Trigger warning: This article discusses suicide. Some readers may find this distressing.
Massive increases in referrals to Child and Adolescent Mental Health Services (CAMHS) over the last few years have led health professionals, including myself as a doctor, to question why.
Child mental health is important to me as I have personally seen peers experience mental health problems at school, and I believe this is such a crucial time to offer support and interventions.
Looking at statistics from the NHS Child and Adolescent Mental Health Services (CAMHS), the number of children currently under CAMHS care has risen from 493,434 in October 2023 to 496,897 in November 2023. Shockingly, the number of children under 18 requiring emergency mental health support has also increased by 53% since 2019.
It is important to think about the contributing factors to these numbers, so professionals can better support young people and implement change that will help. As CAMHS services see a massive surge of referrals at the beginning of the school year, and a large part of life as a child and adolescent is school life, I wanted to explore factors that can occur in a school environment. Specifically, I will explore factors that may be contributing to the increased mental health referrals, and the initiatives schools can implement.
So, let's break down some contributing factors.
1) Academic Pressure and Stress
Over the last several years, there has been a global decrease in school satisfaction for teenage students. This decrease in satisfaction has been linked with perceived school pressure, which is more pronounced in girls compared to boys.
Additionally, this academic pressure can contribute to both physical health symptoms such as fatigue, and mental health problems such as depression, anxiety, and sadly in severe cases, death by suicide.
One study looked at the causes of 595 adolescent suicide cases and found academic pressures were a recurring contributing factor. Additionally, another study found a positive association between academic pressure and timing within the school year (around the exam period), and at least one mental health outcome of anxiety, depression, self-harm, or suicidality.
2) Social Dynamics and Peer Relationships
Recently, social dynamics and peer relationships have gained a lot of media attention due to the COVID-19 pandemic. The pandemic helped to understand the importance of peer relations, as it revealed a lot about the effects of restricted social interactions on school-aged children.
For example, 2,160 parents of children participated in an online survey investigating the effects on mental health with school closure. In 16-17% of the children, there was an increased exposure to mental health and peer problems. In this group, mental health and peer problems were directly associated with a lack of friendship, which highlights the importance of a friendship group for mental well-being.
Importantly, it has also been found that peer support is as protective in preventing low mental well-being as both school, adult support, and family support combined.
3) Bullying and Harassment
Bullying and harassment can take place in many forms for children of school age. This includes physical, verbal, emotional, relational, and more recently cyber bullying.
We know that children who experience more than one form of bullying are more predisposed to longer-term social-emotional effects. These effects can include feeling anxious or depressed, acting out or being aggressive, and having a desire to get back at others.
These physical and psychological symptoms can also predispose young people to later mental health issues, with bullying consistently being associated with poor mental health.
So what can schools do?
The UK government recommend that a whole school multifaceted approach is needed to achieve "a safe, calm and supportive learning environment”. This approach can include promoting inclusivity and respect, enabling student voice, and providing curriculum teaching to support emotional learning. In addition, schools can offer targeted support to those that need it, and work together with parents and carers to support their children.
The Department of Education also emphasises the importance of peer relationships, and recommends school peer mentoring schemes designed to increase self-esteem, emotional health, and wellbeing across the student population.
What about other schemes?
In 2017, the Government outlined plans in the "Green Paper for Transforming children and young people’s mental health", with a goal to enhance mental health access, including establishing community-based mental health support teams (MHSTs), training senior mental health leads and reducing CAMHS waiting times.
The program introduced significant changes, such as establishing MHSTs in educational settings to link with local CAMHS services, with direct NHS supervision. Additionally, the program aimed to train senior mental health leads in all eligible state-funded schools and colleges by 2025.
In addition, individual NHS trusts also have strategies to combat the increasing demand for CAMHS services. An example of this is the CUES program (South London and Maudsley NHS Foundation Trust), designed to equip primary-aged school children with therapy techniques to prevent later mental health problems, with promising outcomes.
Are these schemes adequate?
Despite government initiatives, schools are still struggling to deal with the increasing mental health problems at school.
In a survey of nearly 18,000 members of the National Education Union, educators were questioned about student mental health. Results revealed insufficient access to specialised support services, such as CAMHS, learning support assistants, councillors, nurses, trained mental health first aiders, senior mental health leads. Many teachers cited excessive workload, lack of staff and inadequate government priorities as key barriers to student support. Teachers also expressed concerns over lengthy CAMHS waiting lists, with some children not qualifying for services despite evident need.
Whilst more work is needed, the schemes discussed are a step in the right direction. The government has made a commitment to young people's mental health, with educational settings being a focus of service provision.
Additionally, there is evidence that school-based mental health services overcome some of the barriers that prevent access to mental health services for children and youths, such as shortage of medical or psychological mental health professionals, mental health stigma, or the lack of transportation opportunities. Therefore, I look forward to seeing future progress and the outcomes of the government initiatives!