de-escalation and appropriate use of restraint and restrictive practice. This training should be seen as equivalent to existing ALSG (Advanced Life Support Group) simulation training on resuscitation and safeguarding and should be embedded in training pathways.
What RCPCH is doing
When RCPCH was established in 1996, its mission was to lead the way in children’s health. The College remains committed to improving child health in its broadest sense. The College’s work on mental health includes:
- Establishing a College Officer for Mental Health in 2021, and an intercollegiate Mental Health Committee from 2024 to take forward cross-College work on children’s mental health.
- The College is continuing to develop a portfolio of training courses on mental health and eating disorders to support members, equivalent to level 1, 2 and 3 child protection courses.
- Curriculum and syllabi developed by the College include a focus on skills, knowledge and behaviours related to children and young people’s mental health and wellbeing, alongside their physical health, particularly in the context of long-term conditions. The new Progress+ curriculum includes “an increased emphasis and training to equip trainees with the skills to support children and young people with mental health needs”, and this focus is also reflected in the College ‘Paediatrician of the Future’ training guidance.
- The Child Mental Health Specialty Advisory Committee (CSAC) has developed a special interest SPIN module and sub-specialty training for the smaller number of paediatricians who choose to pursue higher level specialist training in this area.
- The Paediatric Mental Health Association is an RCPCH sub-specialty group who are active in supporting College members with further education resources, training and conferences.
- The College is committed to support the wellbeing of paediatricians, in their working lives and out of it, led by the Thrive Paediatrics programme. A resource hub is available to signpost paediatricians to additional help and support with their own mental health and wellbeing.
- The College is a member of the Children and Young People’s Mental Health Coalition (CYPMHC). CYPMHC has a page of resources for children, young people, parents, and carers which you may want to signpost to. These cover a range of mental health needs, including anxiety, eating disorders, low mood and anger, grief, and how to access mental health support.
- The College continues to advocate for improvements to children’s mental health in national, regional and local health policy across the UK. Recent policy outputs include the RCPCH manifesto, Securing Our Health Future paper (PDF) and work to influence the Major Conditions Strategy, all of which have highlighted children and young people’s mental health and the needs of the paediatric workforce on this issue.
- Children’s mental health will continue to cut across the work of the College, including our engagement with children and young people, and in the upcoming update of the Facing the Future standards for paediatric care.
- 1 a b NHS Digital. Mental Health of Children and Young People in England 2022 - follow up to the 2017 survey. 2022 https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2022-follow-up-to-the-2017-survey
- 2 a b Young Minds. The Impact of Covid-19 on young people with mental health needs. 2021 https://www.youngminds.org.uk/about-us/reports-and-impact/coronavirus-impact-on-young-people-with-mental-health-needs/
- 3Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K., & Walters, E. Lifetime prevalence and age of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 62 (6), 593–602. 2015 jamanetwork.com/journals/jamapsychiatry/fullarticle/208678
- 4 a b NHS Digital. Mental Health of Children and Young People in England. 2017 https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017
- 5NSPCC. Thousands of young people speak to Childline about mental health and abuse during the pandemic. 2021 www.nspcc.org.uk/about-us/news-opinion/2021/children-counselling-sessions-covid-pandemic/
- 6 CQC. State of Care: Children’s and young people’s mental health. 2022 www.cqc.org.uk/publications/major-reports/soc202021_01e_cypmh
- 7 Papyrus. Prevention of young suicide: latest statistics. 2023 www.papyrus-uk.org/latest-statistics/
- 8 Health and Social Care Board. Youth Wellbeing Prevalence Survey 2020. 2020 online.hscni.net/our-work/social-care-and-children/youth-wellbeing-prevalence-survey-2020/
- 9 Meltzer H, Gatward R, Goodman R and Ford T. Mental health of children and adolescents in Great Britain, TSO: London. 2000 pubmed.ncbi.nlm.nih.gov/12745331/
- 10Office for Health Improvement and Disparities. Covid-19 mental health and wellbeing surveillance. 2022. www.gov.uk/government/publications/covid-19-mental-health-and-wellbeing-surveillance-report
- 11 Pierce M, Hope H, Ford T, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. Lancet Psychiatry. 2020. pubmed.ncbi.nlm.nih.gov/32707037/#:~:text=Population%20prevalence%20of%20clinically%20significant,8)%20in%20April%2C%202020.
- 12 Raw JAL, Waite P, Pearcey S, et al. Examining changes in parent-reported child and adolescent mental health throughout the UK's first COVID-19 national lockdown. Journal of Child Psychology and Psychiatry. 2021 pubmed.ncbi.nlm.nih.gov/34327726/
- 13 NHS Confederation. Reaching the tipping point: children and young people’s mental health. 2021 www.nhsconfed.org/system/files/2021-08/Reaching%20the%20tipping%20point%20Final.pdf
- 14 a b NHS Providers. Children and young people’s mental health services survey. 2021 https://nhsproviders.org/media/691473/nhs-providers-children-and-young-peoples-mental-health-services-survey-appendix.pdf
- 15 Young Minds. Youthsight for YoungMinds Movement for Change report and Beano Brain survey for YoungMinds. 2022
- 16British Association of Counselling and Psychotherapy. Public Perceptions Survey. 2023
- 17 NICCY. Still waiting: a rights based review of mental health services and support. 2018 www.niccy.org/wp-content/uploads/media/3114/niccy-still-waiting-report-sept-18-web.pdf
- 18 Based on FOI research from the House and the Guardian, as reported in ‘Buckling NHS fails to treat 250,000 children with mental health problems’, 2023 www.theguardian.com/education/2023/apr/16/buckling-nhs-fails-to-treat-250000-children-with-mental-health-problems
- 19IPSOS. Young People Omnibus, Veracity Index. 2017
- 20 HSSIB. Keeping children and young people with mental health needs safe: the design of the paediatric ward. 2023 www.hssib.org.uk/patient-safety-investigations/keeping-children-and-young-people-with-mental-health-needs-safe-the-design-of-the-paediatric-ward/
- 21 Children’s Commissioner. Children’s mental health services 2021-2022. 2023 assets.childrenscommissioner.gov.uk/wpuploads/2023/03/Childrens-Mental-Health-Services-2021-2022-2.pdf
- 22 RCPCH. Impact of Covid-19 on child health services. 2020. www.rcpch.ac.uk/resources/impact-covid-19-child-health-services-report-2020
- 23 NHS England. Mental Health Dashboard: mental health services funding and investment. 2023 www.england.nhs.uk/mental-health/taskforce/imp/mh-dashboard/
- 24 Department of Health. 2021-2031 Mental Health Strategy. 2021 www.health-ni.gov.uk/sites/default/files/publications/health/doh-mhs-strategy-2021-2031.pdf
- 25 Scottish Government Mental Health Directorate. Child and adolescent mental health services financial aid: FOI release. 2022 www.gov.scot/publications/foi-202200278374/
- 26 Please note that Northern Ireland has a governmental ‘Mental Health Champion’ to advise the government on mental health policy and support the delivery of the NI mental health strategy. Given this background, these clinical mental health champion roles may need to be renamed and adapted for the NI context.
- 27 RCPCH. Paediatrician of the future: delivering really good training. 2020 www.rcpch.ac.uk/sites/default/files/2021-03/rcpch-paediatrician-of-the-future-delivering-really-good-training.pdf