Emergent properties: structural
A diverse range of providers, such as health providers (both in primary, secondary and tertiary care), voluntary sector providers, social care and, increasingly, schools, work to support child mental health across various agencies . A lack of quality data to support this system is perceived as a major issue, with services having been described as “working in a fog” . The central flow of child-level data to NHS Digital was only initiated in mid-2016, following a decade-long process of implementing a national dataset for child mental health and, to date, returns are still limited in quality and quantity. Whilst there has been a policy and practice commitment with regards to the need for integrated cross-agency collaboration and co-ordination, and appropriate use of data for more than a decade, fragmentation and confusion have been the described emergent defining features of the system [18, 19].
Agents within the system
Agents within the system include (but are not limited to) children and young people with mental health issues, their parents and family members, school staff, primary care providers (including GPs and school nurses), specialist mental health providers (both voluntary, statutory and independent), care providers, trainers of specialist mental health providers, professional bodies of specialist mental health providers, pharmaceutical companies, psychological treatment developers, policymakers, politicians, civil servants, data analysts, commissioners, researchers, service support and improvement organisations (e.g. NHS Improvement), service review and assessment organisations (e.g. Care Quality Commission), and guideline developers (e.g. National Institute for Health and Care Excellence (NICE)).
Emergent properties: cultural
Whilst there are debates between agents within the system about the causes and nature of mental health problems and the best approaches to take, a dominant and consensual narrative is the need for earlier intervention and, in particular, faster and easier access to specialist services (e.g. [17, 20]). There is also a shared emphasis on the need to address the stigma surrounding mental health issues that are seen as blocking people from accessing help (e.g. the ‘Time to Talk’ campaign). Public discourse, guidance to policymakers and the wider public tend to emphasise the fact that many mental health problems in adulthood are reported to have originated in childhood; 75% of adult mental health problems start before the age of 18 , one in four children has a mental health problem at any one time , and these mental health problems may have long-term negative impacts if not successfully addressed .
The existence of a range of evidence-based treatments, whose effectiveness is based on comparison of differences in group means in randomised control trials, are emphasised. Thus, websites offering information to the public stress the advantages of accessing specialist help and suggest that, without help, children and adolescents will fail to improve. For example, “Like other medical conditions, anxiety disorders tend to be chronic unless properly treated. Most kids find that they need professional guidance to successfully manage and overcome their anxiety” . These data and statements are regularly mobilised as part of an argument for more services and to encourage children and their parents to seek help sooner rather than later.
Less quoted in both public and professional discourse is what is known about rates of spontaneous improvement (which might in fact be better defined as improvement that occurs without professional input, since it may include interventions and input from many other agents in the system). The rates of non-professionally mediated improvement for key difficulties may be as high as 60% for adolescent depression . Whilst a number of systematic reviews have identified effective prevention interventions for mental ill health in children, with moderate effect sizes across diverse populations [26,27,28], there is still a need for further evidence of the best ways forward in terms of early intervention or prevention and how to ensure there are no unintended harms [29, 30]. There is also little discussion of likely rates of recovery or non-recovery following treatment . Further, no NICE guideline for child mental health contains any reference to non-response or how children should be supported if they do not respond to treatment.
Current system challenges: implications for feedback and adaptation
The complex and dynamic child mental health system is particularly beset at the moment with a range of challenges. The system faces a heady mix of increased prevalence rates [32, 33], cuts across a number of the diverse range of services , and increased pressure on both schools and specialist services [35, 36]. There has also been more public scrutiny and concern; in the last 5 years, there have been over five national reviews, three health committee reports, several policy documents and a Green Paper currently out for consultation. The outputs of these reports tend to repeat the same messages of the need for better coordination, earlier intervention and more resources. Given this context, it is anticipated that many stakeholders will be particularly sensitive and wary of any data that might undermine existing discourses on the benefits of increased provision and the need for more resources. In particular, there are likely concerns that any suggestion of poor performance on the part of current services may lead to further cuts and loss for children and families.
An attempt to ‘transform’ the system
A major initiative within the system was the Children and Young People’s Improving Access to Psychological Therapy (CYP IAPT) programme, led by the Department of Health and NHS England, and involving geographical partnerships between NHS providers, local authorities and voluntary sector providers across five areas (London and the South East, the North West, Oxford/Reading, Yorkshire, Humber and the North East, and the South West). The programme sought to embed best practice in child mental health provision by focussing on specific elements of participating services, namely helping them work effectively in partnership with children and young people so that they were active in shaping their local services; supporting services to develop a culture of reflective practice and accountability; improving the workforce through training in best evidence-based practice; developing mechanisms to deliver frequent outcome monitoring to help the therapist and service user work together in their session, and to help supervisors support therapists in improving outcomes; and supporting local areas in improving the infrastructure they use to collect and analyse data to assess whether children and young people are getting better.
The premise of CYP IAPT was to train a selection of practitioners, supervisors and managers, alongside providing additional resources for infrastructure and building regional and national collaborations to support best practice. In this way, the aim was to maximise limited resources and facilitate the embedding of sustainability. Specific training programmes were developed for both practice and supervision in cognitive behavioural therapy for anxiety, parent training for behavioural difficulties in children under the age of 9, systemic family therapy for eating disorders, conduct disorders and depression, interpersonal psychotherapy for adolescent depression, leadership, service development, supervision skills and service transformation skills, and enhanced evidence-based practice.
The programme was rolled out over 4 years (2011–2015) and sought to embed seven key principles in child mental health services, namely to support whole service transformation through leadership; to improve access through self-referral; to work in partnership with the young person and their parent/carer in service delivery and design; to deliver evidence-based psychological treatments; to deliver outcomes-focused psychological treatments; to work in partnership with the young person and their parent/carer throughout treatment; and to provide supervision to support the delivery of evidence-based, service user-informed and outcomes-informed practice. The programme involved directly training over 1000 clinicians and service managers in evidence-based approaches and leadership . The vision was that these trained staff would lead service transformation and more effective practice within their organisations.
A key aspect of this initiative was the emphasis on the collection of child- and parent-reported questionnaire data throughout the course of treatment that sought to capture change in symptoms, wellbeing, functioning or achievement of goals during the course of treatment . Between 2011 and 2015, the lead author (MW) and colleagues were commissioned first by the Department of Health and then NHS England to agree which data to collect and then to collect and analyse routinely collected CYP IAPT data with a particular focus on the child- and parent- reported outcome data .
An outcomes and evaluation group was convened, chaired by MW. This group oversaw measure selection and the approach to data collection; chose measures based on review of psychometric properties, feasibility, utility, compatibility and cost; advised on how to implement routine outcome measures and how to report findings; and consulted with wider networks and held regular public consultations on measures to include in the dataset . Out of this process, 21 child-report scales and 15 parent-report scales were used to cover the range of problems seen in child mental health services. Since there was no national data flow, patient-level data from participating sites were submitted quarterly using an agreed data specification. Data were uploaded via secure data handling to a data storage provider and collated centrally. In the first year of a site’s involvement in the initiative, data were largely sent from those involved directly in the training; from the second year of involvement onwards, data were sent from all practitioners across the partnership. Data collected included demographic information and outcome and experience measures, with a particular emphasis on child and parent reports .