Role of paediatricians in supporting children and young people's mental health - position statement

Key facts

• Mental health problems in children and young people are a broad and diverse category of conditions, encompassing emotional, behavioural and neurodevelopmental presentations.
• Mental health problems are common and increasing in the child and adolescent population. One in eight 5-19-year-olds in England have a mental health problem, while 17-19-year-old girls have the highest prevalence rate of one in four. Rates of emotional disorders (anxiety and depression) show the biggest increase, from 3.9% in 2004 to 5.8% in 2017.1  Better prevalence data across the UK is a key recommendation in the State of Child Health 2020 report.2
• Nearly three quarters of children and young people with a mental disorder also have a physical or developmental problem.1  Having any physical complaint (compared with no physical health condition) increases the odds of having a mental disorder by 82%.3
• Most mental health problems present in the child and adolescent age range. Fifty percent of all mental health problems are established by 14 years of age and 75% by age 24.4
• Suicide is now the leading cause of death for both males and females 5-19 years of age across England and Wales.5  Suicide rates are significantly higher in children and young people in Northern Ireland than the rest of the UK.6  
• Risk of developing an eating disorder is highest in males and females between 13 and 17 years of age. Anorexia nervosa has the highest mortality of any psychiatric disorder in adolescence.7

The COVID-19 pandemic has further increased concerns of mental health problems in children and young people due to the stresses associated with prolonged school closures, social isolation, adverse social and environmental circumstances and the lack of access to the usual support services. 

Key considerations

• Mental health problems present as primary, secondary or comorbid problems to paediatricians across all settings including acute presentations, inpatient admissions, emergency settings, general paediatric outpatients and community child health services. Anecdotal evidence from RCPCH members suggests that mental health issues are present in approximately 20% of acute admissions and 40% of outpatient consultations.
• Historically, it has been challenging for paediatricians to recognise and address mental health issues. Twenty percent of children in general paediatric outpatient departments have a diagnosable mental health problem, but only 25% of these are detected by paediatricians. Mental health problems are more prevalent in those with long term physical health conditions and in some conditions, such as epilepsy, is as high as 75%.8
• Children and young people with comorbid physical ill-health and mental ill-health appear even less likely than other children to have their mental illness detected, diagnosed and correctly treated.8  The mental health aspects of unexplained physical presentations are not always evident to paediatricians, which can lead to an unnecessary and potentially harmful overemphasis on medical investigations.9
• Community and neurodisability paediatricians frequently take a lead role the assessment and management of neurodevelopmental disorders such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD).
• Mental health problems are more common in vulnerable children and adolescents, such as from low income families, those with parental mental health problems, LGBTQ+, special educational needs, not attending school, on child protection plans, looked after children, and in the criminal justice system.
• According to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), mental health care is not given the same level of importance as physical health care for young people and young adults in general hospitals across the UK. Their recommendations include a clinical lead for children and young people’s mental health in all acute general hospitals.10
• The underinvestment in children and young people’s mental health and difficulties in accessing specialist Child and Adolescent mental Health services (CAMHS) for children and young people have been a longstanding concern across the UK.11 12  13  14
• There are key policy documents for England, Scotland, Wales, and a draft for Northern Ireland, which have common expectations around the emotional wellbeing and mental health services for children and young people. These include a focus on mental health support in schools, promotion of mental wellbeing, early recognition of mental health problems, and early intervention and support by the whole children’s workforce before the level of specialist CAMHS, with improved access to local specialist services.15  16  17  18  
• The NHS in England, Scotland and Wales have committed to additional funding for child and adolescent mental health services that will grow faster than both overall NHS funding and total mental health spending. All have similar expectations that include increased access to CAMHS, developing services for 0-25 year olds, 24 hour mental health crisis care provision and mental health liaison services that will meet the needs of children and young in acute hospitals. In addition to upskilling of the whole children’s workforce with an emphasis on integrated working.16  17  19  
• There are specific standards for access and waiting times for children and young people with eating disorders in England, with clear direction on the involvement of paediatricians in the patient pathway.20

Key messages

It is not intended that paediatricians take on psychiatric roles such as the diagnosis and pharmacological treatment of mental illness, nor that paediatric services take on patients who would otherwise be referred to CAMHS. However, the mental health of our patients is our business.

• Paediatricians have a role in raising awareness of mental health problems in children and young people, promoting parity of esteem for physical and mental health, and reducing stigma associated with mental illness.
• Paediatricians should be promoting good mental health in all their interactions with children and young people by encouraging good sleep, exercise and eating habits, promoting good parenting, education, and being aware of and signposting to appropriate online and community-based resources. 
• Paediatricians should be able to assess any children and young people by considering the biological, psychological and social factors contributing to their presentation.
• Paediatricians, working across all areas of child health, must develop the knowledge and skills to identify, support and make appropriate onward referrals for common mental health problems in the children and young people that they see. Those likely to encounter high rates or greater complexity, such as Community Child Health, emergency medicine and neurology, should develop additional competencies through more in-depth training. Paediatricians working with children and young people with long term health conditions should consider regular screening for mental health problems.
• Paediatricians must protect young people from over medicalisation and harm from unnecessary investigation for physical symptoms when the biopsychosocial assessment suggests there are more appropriate pathways of support. They should feel comfortable explaining the link between mind and body to children and young people and their families.
• Paediatricians should have knowledge of the appropriate legislation around mental capacity and the legal frameworks within which mental illness can be assessed and treated without consent in the country in which they work.
• Paediatricians should be committed to developing effective joint working and integration with mental health services for children and young people to provide patient centred pathways that meet mental health needs as well as physical needs. In addition to the local Child and Adolescent Mental Health services this will include the mental health support available through the wider children's workforce including the third sector, social care and education services.

What is RCPCH doing about this?

• We have a Child Mental Health (CMH) Specialty Advisory Committee (CSAC), who are developing a Special Interest (SPIN) module. The CMH CSAC also oversees the small number of sub-specialty trainees on the Paediatrics (Child Mental Health) sub-specialty training pathway.
• We have developed the Progress curriculum for all paediatric trainees to include children and young people’s mental health at all levels and in all domains. We are now working with local schools of paediatrics on delivering more training opportunities for all trainees in the mental health aspects of the curriculum, following implementation of the new Shape of Training pathway.
• We are running regular courses for paediatricians to improve practice in this area and are developing webinars on key topic areas.
• We have partnered with MindEd to produce a paediatric ‘learning path’ so that paediatricians can select content relevant to their needs as part of online training and CPD.
• We are working with colleagues in other professional organisations, including Royal College of Psychiatrists, Royal College of General Practitioners and British Psychological Society to build partnerships in training, research and policy.
• We have an Assistant Officer for Mental Health on the Health Improvement Committee. Part of their work is to advocate for children and young people’s mental health in all areas of College work.
• We host a multi professional organisation steering group who are working alongside NHS England (NHSE) and Health Education England (HEE) to support the implementation of the NHSE Long Term Plan (LTP) for children and young people’s mental health. 
• In England we have developed RCPCH Ambassador roles to work with local Sustainability and Transformation Partnerships and Integrated Care Systems to advocate for the needs of children and young people and to support appropriate implementation of the NHSE LTP in local areas, with a spotlight on children and young people’s mental health services.
• We developed Facing the Future: Standards for paediatric care which outlines how to ensure children and young people have timely access to mental health services.

RCPCH recommendations

Training

• Paediatric training (general and sub-specialty) must include promotion of mental wellbeing in children and young people, and identification and management of common primary, secondary and comorbid mental health problems presenting in paediatric settings.
• Paediatricians who are likely to encounter higher rates or greater complexity of mental health problems, such as community paediatrics, emergency medicine and neurology, need more extensive training and support.
• Increasing numbers of paediatricians with a special interest in mental health are needed to advocate for the mental health needs of children and young people, educate colleagues, develop mental health services for children and young people in paediatric settings and develop working relationships and integrated pathways with CAMHS and other community services for children and young people’s mental health.

Service system

• Paediatric services should work with their local commissioning structures to provide local pathways, which improve access to mental health services, alongside CAMHS and other agencies in their area.
• All paediatric teams should have a nominated lead for mental health.
• For common presentations to paediatric settings where both physical and mental health input is needed to provide the most appropriate care, local protocols should be agreed which provide effective joined up working with mental health services, minimises duplication and makes the most efficient use of resources in a safe manner.
• Use of mental health screening tools in higher risk children and young people in paediatric settings should be considered.
• Paediatricians should not be expected to work in isolation managing children and young people with serious mental illness. There should be provision for consultation and direct input from mental health specialists through age appropriate hospital mental health liaison teams.
• Clear pathways should be developed for neurodevelopment disorders which incorporate input from all relevant agencies and provides clarity on where responsibilities lie.

• 1 a b NHS Digital. Mental Health of Children and Young people in England. 2017
• 2Royal College of Paediatrics and Child Health. State of Child Health. 2020. stateofchildhealth.rcpch.ac.uk/
• 3Meltzer H, Gatward R, Goodman R and Ford T. Mental health of children and adolescents in Great Britain, TSO: London. 2000
• 4Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. 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. 2005
• 5Office for National Statistics. Deaths registered in England and Wales: 2019.
• 6Department of Health, Social Services and Public Safety (DHSSPS) Northern Ireland Executive. 2015
• 7National Institute for Health and Care Excellence. Eating disorders: recognition and treatment NICE guideline [NG69] 2017
• 8 a b Glazebrook C, Hollis C, Heussler H, Goodman R, Coates L. Detecting emotional and behavioural problems in paediatric clinics. Child: Care, Health & Development 29: 141-149. 2003
• 9Garralda ME. Hospital management of paediatric functional somatic symptoms. Acta Paediatrica 105: 452–453 2016
• 10National Confidential Enquiry into Patient Outcomes and Death. Mental healthcare in young people and young adults. 2019.
• 11Children’s Commissioner. The state of children’s mental health services. 2020
• 12The Scottish Government. Children and Young People’s Mental Health Task Force: Delivery Plan. 2018
• 13Nation Assembly for Wales. Mind over matter: A report on the step change needed in emotional and mental health support for children and young people in Wales. 2018 www.assembly.wales/laid%20documents/cr-ld11522/cr-ld11522-e.pdf
• 14NICCY. Still Waiting: A rights based review of mental health services and support for children and young people in Northern Ireland. 2018
• 15Department of Health and Department of Education. Transforming Children and Young People’s Mental Health Provision: a Green Paper. 2017.
• 16 a b Scottish Government. Mental Health Strategy 2017-2027. 2017
• 17 a b NHS Wales. Together for Children and Young People. 2015.
• 18Northern Ireland Office. New Decade, New Approach. 2020
• 19NHS England. NHS Long Term Plan. 2019.
• 20NHS England. Access and waiting time standard for children and young people with eating disorders. 2017.