Children and young people and mental health

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Introduction
Statistics
The prevalence of mental health problems
Children and psychiatric services
The legal framework
Consent to treatment
The Mental Health Act (1983)
The National Service Framework for Children
The Children Act 2004
Contexts
Relationships and families
Adoption
Children in care
Children in prison
School
Physical and sexual abuse/violence
Emotional abuse
Discrimination
Mental health issues
Sexual identity
Alcohol, drugs and substance abuse
Alcohol
Drugs
Other substances
Anxiety and anxiety-related problems
Sleep problems
Depression
Self-harm
Suicide
Eating distress
Attention deficit hyperactivity disorder (ADHD)
Schizophrenia
Hearing voices
Specific groups
Young carers
Black and minority ethnic children and young people
Refugees
Disability
HIV and AIDS
Treatment
Talking treatments
Cognitive behaviour therapy
Medication
Electroconvulsive therapy (ECT)
Services: what help is available?
Child and adolescent psychiatry
Therapeutic communities
Further reading
Useful contacts
References

Introduction

This factsheet explores some key issues relating to the mental health of children and young people. It outlines the prevalence of mental distress among the young, and recent government initiatives to try to tackle the problem. It sets out some of the contexts, including problems at home and at school, and outlines several specific mental health issues that may affect children, including anxiety, depression and self-harm. It goes on to look at problems faced by specific groups, including young carers and children from minority ethnic communities. Finally, it outlines the treatment options and services available to children.

This factsheet is designed to be read by professionals, students and other people working with children and young people. For information specifically for parents, families and carers, see Mind's Understanding childhood distress. Mind's Young person's introduction to mental health has been written for young people themselves.

Statistics

In 2002, the population of the UK was an estimated 59.2 million. Children aged up to 16 made up 20 per cent of the population (11.8 million), while young people aged 16-24 amounted to 11 per cent (6.5 million). [1] In 2000, the total minority ethnic population of those under 20 in Great Britain was 1.48 million (10 per cent of the population in this age group in that year). [2]

A survey published in 2000 showed that 10 per cent of children aged 5 to 15 had a mental health problem.[3] The three most common groups of childhood mental health problems are:

• emotional disorders (such as depression, anxiety and obsessions)
• hyperactivity (involving inattention and over-activity)
• conduct disorders (involving awkward, troublesome, aggressive and antisocial behaviour).

Less common mental disorders include autistic spectrum disorders, neurological disorders such as Tourette's Syndrome, and eating distress.

There is evidence that more mental health problems are being diagnosed. However, some doctors believe this is due in part to an increasing trend towards 'medicalising' distress, classifying 'ordinary', often transient problems as illness. [4]

The prevalence of mental health problems

Mental health problems are more common in boys than girls, with 11.4 per cent of boys aged 5 to 15 having a problem, compared to 7.6 per cent of girls (see table below). Children with mental health problems, especially emotional and conduct disorders, were also very likely to smoke, drink alcohol and use cannabis. [5]

Prevalence of psychiatric disorders by sex and age, 1999, Great Britain, percentages

Prevalence rates are greater among children in single parent families and step-families, in large families (of five or more children), those whose parents have no educational qualifications, and/or are unemployed, in low income families, in social class V (compared with social class I) and those in social housing. [6]

Children's welfare is significantly affected by their parents', and especially their mothers', mental health. The scale of the problem is unknown, but it has been estimated that about 16 per cent of parents have mental health problems. [7] The mental health problems of parents may affect their children's ability to form attachments, their emotional development and their own mental health. Singer et al (2000) found high rates of psychiatric disturbance in a small group of children whose parents were inpatients in psychiatric wards. [8]

The charity YoungMinds has recommended that when an adult is sectioned under the Mental Health Act, the diagnosing psychiatrist should find out whether they are responsible for a child and, if necessary, inform social services so the child's needs may be assessed. [9]

Children and psychiatric services

Between 1994 and 1995, the number of 'finished consultant episodes' [10] by mental health specialists was 2,690 for those aged 11 to 16 and 24,890 for 17 to 25 year-olds. The corresponding figures for the year 1991 to 1992 were 2,040 and 23,230 respectively, and for the year 1989 to 1990, 2,830 and 24,150. [11] (These figures do not relate to individuals, since a patient may be admitted more than once in a year.)

Secure accommodation is provided for young people aged 10 to 18 who are likely to cause serious injury to themselves or others if they are placed in other forms of accommodation, and for those who are likely to abscond from other forms of accommodation. At 31 March 2000, there were 377 children in secure accommodation in England and Wales. The majority of these were boys (73 per cent). Two per cent were aged 16 and over, 60 per cent were aged between 14 and 15, 15 per cent were 12 to13, and 0.02 per cent were under 12. The majority of children stayed less than three months. [12]

The legal framework

Consent to treatment

A parent has the right to give consent to treatment for a child under 18, provided it is in the child's interests. In cases where a parent refuses to consent to treatment that doctors consider to be in the child's best interests, the child may be made a ward of court. The court can then overrule the parent's refusal.

In the Gillick case in 1985 the House of Lords established the principle that a doctor could give contraceptives to a girl under 16 without her parents' consent, provided she had sufficient intelligence and understanding to fully comprehend what was proposed. They did not specify an age at which children become competent. Since this case, the concept of 'Gillick competence' has been extended to other treatments.

For children aged 16 and 17 the provisions of the Family Law Reform Act 1969, section eight apply. This states that: "...the consent of a minor who has attained the age of 16 years, to any surgical, medical, or dental treatment, which in the absence of consent would constitute a trespass to the person, shall be as effective as it would be if he were of full age; and where a minor has by virtue of this section given an effective consent to any treatment it shall not be necessary to obtain any consent for it from his parent or guardian". Perversely, the same law does not give the child the same right to refuse treatment. [13]

Many paediatricians feel children should have treatments explained to them and their consent sought whenever possible. There is evidence that even young children can often understand quite complicated medical issues. A study of children undergoing orthopaedic surgery found that relevant experience of illness, treatment or disability was far more important than age for acquiring competence.[14] YoungMinds considers that children should be considered competent to make decisions from the age of 12.

The Mental Health Act (1983)

There is no lower age limit to the Mental Health Act (1983) and there are no specific provisions in the Act relating to children. In theory, children and young people may be treated or compulsorily detained under it, but in practice very young children are not detained under the Act, with the majority being admitted as 'informal' patients by their parents.

YoungMinds believes that the needs of children should be addressed in any proposed new mental health legislation. [15]

The National Service Framework for Children

The National Service Framework for Children, Young People and Maternity Services (NSF), which was published in September 2004 by the Department for Education and Skills, sets out national standards for children's health and social services. It proposes the following standards for the care of children and adolescents.

• The promotion of health and wellbeing, identifying needs and early intervention, led by the NHS in partnership with local authorities.
• Supporting parenting, by providing information and support for parents to help them care for their children and equip them for life.
• The provision of child-, young person- and family-centred services, tailored to individual needs and taking account of their views.
• The development of age-appropriate services responsive to need.
• Safeguarding and promoting the welfare of children and young people, preventing harm, promoting welfare and addressing needs.
• Implementing timely access to appropriate and effective services to meet the health, social, educational and emotional needs of children and young people who are ill, throughout their period of illness.
• The provision of high quality, evidence-based hospital care for children and young people in hospital, developed through clinical governance in appropriate settings.
• The development of coordinated, high quality family-centred services for disabled children and young people and for those with complex health needs, promoting social inclusion, enabling them to live ordinary lives.
• Promoting the mental health and psychological wellbeing of children and young people, by providing access to timely, integrated, high quality multidisciplinary mental health services to ensure effective assessment, treatment and support.
• Making sure children, young people, their parents or carers, and health care professionals in all settings can make decisions about medicines based on sound information about risk and benefit.

The National Service Framework stipulates that services must be developed to meet the needs of young people aged 16 to 17, who often fall between child and adult services. A flexible approach is suggested, so that young people receive care and treatment most appropriate to them as individuals, which might be in either child or adult services.

The National Service Framework highlights the need for appropriate services for young people and children with learning disabilities, who often have mental heath problems. The Framework also acknowledges the need for more staff, new ways of working, new roles, and additional training.

The National Service Framework includes the following 'four tier strategic framework', [16] outlining access to services. (In the Framework, it is pointed out that this is a conceptual tool – neither services nor people will fall neatly into tiers, and some people may need services from more than one tier at the same time.)

The Children Act 2004

The Children Act 2004 provides the legislative foundation for the changes outlined in the National Service Framework.

The Act provides for the establishment of a new Children's Commissioner for England, working with close counterparts in the rest of the UK, whose role will be to raise awareness of the best interests of children and young people. The first Commissioner, Professor Al Aynsley-Green, was appointed in March 2005. The Commissioner is required to involve children and young people closely in his work, but will look at individual cases only in so far as they have implications for public policy.

The Act also places a duty on local authorities and other agencies caring for children to cooperate and take part in joint arrangements. Children's trusts will be set up with the primary role of securing integrated commissioning, leading to more integrated service delivery. They will be based in local government, but be formed through pooling the resources of local education authorities, children's social services, certain health services, Connexions (a support service for children and young people aged 13 to 19), and, where agreed locally, youth offending teams.

Local authorities must have children and young people's plans in place and must have set up local safeguarding children boards by April 2006. By 2008, authorities must have appointed a director of children's services who will, at a minimum, be responsible for education and social services for children, and may also cover leisure or housing services.

Contexts

Relationships and families

A stable home environment is an important factor in the development of children and young people, who need security and boundaries within which to thrive. This does not mean that the nuclear family, with two parents plus dependent children, is necessarily the best or the only situation in which to bring up mentally healthy children. There are many examples of healthy, stable children brought up by lone parents, gay couples or in shared child-care arrangements, and in many societies extended families and shared care are the norm.

But it does seem that poverty and family conflict are the most important factors in increasing the risk of childhood mental health problems. [17] And poverty and family discord are more likely to occur when the parents are unemployed, divorced, living alone or homeless. [18]

The number of children aged under 16 in England and Wales who experienced the divorce of their parents peaked in 1993 at almost 176,000. This fell to 142,000 in 2000, and then increased each year up to 2003. Just over 20 per cent of children affected by divorce were under five years old and nearly two thirds were aged 10 or under. Some three million children in this country have experienced the separation of their parents. [19]

People experience divorce, separation, or relationship breakdown in different ways. Many children or young people feel loss, anger and guilt, whereas others may actually benefit, particularly if they have been removed from situations of long-standing conflict. The golden rule mentioned by children who have been through the breakdown of a parent's relationship is to talk about it. Children dislike being kept in the dark, and need to be told the truth.

One study found that there is a significant link between the level of involvement by fathers and boys being in trouble with the police. [20] The study found that 35 per cent of boys with little or no involvement from their father had offended, compared to 18 per cent of boys with a highly involved father. Highly involved fathers emerged as a major factor in boys' general wellbeing, protecting boys against depression or suicidal thoughts.

Adoption

In 2003 there were 5,354 registered adoptions, of which 213 (4 per cent) were children under the age of one; 2,481 (46 per cent) were aged 1 to 4 years; 1,695 (32 per cent) were aged 5 to 9; 749 (14 per cent) were aged 10 to 14; and 216 (4 per cent) were aged 15 to17. Adoption figures peaked at 25,000 in 1968, fell markedly in the mid 1970s and have remained fairly constant at about 5,000 per year in the last 10 years. Step-parent adoptions peaked at almost 15,000 in 1974 and have also fallen markedly since. [21]

Unresolved anxieties about identity may underlie mental health problems in some adopted children, especially if their adoptive parents are reluctant to talk about the situation. It is generally accepted that all adopted children should be told about their adoption as soon as they are able to understand. Many adopted people have a yearning to meet their birth parents and, since the Children's Act 1975, which gave them access to their original birth certificates, many have been able to do so.

In 2003, 992 men and 1,195 women received counselling from adoption counsellors at the Family Records Centre, social services departments, or an adoption society. These figures have fallen in recent years. [22]

Children in care

As of 31 March 2004 there were 61,100 children in care in England. [23]

A study of the prevalence of mental disorders in children aged 5 to 10 who were looked after by local authorities showed that they were five times more likely to have a mental health problem than children in private households. Eleven per cent had emotional disorders (compared to 3 per cent of children in private households/with their own family), 36 per cent had a conduct disorder (compared to 5 per cent), and 11 per cent had a hyperkinetic disorder (compared to 2 per cent). [24]

Among 11 to 15 year-olds, those children who were looked after by local authorities were four or five times more likely to have a mental health problem – 49 per cent (compared with 11 per cent of children in private households/with their own family). Twelve per cent had emotional disorders (compared to 6 per cent), 20 per cent had a conduct disorders (compared to 6 per cent), and 7 percent had a hyperkinetic disorder (compared to 1 per cent). [25]

In younger children, boys are more likely than girls to have a mental disorder, but by the age of 16 to 17 there is no difference between the sexes (see table below). [26]

Mental health problems in looked after children in England

Many children go in and out of care and frequently change their placement. The prevalence of mental health problems tends to decrease with the length of time in a placement, suggesting, not surprisingly, that stability and continuity of care is a significant factor in a child's mental health.

Three per cent of the children surveyed by the DfES (Department for Education and Skills) were taking medication for attention and hyperactivity disorders, one per cent were taking antidepressants (Prozac), and one per cent were taking antipsychotic medication for conditions including manic depression, severe anxiety and autism.

About one third of 11 to 15 year-olds in care sought help because they felt unhappy or were worried. Girls were more likely than boys to seek help. Over a third of children (34 per cent) had been in touch with a specialist in child mental health, and 23 per cent had had some contact with special education services.[27]

There are many reasons why children end up in care. They cannot be put into care simply because they have mental health problems, but if their disturbed behaviour means that their parents are unable or unwilling to look after them, they may be placed in the care of the local authority.

Statistics are not available on how often children and young people are put in care because of a parent's (usually the mother's) mental distress, but research suggests that it is common. One study found that nearly half the mothers of children who had been in care at least twice had been psychiatric inpatients.[28] Black women are particularly likely to have children taken into care following a psychiatric diagnosis. One study found 80 per cent of black mothers with children in care were referred for mental health reasons, as compared to only 20 per cent of white mothers. [29]

There has recently been more attention on the standard of care in children's homes. Prompted by cases of sexual abuse in children's homes, the Department of Health commissioned Norman Warner to lead an enquiry; one of eight enquiries on children's homes since 1985. The report reveals an estimated one third of children in homes are victims of sexual abuse and, although many children in care have severe emotional and/or behavioural problems, they are often looked after by unqualified and sometimes untrained staff. [30] Some children's homes have used a range of degrading and inhumane punishments for 'bad' behaviour, such as corporal punishment, deprivation of food, drink and sleep, as well as locking children in darkened rooms for many hours (sometimes with no clothing or blankets).

Children in prison

There are currently just under 11,000 children and young people under the age of 21 in prison in the UK, of whom about 3,000 were held in young offender institutions. The number of children in prison in the UK has more than doubled since 1993, in spite of the fact that the number of children cautioned for offences has fallen. More children are locked up in the UK than in any other country in Europe. [31]

Many imprisoned children and young people are depressed, and some harm themselves. In 2003, 13 young people killed themselves in prison, in 2002 there were 16 suicides, in 2001 there were 15, and in 2000,18. [32]

School

School can be an exciting and stimulating place, where children and young people learn, make friends, are challenged and have new experiences. Unfortunately, some pupils have problems at school, including lack of family support, bullying, peer pressure, boredom, and worries about tests and exams. Most pupils find satisfactory solutions to these problems, but some may respond by truanting, being disruptive or underachieving. They may become distressed and in severe cases may become ill or develop a school phobia.

School phobia, in which a child experiences extreme anxiety and distress about going to school or when thinking about school, is rare.

A far more common problem is bullying. Kidscape, the charity which tackles bullying and child abuse, highlights the following statistics.

• Each year 10 to 14 youth suicides are directly attributed to bullying.
• Bullied children are six times more likely to contemplate suicide than those who are not bullied.
• One in 12 children are badly bullied to the point that it affects their education, relationships and even their prospects for jobs in later life.[33]

Young people who identify themselves as lesbian, gay or bisexual have been found to be more susceptible to bullying at school.

Bullying is increasingly recognised by schools as a serious problem that should not be tolerated, and many schools have taken steps to tackle it. Children who are being bullied can ring ChildLine, and can also contact the Anti-bullying campaign, which also offers support to parents. Education welfare officers and educational psychologists can help with school problems and can be contacted through school or GP.

In recent years there has been an alarming decline in boys' attainment and participation at school. Boys' examination results, literacy rates and retention rates are falling. Parents and teachers note that boys both have trouble and cause trouble at school more than girls. Teachers point out that boys often lack motivation, are depressed and demoralised about their future.

Physical and sexual abuse/violence

As at March 2002, there were around 25,700 children on child protection registers in England, with slightly more boys than girls. The type of abuse was similar for each of the sexes, apart from sexual abuse. Sexual abuse accounted for 13 per cent of girls on the register, compared with 8 per cent of boys. [34]

Studies have found that almost half of psychiatric inpatients have histories of physical and/or sexual abuse. An Australian study of people who were sexually abused in childhood showed that, compared to the general population, they had had significantly higher rates of psychiatric treatment (12.4 per cent, compared to 3.6 per cent). Rates were higher for childhood mental health problems, personality disorders, anxiety and acute stress disorders, and major mood disorders, but not for schizophrenia. The incidence of personality disorder was five times higher in people who had been abused. There was no apparent association in this study between child sexual abuse and subsequent alcohol- and drug-related disorders. Male victims were more likely to have had treatment than females (22.8 per cent, compared to 10.2 per cent). [35]

A study of suicide and self-harm among young prisoners showed that they were more likely to have been sexually abused as children, compared to a group of prisoners who had not attempted suicide or self-harmed. [36] This suggests a powerful connection between childhood sexual abuse and later self-injury or suicide.

Reports highlight the vulnerability of disabled children to physical, emotional and sexual abuse. Surveys by the NSPCC [37] remind people that, contrary to the assumption that disability protects children from abuse, children with great dependency needs and limited communication skills are at risk of abuse, particularly from their carers.

Emotional abuse

Emotional abuse tends not to be addressed with the same urgency as physical abuse of children, but early intervention is necessary to avoid long-term consequences for the emotional health of the child.

For the purposes of child protection, the Department of Health uses the following definition of emotional abuse: "...the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. It may involve causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of ill treatment of a child, though it may occur alone." [38] Gabarino puts forward five types of damaging behaviour: rejecting, isolating, terrorising, ignoring and corrupting. [39] These have been expanded by subsequent writers on the topic, but remain the core issues.

Research suggests that emotional abuse is associated with parents who are alcoholic or abuse street drugs or other substances, with parents who have depression, in families where there is domestic violence, and among children with physical disabilities and their siblings.

Because it is invisible, emotional abuse is the most insidious and under-recognised form of child abuse. Emotional abuse occurring alone accounts for the smallest number of cases on child protection registers. The percentage of children registered for emotional abuse rose from 16 per cent of children on the registers in 1997 to 18 per cent in 2001.[40] Surveys by the NSPCC suggest that the true incidence would make emotional abuse the commonest form of maltreatment, rather than the least common. [41]

Discrimination

Discrimination on the grounds of race, sex, sexuality and disability can induce fear, undermine self-confidence, and reduce opportunities in education, housing and employment – all of which can be distressing experiences. Examples include black children experiencing racist comments at school, children being ostracised and excluded by their peers on the grounds of their sexuality, and black children not being encouraged to succeed at school because of institutional racism. Mixed race children may experience exclusion by both black and white peers.

Once in the mental health system, young people may meet a second form of discrimination, from mental health workers, which aggravates the situation. This type of discrimination can have a severe impact on a young person, at a time when they are most vulnerable and most easily influenced, damaging their self-esteem and restricting their opportunities.

Mental health issues

Sexual identity

Sex and sexuality can be difficult to talk about and understand, and most young people find it hard to discuss these issues with their parents. It is illegal for a boy or man to have sex with a girl under 16. A woman or girl cannot be charged with 'unlawful sexual intercourse' with men or boys of any age, but could be charged with indecent assault or gross indecency. The age of consent for gay men remained at 21 (compared to 16 for heterosexuals) until 1994, when it was lowered to 18 after a fierce debate in the Commons and Lords. A new Sexual Offences Act was passed in January 2001, equalising the age of consent with heterosexuals at 16.

Issues of sexual identity can be especially troubling during teenage years, when identity in general is being questioned. Choice of job, friends and beliefs are all developing issues, and self-doubt and uncertainty are to be expected. Young lesbians and gays are often told they are going through 'a phase', which they will grow out of. This can encourage denial and promote negative thoughts about being lesbian or gay. It might be more appropriate for the young person to talk through their feelings, with a counsellor, teacher or youth worker, or someone from a gay and lesbian helpline.

Alcohol, drugs and substance abuse

Alcohol

The World Health Organisation's European Charter on Alcohol, signed by all member states of the EU states: "All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption, and to the extent possible, from the promotion of alcoholic beverages."

In the inter-war period young people aged 18 to 24 were the lightest drinkers in the population, and the group most likely to not to drink at all. By the 1980s, this group had become the heaviest drinkers in the population and the least likely to abstain. Nowadays, most young people drink regularly by the age of 14 or 15, and one survey found that more than a quarter of boys aged 9 to 10 were drinking regularly at home. The latest survey data shows that girls are now binge drinking as much as boys. Minority ethnic teenagers are less likely to drink alcohol than their white counterparts. [42]

A survey of secondary school heads in 2004 found that a majority considered that alcohol was a bigger problem in school than drug abuse. Binge drinking results in unsafe sex, injury and illness, dangerous behaviour, and is linked with being in trouble with the police. Between 2002 and 2003, 3,322 children aged 11 to 15 years were admitted in NHS hospitals in England with alcohol-related diagnoses. [43]

In the long-term, continued alcohol misuse is likely to affect social functioning, including school performance. Alcohol misuse while young is associated with heavy drinking in later life, and there is an association between alcohol and the use of illegal drugs. There is evidence that it is associated with poor nutrition, and that alcohol can disrupt some of the biological mechanisms involved in physical growth during puberty. It may also impair psychological and emotional development. [44]

Drugs

Most children and young people do not use drugs and most that do never get beyond experimenting with them. However, the use of drugs is a significant issue in many young people's lives, whether it is a matter keeping up with peers, rebelling against authority, or escaping from a difficult life.

Findings from the 2001/2002 British Crime Survey indicate that people aged between 16 and 24 are significantly more likely to have used drugs in the last year and the last month than older people. The use of Class A drugs in this age group has not changed significantly since 1994. While the use of amphetamines, LSD, magic mushrooms, methadone and glue among 16 to 24 year-olds has decreased significantly since 1998, cocaine and ecstasy use has increased significantly. Cannabis is the easiest drug to obtain, has the youngest mean age of first use at 15.5 years, and was used by 27 per cent of 16 to 24 year-olds. [45]

The taking of legal and illegal drugs can be both physically and emotionally addictive, and should not be ignored as a passing phase. Use of illegal drugs such as cannabis and ecstasy has been linked with the development of depression and psychosis in some susceptible individuals. Some people also react to steroids, used to enhance performance in sport, by becoming violent or manic. There is the additional risk of HIV infection if drugs are injected.

Other substances

The number of deaths from volatile substance abuse (inhaling such substances as lighters, paint, aerosols and thinners) in children aged 10 to 14 has risen from 7 in 2001 to 12 in 2002, the highest number in that age group since 1991. Total deaths across all ages peaked at 152 in 1990, fell rapidly in 1992 in association with a campaign to publicise the problem, and since then the figure has remained relatively stable at about 73 per year. Deaths due to volatile substance abuse are much more common among boys than girls. In 2002 girls accounted for 25 per cent of deaths. The majority of deaths in children occurred in a public place. [46]

Anxiety and anxiety-related problems

Anxiety and phobias are among the most common mental health problems of childhood. Anxiety and its related problems are linked to fear. This could involve fear of a situation (meeting new people), fear of a place (school, for example), fear of an object (needles, spiders) or of a person. Anxiety causes what is commonly called the fight or flight response, or a feeling of being under attack. Symptoms are tense muscles, rapid heart beat and breathing, sweating and dry mouth.

Panic attacks can occur as a result of extreme anxiety. In this case, the fight or flight response is very strong. The panic causes a range of symptoms, including over-breathing, palpitations and pains in the chest, which can be very alarming.

A phobia is an irrational and uncontrollable fear of an object or a situation that most people can face without anxiety. Feelings of intense panic are common when confronted with the source of fear. Most people go to considerable lengths to avoid the cause of distress.

Obsessions, like phobias, are irrational and uncontrollable. They appear as recurring thoughts or ideas, which are frightening or distressing. The obsessions may be accompanied by ritual behaviour, which may be compulsive. Obsessive compulsive disorder is rare in young children, but the rate increases towards adult rates at puberty.

Some people are prescribed tranquillisers and sleeping pills for anxiety and anxiety- related problems. However, due to unpleasant side-effects and problems with addiction, other treatments are generally preferred, such as relaxation techniques, psychotherapy and counselling, self-help groups and cognitive behaviour therapy.

Sleep problems

Many children and young people have sleep problems. These can include nightmares, night terrors and sleepwalking. As with all sleep problems, nightmares do not necessarily mean that a child is emotionally disturbed. They could be triggered, for example, by a television programme, or by the sight of a frightening dog in the park. If they remember the nightmare the next day, they may be afraid to go to sleep. But if the nightmares persist, there could be a deeper cause.

Night terrors occur most often in small children – a child sits up in bed, staring into space and screaming in apparent terror. Mostly, children do not remember these episodes. Night terrors are not always a sign of some deeper problem or worry, but this may be the case.

Sleepwalking is quite common in children and young people, and normally tails off in the late teens. It usually occurs in the deep stages of sleep and the child is not aware of it. It may be a sign of a minor anxiety, but if it happens regularly there could be a deeper emotional cause.

Sleep problems can be discussed with a GP, and sometimes a referral can be made to a sleep clinic, where parents will learn about the sleep problems faced by children and learn how to deal with them. Counselling may also be appropriate, to help families deal with problems which may occur.

Depression

Depression may include symptoms such as depressed mood, loss of interest and pleasure in activities, reduced energy, suicidal ideas, and sleep and appetite disturbance. The depressed child may feel sad or irritable, and may have problems at school due to difficulties in concentrating.

About two in 100 children under the age of 12 are depressed to the extent that they would benefit from seeing a specialist child psychiatrist. About four or five per cent in this age group show significant distress and some of these could be described as on the edge of depression. The rate increases with age, so that at least five per cent of teenagers are seriously depressed and at least twice that number show significant distress. These figures apply to children living in stable, settled populations in reasonably good social circumstances. In troubled, inner city areas with high rates of broken homes, poor community support and raised neighbourhood crime rates, the level of depression may be double that quoted. [47]

Causes of depression amongst children and young people are as many and varied as in the adult population, and can be linked to family or relationship problems, academic pressure or worries about the future.

Young people who are depressed are often referred to specialist child and adolescent mental health services, both in community and hospital settings, which may involve working with the family as well as the young person. Counselling, psychotherapy and psychological methods such as cognitive or behavioural therapies and drugs are used for the treatment of depression.

In 2003, the Medicines and Healthcare products Regulatory Agency issued new guidance on the prescription of SSRI antidepressants for children and young people under the age of 18. Because there is insufficient evidence for their efficacy and some evidence that they cause increased suicidal feelings in this age group, the only SSRI that may be given for depression in children is Prozac (fluoxetine), which must be prescribed by a child psychiatrist. There is also little evidence for the efficacy of other, older antidepressants in children. [48]

Self-harm

Self-harm includes a range of behaviours, including self-cutting, burning and deliberately taking harmful substances. Although acts of self-harm may be suicidal in intent or associated with suicidal thoughts, there may be other motivations. The person who self-harms may be trying to take control of distress, express painful feelings or may use their destructive behaviour as a form of release.

Research suggests self-harm is becoming increasingly common among young people. According to Samaritans, 43 per cent of us know someone who has self-harmed. In 1998, 160,000 people were seen at accident and emergency departments for treatment of injuries associated with self-harm, of whom 24,000 were aged between 15 and 19 years.[49]

A survey of deliberate self-harm in adolescents in 2002, [50] in which 6,020 young people aged 15 to 16 completed an anonymous questionnaire, showed that 6.9 per cent had committed an act of self-harm in the previous year, and 12.6 per cent of these episodes resulted in a visit to hospital. Self-harm was more common in girls than boys (11.2 per cent compared to 3.2 per cent). Factors associated with self-harm among girls include recent self-harm by friends and family members, drug misuse, depression, anxiety, impulsivity and low self-esteem. In boys it was associated with suicidal behaviour in friends and family members, drug use and low self-esteem.

Self-harm was more common in adolescents who had been bullied and was strongly associated with physical and sexual abuse in both boys and girls. It was also associated with anxiety about sexual orientation.

Suicide

Number of deaths by suicide in children and young people [51]

In young men aged 15 to 24 the suicide rate rose from nine per 100,000 population in 1979 to 13 per 100,000 in 1999; a rise of almost 50 per cent.Attempted suicide is much more frequent, especially in girls, and as many as two or three girls in every 100 make a suicide attempt at some time during their teenage years.

A study of life events preceding suicide suggests that they fall into four categories – relationship problems, illness, family disruption and loss.[52] These broad categories cover a wide range of individual stories, for example, discovering you are gay, arguing with parents, wanting to be with someone who has died, being diagnosed HIV-positive, failing an exam.

Race and cultural background can be a major influence on suicidal behaviour. Patterns of suicide among minority ethnic groups are different to the patterns among white groups. For example, one study of young people of Asian origin in the UK found that the suicide rate of 16 to 24 year-old women was three times higher than that of white women in the same age range. [53] Asian women's groups have linked these high suicide rates to cultural pressures: conservative parental values and traditions, such as arranged marriages, may clash with the wishes and expectations of young women themselves.

Eating distress

Many children and young people struggle with their body image. They are, after all, growing up in a culture where they are constantly faced with images and messages about the desirability of being thin, from television, magazines and advertisements.

Eating distress can take different forms. People with anorexia starve themselves by eating little or nothing, while people with bulimia binge or stuff themselves with food then induce vomiting and/or take laxatives. Both conditions can cause severe weight loss or gain, other physical health problems and can sometimes result in death. Between one in five to one in seven of those with anorexia die as a result of their illness or take their own lives. The average age of onset of anorexia is 15 and of bulimia, 18.

Eating problems are more common among girls and young women, but more boys and young men are experiencing problems with food. Around 10 per cent of cases of anorexia are male. [54] In the past, there has been less cultural pressure on men than women to stay slim, but this is changing.

A specialist in eating disorders, Professor Arthur Crisp, says that, since anorexia so often starts at puberty, it is linked with a fear of growing up and a desire to avoid the physical and emotional changes of adolescence. "Puberty isn't invited and some people find it very threatening. They panic about the physical changes and they panic about the challenges they are facing within their family and within society. If they don't have the coping skills to deal with all these changes, they may use dieting as a way of coping, but they need help to accept the process of growth and maturation." [55]

Helping children to have a more positive body image could prevent eating problems such as anorexia and bulimia. Therapy sessions that involve all the family may be particularly helpful for people whose anorexia started under the age of 17.

Attention deficit hyperactivity disorder (ADHD)

Some children are consistently found difficult to manage. They may have problems concentrating, are quick to react, tend to act impulsively, cannot settle, lack self-confidence and may be both disruptive and destructive. These children are often described as suffering from 'attention deficit hyperactivity disorder' (ADHD).

Some child psychiatrists advocate treatment with amphetamine-related stimulant drugs such as Ritalin (methylphenidate). The British National Formulary advises that this drug is not given to children under six, and cautions that it should be used selectively, since one side-effect is to retard growth and the long-term effects are not known. Many experts believe that drug treatment is only appropriate in the most severe cases, and would advocate its use only in combination with psychological therapies.

It has been suggested that ADHD is closely related to lack of sleep. Many parents do not put their children to bed nearly as early as was normal 30 or 40 years ago, and many children have television and computers in their bedrooms, encouraging them to stay awake. Lack of sleep causes people to feel restless and makes concentration difficult. Diet is also implicated in ADHD. Children's behaviour and concentration frequently improves with a diet that is low in sugar, carbonated drinks, and artificial colourants.

Schizophrenia

Schizophrenia is the name given to describe a range of symptoms which cause a dramatic disturbance in an individual's thoughts, feelings and perception of their surroundings. These symptoms include hallucinations, delusions and thought disorder, in which ideas seem jumbled and illogical to the listener.

Schizophrenia affects about 0.4 per cent of people in Britain at any one time and about 1 in 100 people during their lifetime. The onset of childhood schizophrenia is usually at puberty. Figures show rates of 0.02 per cent of 12 to 16 year-olds and 0.5 per cent of 17 to 19 year-olds. [56] Antipsychotic medication is the usual treatment, with periods of time in hospital when the situation is desperate. Some people are offered counselling or psychotherapy, and treatment often involves working with the whole family to look at how they deal with emotional problems.

Hearing voices

A study has suggested that about 8 per cent of children hear voices, and about one third of these fulfil the criteria for some kind of psychiatric diagnosis. This indicates that for most children voices are not a sign of mental disturbance. The voices were more likely to persist in cases where they were more frequent and perceived as negative, and were associated with anxiety or depression, appeared more randomly, and when the child had told more people about them. Being in receipt of mental health care did not influence their persistence. [57]

Specific groups

Young carers

Accurate figures on children who are carers are hard to obtain because of the hidden nature of caring. Identification of young carers from black and minority ethnic groups can be even more difficult due to differing racial, cultural and religious needs and family structures.

Research published by the health services management unit at Manchester University in March 1995 indicates that there are probably between 15,000 and 40,000 young carers nationally. This was based on an evaluation of the first three young carers projects on Merseyside.

Data from 87 specialist young carers projects suggests that in 2004 the average age of young carers in contact with projects was 12. One in 10 of the young carers was caring for more than one person. Fifty six per cent are from one-parent families. Forty four per cent have been caring for three to five years, and 18 per cent for six to ten years. More than a quarter of those who are of secondary school age are having problems at school.[58] A survey by Barnardo's and the Carers National Association revealed that children as young as nine are neglecting schoolwork and friends to look after parents with disabilities or mental health problems.[59]

Young carers and their parents are often silent about the extent of caring through fear of separation, guilt, pride and a desire to 'keep it in the family'. The effects of caring on young carers include physical problems due to lifting, disturbed sleep patterns, emotional stress, social isolation, stigma caused by a home life that is different from other people or by the nature of the condition their relative suffers from, poverty and low income, and loss of educational and careers opportunities. [60] The stress of caring may have a long-term impact on the mental health of the child or young person.

Black and Minority Ethnic children and young people

Minority ethnic groups have a younger age structure than the white population in the UK, reflecting past immigration patterns and differences in family size. In Great Britain, the total population of those under 20 and from a minority ethnic community rose from 1,263,000 in 1992 to 1,480,000 in 2000, or from 9 per cent of the total population in this age group to 10 per cent. The increase was mainly among black African, black mixed and Bangladeshi ethnic groups.[61] In 2003, 37 per cent of the Pakistani/Bangladeshi population was under the age of 16, compared with 20 per cent of the white community. [62] In 2001/2002 the mixed group had the youngest age structure, with 55 per cent under the age of 16. In the Bangladeshi population 38 per cent were under 16, while in the white population only 19 per cent were under 16. [63]

People from minority ethnic groups are more likely than the general population to experience social exclusion, to be poor and live in deprived areas. Unemployment, low wages, long working hours, overcrowding and poor housing can all have an impact on children's psychological development.

And, in a culture where discrimination is commonplace, children from minority ethnic communities are vulnerable to the influences of racism and prejudice. Ideas, beliefs, feelings, attitudes and behaviour relating to race and skin colour are communicated by parents, siblings, peers, teachers, the media, churches and other cultural agents.

In white-dominated multi-racial societies it has been found that young children from all racial backgrounds tend to prefer and identify with lighter skinned people rather than darker-skinned people. This implies that children, sensitive to the nature of existing race relationships, tend to prefer the racial category with the most favourable position in the social structure.[64]

A study of adolescent psychiatric inpatients found that those from the black communities (African, Caribbean and British) were over-represented among those admitted with a psychotic disorder, compared to those from white groups. They were also more likely to be detained under the Mental Health Act, and to have been born outside the UK and have a refugee background. [65] This suggests that while they may well be subject to discrimination within the system, they may also be more vulnerable to serious mental health problems because of early life experiences.

Refugees

Young refugees face a series of problems, including isolation and feelings of loss, confusion and sometimes bereavement. They may have witnessed extreme violence, which may cause disturbing memories and induce feelings of guilt about surviving. There may be conflicts within their families if their values conflict with the traditional attitudes of their parents or elders. They may have problems with their cultural identity as they begin to settle into a new society. [66]

And many refugee families will also be facing the practical problems of surviving in the UK. Many refugees are housed in bed and breakfast accommodation in squalid conditions. Parents are under stress and find it difficult to cope with their children in these conditions. They may find it difficult to register with a GP and they very often have no medical records.

Income support has recently been denied to certain categories of asylum seekers, making their plight even more difficult. The UN Convention on the Rights of the Child forbids discrimination on the basis of the parents' status, and children are still entitled to assistance under section 17 of the Children Act 1989, which means that social services are obliged to support them until other provision can be made.

A report by the Daycare Trust on the needs of refugee children from the Horn of Africa says: "Refugee parents had three main worries about the health of their children – that they were suffering from physical and mental problems because of their experiences, their inability to speak English would hinder their progress, and there were illnesses common to Britain they knew nothing about".[67] Children may also find themselves caring for younger siblings, while none of their own needs are being met.

Occasionally, quite young children come to the UK unaccompanied and with nowhere to go. While their case is investigated they become the responsibility of the social services department in the area of their point of entry. They may be placed in care, and may remain ignorant of their parents' whereabouts and wellbeing for years afterwards. Some refugee children are afraid to say where they come from or to speak their own language for fear of discrimination.

A mental health worker at a refugee project has said: "Coming from a society where people have been imprisoned or killed because of their political affiliation, children are extremely aware of the need not to give away any details about their families. So it's hard for children to be able to talk about their feelings for their parents. Often they may be angry, homesick, or they may feel guilty because they have been telling people their parents are dead." [68]

Disability

The Department for Work and Pensions estimates that about 700,000 children in Britain are covered by the Disability Discrimination Act 1995. This number includes all those aged 18 and under who are not married and are in full-time, non-advanced education and live at home. [69]

Physical disability may affect communication skills and mobility, and may limit access to both work and leisure activities. This may lead to the person with disabilities feeling demoralised by the lack of opportunities and discriminatory attitudes, and may have an impact on their mental health. As R Kadamdari puts it: "Thus demoralized, a person may suffer from a variety of mental health problems. Frequent symptoms are anxiety, helplessness, low self-esteem, despair, fear of loss of control, guilt, sleep problems and a sense of foreboding." [70]

HIV and AIDS

Children may be affected by HIV and AIDS in several ways. Someone in their family may have the virus or may have died of AIDS. They themselves may have the disease, or they may have other relatives or friends who are living with the virus or have died from it.

By the end of September 2004, paediatricians and obstetricians reported that 5,213 children had been born to HIV-infected mothers. Of these, 1,225 have contracted AIDS or have tested positive for HIV. [71]

HIV-affected children are more likely to be badly off or be living in poor housing conditions. Many older children have to care for sick parents and for other brothers and sisters, and they also have to cope with their parents being in hospitals for increasingly long periods, as well as with the possibility of their parents' premature death. Some children have lost both their parents as well as younger siblings to AIDS.

Treatment

Talking treatments

Counselling and psychotherapy are talking treatments used by trained counsellors or psychotherapists to help people with their emotional problems. Both offer the individual, family or group a space to talk about their problems, to explore the past and possibly to find causes and possible solutions.

Counselling is usually offered once a week and may last for several weeks. It is most often used as a way of getting over a particular life event or problem such as bereavement, divorce, relationship problems or bullying. Generally, counselling is thought to be less intensive and less substantial than psychotherapy and therefore not suitable for children or young people with severe emotional or behavioural problems. Counselling for young people is generally offered by voluntary sector agencies. For NHS counselling, contact your GP, who can refer on to a child guidance unit if necessary.

Child psychotherapists treat severe depression, anxiety, aggressive behaviour, learning and other difficulties, such as eating and sleeping problems. They work with abused, neglected and bereaved children, children with disabilities, and those who are ill, injured or dying. Treatment is based on observing and discussing deep feelings and conflicts expressed by the child through words, play or drawing, in sessions dedicated entirely to the child. Children and young people are usually relieved to have their fears and feelings heard and understood.

The role of child psychotherapists includes:

• helping to identify, prevent and treat emotional and behavioural problems from infancy to adulthood
• working as part of local teams looking after the mental health needs of children in community based clinics, hospital departments and special schools
• contributing to prevention by passing on skills and knowledge to parents, and others working with children and families.

Child psychotherapy may be offered by child guidance units as well as community-based clinics, hospitals, consultation centres for adolescents and young people, social services departments and schools. There are fewer than 200 whole-time equivalent posts in the NHS in the UK, and child psychotherapists are not available in many areas.[72] Partly because there are four training schools for child psychotherapists in north London, London has a disproportionate number of child psychotherapists. There are also training schools in Birmingham and Glasgow.

Cognitive behaviour therapy

Cognitive behaviour therapy is practised by psychologists and is based on the idea that all behaviour is learnt and can therefore be unlearnt. A variety of mental health problems such as phobias, obsessions and eating problems are thought to stem from problems with learned behaviour.

Psychologists use methods such as keeping diaries, identifying thought patterns which underpin problematic behaviour, and learning new ways of thinking and interpreting situations so as to achieve more successful and rewarding interactions and ways of dealing with life.

Psychology services can be contacted via a GP, school educational psychologist, and by contacting the British Psychological Society.

Medication

Psychiatric drugs fall into three broad categories: minor tranquillisers, neuroleptics and antidepressants. Minor tranquillisers, most of which are benzodiazepines, are used for insomnia and sometimes for anxiety. Neuroleptics, also known as antipsychotics or major tranquillisers, are used to treat psychotic episodes and illnesses such as schizophrenia. Antidepressants are prescribed for depression and some of the serotonin specific antidepressants are given for types of anxiety such as panic attacks and obsessions, and also for bulimia nervosa.

Medical consensus seems to be that doctors should prescribe psychiatric drugs to children and young people sparingly and in conjunction with talking treatments. Psychiatric drugs are not tested on children and the British National Formulary usually states that their use is not recommended in children – in some cases an age is specified below which a drug should not be given. The Medicines and Healthcare products Regulatory Agency has recently produced guidelines on the prescribing of antidepressants for children, making them much less readily available (see Depression, above).

Mind is very concerned about the use of psychiatric drugs in children and young people given the particular risks and adverse effects when their nervous and endocrine systems are developing.

Electroconvulsive therapy (ECT)

A survey of child and adolescent psychiatrists carried out in 1991 by the Royal College of Psychiatrists showed that in the previous 10 years 65 young people under the age of 18 had been treated with electroconvulsive therapy (ECT). Over 60 per cent of these were aged between 16 and 18. However, this study detected only those cases which were treated by child and adolescent psychiatrists, and not adolescents treated in adult wards. There is no evidence that ECT is being used on children aged 12 and under in the UK or Ireland. [73]

The indications for ECT treatment in young people aged 13 to 18 are essentially the same as for adults: severe depression, which has not responded to treatment with antidepressant medication or psychotherapy. The ECT Handbook says that depressive illnesses in adolescents can be just as severe as in adults and can be associated with a considerable risk of self-harm, either through suicidal behaviour or because of inability or refusal to eat and drink. In these circumstances ECT can be life-saving. ECT is occasionally indicated for other conditions in those under 18, such as schizophrenia or mania. There are no conditions unique to childhood for which ECT is indicated. [74]

Mind is opposed to the use of ECT on children and young people for several reasons:

• ECT may affect the young person's developing neurological system.
• It may be experienced as a form of torture or punishment.
• ECT may encourage a sense of hopelessness due to its association with 'no hope' cases, giving negative messages to a child about their future prognosis.
• The treatment may alleviate depression, but it does not provide a strategy for coping in the long term.

The Royal College of Psychiatrists says it would not recommend a ban on ECT for this age group since there might be unique clinical circumstances when it may be the best available treatment. [75]

Services: what help is available?

In recent years there has been a move towards the provision of more treatments in the child's home environment, such as at home or school. The proposals contained in the National Service Framework for Children (see above) show that the intention is for services to be better coordinated than in the past, and more child- and family-centred.

The proposals outlined in the Green Paper Every child matters: next steps, which preceded the National Service Framework, suggest that change is needed right across the system, incorporating accountability, flexibility, investment in skills, and support for improvement and a change in culture. Workforce reform is proposed, with a children's workforce unit set up in the Department of Education and Skills, bringing together all those who work with children, including health services, law enforcement, sport and recreations, and education. [76]

Child and adolescent psychiatry

Child and adolescent psychiatry exists to treat children and young people either on an inpatient or outpatient basis in hospitals or in child guidance centres. Generally, psychiatrists see children when their mental health problems are thought to be severe, with GPs and child guidance centres being the first port of call for referrals. The preferred practice is for children and young people to remain in their home environment, but in some cases the child may need to stay in hospital if the home is part of or contributing to their problem.

Children and adolescents are usually placed in specific wards. The code of practice on the Mental Health Act 1983 [77] states that children and young people admitted to hospital should not be placed on adult wards unless the condition of the patient means that admission in an emergency is necessary and no alternative is available.

The NHS Advisory Service believes that an important principle is that no young person under the age of 16 should be admitted to an adult psychiatric inpatient unit, unless there are major extenuating circumstances. [78]

Child psychiatrists can prescribe a full range of psychiatric drugs and ECT.

Therapeutic communities

Therapeutic communities exist to provide residential accommodation for young people (generally over 13) with severe emotional problems and highly disturbed behaviour. They are often placed in a community as a last resort before being referred to a secure unit.

Care in therapeutic communities is acknowledged to be of a high standard, with substantial success in helping young people. Surveys have shown that many children successfully return home, and that many are able to resolve their behavioural and emotional problems and develop emotionally. [79]

The high staff-to-young person ratio and the therapeutic element of the care make therapeutic communities expensive to run. Unfortunately, local authorities are finding it difficult to finance therapeutic communities, forcing them to close.

  Further reading

Mind's factsheets

Men's mental health
Resource list for people who were sexually abused as children
Suicide
The effects of cannabis on mind and body
Young person's introduction to mental health

Mind's booklets

How to cope as a carer
How to cope with doubts about your sexual identity
How to cope with exam stress
How to cope with panic attacks
How to cope with the stress of student life
How to help someone who is suicidal
How to recognise the early signs of mental distress
How to survive family life
Making sense of antidepressants
Making sense of antipsychotics
Making sense of minor tranquillisers
Making sense of sleeping pills
Making sense of ECT
Making sense of cognitive behaviour therapy
Making sense of counselling
Making sense of psychotherapy and psychoanalysis
Understanding anxiety
Understanding attention deficit hyperactivity disorder
Understanding autistic spectrum disorders
Understanding bereavement
Understanding borderline personality disorder
Understanding childhood distress
Understanding depression
Understanding eating distress
Understanding obsessive compulsive disorder
Understanding personality disorder
Understanding phobias
Understanding premenstrual syndrome
Understanding the psychological effects of street drugs
Understanding psychotic experiences
Understanding schizophrenia
Understanding self-harm
Understanding talking treatments

Books

The following books are available from the bookshop, Mind Publications on 0844 448 4448 or publications@mind.org.uk.

Abraham, S. and Llewellyn Jones, D. 2001, Eating disorders: the facts, OUP.
Breggin, P and Cohen, D. 2000,Your drug may be your problem: how and why to stop taking psychiatric medications, Perseus.
CVS Consultants and Migrant and Refugee Communities Forum. 2000, A shattered world: the mental health needs of refugees and newly arrived communities, CVS.
Fitzpatrick, C. and Sharry, J. 2004, Coping with depression in young people: a guide for parents, John Wiley and Sons.
Geary, A. 2001, The food and mood handbook, Thorsons.
Idzikowski, C. 2000, Learn to sleep well, DBP.
Kennerley, H. 2000, Overcoming childhood trauma: a self-help guide using cognitive behavioural techniques, Robinson.
Mind. 2001,The bird and the word: the Mind education pack.
Rachman, S and de Silva, P. 2001, Obsessive-compulsive disorder: the facts, OUP.
Rachman, S and de Silva, P. 2004, Panic disorder: the facts, OUP.
Robson, P. 1999, Forbidden drugs, OUP.
Romme, M and Escher, S (eds). 1993, Accepting voices, Mind.
Savona, N. 2003, The kitchen shrink: foods and recipes for a healthy mind, DBP.
Selikowitz, M. 2004, ADHD: the facts, OUP.
Spander, H. 2001. Who's hurting who? Young people, self-harm and suicide, 42nd Street.
Tsuang, M. and Faraone, S. 1997, Schizophrenia: the facts, OUP.
Wilson, J. 2000, The illustrated Mum, Corgi Children's Books.

Useful contacts

Anti-Bullying Campaign
185 Tower Bridge Road
London SE1 2UF
helpline: 020 7378 1446
fax: 020 7378 8374
Telephone helpline offering support and advice for parents whose children have been bullied at school. Offers advice on how to support children, what steps to take with the school and within the education system. Provides training for teachers and pupils.

The Association of Child Psychotherapists
120 West Heath Road
London NW3 7TU
tel: 020 8458 1609

Barnardo's
Tanners Lane
Barkingside
Ilford
Essex IG6 1QG
tel: 020 8550 8822
fax: 020 8551 6870
email: dorothy.howes@barnardos.org.uk
website: www.barnardos.org.uk
Barnardo's work to give disadvantaged children the help they need to build a better future. Through almost 300 projects nation-wide, they help young people and their families to overcome the most severe disadvantages – problems like abuse, homelessness and poverty – and to tackle the challenges of disability.

Bristol Crisis Service For Women
PO Box 654
Bristol BS99 1XH
helpline: 0117 925 1119 (Fri and Sat 9pm-12.30am, Sun 6-9pm)
tel: 0117 927 9600
email: bcsw@btconnect.com
website: www.users.zetnet.co.uk/bcsw 
Telephone counselling for any woman in distress, with a particular focus on self-injury. Offers listening, telephone counselling and information on local services. Also produces publications and runs training on self-injury.

British Agencies for Adoption and Fostering
Skyline House
200 Union Street
London SE1 0LX
tel: 020 7593 2000
fax: 020 7593 2001
email: mail@baaf.org.uk
website: www.baaf.org.uk
Membership organisation for local authorities, voluntary adoption agencies, legal advisers, child care practitioners and the general public with an interest in adoption and fostering. Aims to promote high standards in adoption and fostering, to promote public and professional understanding of the issues and to be an independent voice in field of child care, informing and influencing policy makers.

British Association for Counselling and Psychotherapy
35-37 Albert Street
Rugby
Warwickshire CV21 2SG
tel: 0870 443 5252
fax: 0870 443 5161
email: bacp@bacp.co.uk
website: www.bacp.co.uk
Produces a directory of counselling and psychotherapy resources in the UK. Will send out a list of counsellors and therapists in a particular area on receipt of a stamped, addressed envelope. Send an SAE to United Kingdom Counsellors, PO Box 1050, Rugby, CV21 5HZ.

British Psychological Society
St Andrews House
48 Princess Road East
Leicester LE1 7DR
tel: 0116 254 9568
fax: 0116 247 0787
email: enquiry@bps.org.uk
website: www.bps.org.uk
The representative body for psychologists and psychology in the UK. Produces the Directory of Chartered Psychologists. This can be used to search for a psychologist offering services to particular clients or dealing with specific problems in your geographical area.

Brook Advisory Centres
421 Highgate Studios
53-79 Highgate Road
London NW5 1TL
helpline: 0800 018 5023 (Mon to Fri 9am-5pm)
tel: 020 7284 6040
fax: 020 7284 6050
email: admin@brookcentres.org.uk 
website: www.brook.org.uk
Each centre offers young people (under 25) advice, counselling and medical help around contraception, pregnancy, abortion and sexual health. Head office acts as a first stop advice point, referring callers to their nearest local centre and other relevant services.

Careline
Cardinal Heenan Centre
326-328 High Road
Ilford
Essex IG1 1QP
tel: 020 8514 1177 (Mon to Fri 10am-1pm and 7-10 pm)
website: www.carelineuk.org 
Telephone counselling service for children, young people and adults on any issue, including relationship difficulties, depression, mental health, child abuse, bullying, rape and sexual assault, domestic violence, addictions, stress. Face-to-face counselling for adults. Referrals to other agencies and support groups throughout the country.

ChildLine
45 Folgate Street
London E1 6GL
helpline: 0800 11 11 (24 hours)
minicom: 0800 400 222 (9.30am-9.30pm weekdays, and 9.30am-8pm weekends)
Helpline for children away from home: 0800 88 44 44 (Mon to Fri 3.30-9.30pm, Sat and Sun 2-8pm)website: www.childline.org.uk
Offers telephone counselling for any child with any problem. Provide support and advice and refer children in danger to appropriate helping agencies.

The Children's Legal Centre
Wivenhoe Park
University of Essex
Colchester CO4 3SQ
tel: 01206 872 466
email: clc@essex.ac.uk 
website: www.childrenslegalcentre.com 
Advice and information service on all aspects of law and policy affecting children and young people. Education legal advocacy unit for South East England provides advice and representation for children and/or parents involved in education disputes with a school or LEA. Publications, research and consultancy, policy and campaigns work.

The Children's Society
Edward Rudolf House
Margery Street
London WC1X 0JL
tel: 0945 300 1128 (local rate)
website: www.the-childrens-society.org.uk 
The Children's Society runs over 90 projects across England and Wales working with vulnerable young people. Work includes help for runaways in danger on the streets, working in schools with children who have been bullied or are at risk of exclusion, and help for families in deprived and isolated communities.

Drugscope
Waterbridge House
32-36 Loman Street
London SE1 0EE
tel: 020 7928 1211
fax: 020 7928 8780
email: reception@drugscope.org.uk 
website: www.drugscope.org.uk 
Drugscope (formerly SCODA) seeks to reduce the harmful effects of drug use through informed debate, and through the promotion of best practice and effective, comprehensive services. Drugscope is currently involved in many projects, including education and prevention, developing guidelines for good practice in treatment services for young people and early intervention.

Eating Disorders Association
First Floor
Wensum House
103 Prince of Wales Road
Norwich NR1 1DW
youthline: 0845 634 7650 (18 and under: Mon to Fri 4-6.30pm and Sat 1-4.30pm)
textphone: 01603 753 322 (weekdays 8.30am-8.30pm)
tel: 0870 770 3256
email: info@edauk.com
website: www.edauk.com 
Telephone helplines for people affected by eating disorders, including anorexia nervosa and bulimia nervosa. Provides a listening ear and understanding. Runs a network of support groups, postal and telephone contacts throughout the UK. 

Family Welfare Association
501-505 Kingsland Road
London E8 4AU
tel: 020 7254 6251
fax: 020 7249 5443
email: fwa.headoffice@fwa.org.uk
website: www.fwa.org.uk 
Runs family centres, administers small grants funds and runs educational grants advisory service.

Gay Youth UK
email: info@gayyouthuk.org.uk
website: www.gayyouthuk.org.uk 
An online community featuring information and support for young, gay people in the UK. Advice from agony aunts and uncles.

Gingerbread
7 Sovereign Close
Sovereign Court
London E1W 2HW
helpline: 0800 018 4318 (Mon to Fri 9am-5pm)
tel: 020 7488 9300
fax: 020 7488 9333
email: advice@gingerbread.org.uk 
website: www.gingerbread.org.uk 
Advice line for lone parents providing a listening ear and emotional support. Offers advice on rights and responsibilities. Information on benefits including New Deal for lone parents, contact and residence, Child Support Act, housing, divorce, separation, solicitors and childcare. Publishes a newsletter and leaflets. Network of local groups.

Kidscape
2 Grosvenor Gardens
London SW1W 0DH
helpline: 0845 120 5204
tel: 020 7730 3300
fax: 020 7730 7081
website: www.kidscape.org.uk 
Kidscape is the only national charity dedicated to preventing bullying and child sexual abuse. Kidscape works UK-wide to provide individuals and organisations with practical skills and resources necessary to keep children safe from harm.

London Lesbian and Gay Switchboard
PO Box 7324
London N1 9QS
helpline: 020 7837 7324
admin: 020 7837 6768
fax: 020 7837 7300
email: admin@llgs.org.uk 
website: www.llgs.org.uk 
London Lesbian and Gay Switchboard is a voluntary organisation which aims to provide a 24-hour information, support and referral service for lesbians and gay men from all backgrounds throughout the United Kingdom.

Mental Health Foundation
20 Upper Ground
London SE1 9QB
tel: 020 7803 1100
fax: 020 7803 1111
email: mhf@mhf.org.uk 
website: www.mentalhealth.org.uk 
With research and community projects, the Mental Health Foundation aim to improve the support available for people with mental health problems and people with learning disabilities. Also work with children, young people and those who care for them.

Nafsiyat Intercultural Therapy Centre
262 Holloway Road
London N7 6NE
tel: 020 7686 8666
fax: 020 7686 8667
email: admin@nafsiyat.org.uk
website: www.nafsiyat.org.uk
Mental health counselling and therapy for people from ethnic and cultural minorities.

National Association of Child Contact Centres
Minerva House
Spaniel Row
Nottingham NG1 6EP
helpline: 0845 4500 280
fax: 0845 4500 420
email: contact@naccc.org.uk 
website: www.naccc.org.uk 
Child Contact Centres are neutral venues where children of separated parents can meet with their non-resident parent, and sometimes other family members, in a safe and comfortable environment when there is no viable alternative.

National Council for One Parent Families
255 Kentish Town Road
London NW5 2LX
helpline: 0800 018 5026 (Mon to Fri 9am-5pm)
tel: 020 7428 5400
fax: 020 7482 4851
email: info@oneparentfamilies.org.uk 
website: www.oneparentfamilies.org.uk 
Information for lone parents on housing, benefits, family law, maintenance, pregnancy, splitting up, childcare and holidays. Lobbies on issues affecting one parent families. Information available on a subscription basis or by ordering on the website.

NCH
85 Highbury Park
London N5 1UD
tel: 020 7704 7000
fax: 020 7226 2537
website: www.nchafc.org.uk 
NCH supports children, young people and families disadvantaged by poverty, disability, neglect and abuse. They offer a range of services to meet their needs, and work with them to ensure they have every opportunity they need to reach their unique potential.

NSPCC
Weston House
42 Curtain Road
London EC2A 3NH
helpline: 0808 800 5000
tel: 020 7825 2500
fax: 020 7825 2525
email: help@nspcc.org.uk 
website: www.nspcc.org.uk 
The NSPCC Child Protection Helpline is a free, 24-hour service that provides counselling, information and advice to anyone concerned about a child at risk of ill treatment or abuse. See website for helplines in languages other than English.

Papyrus
Rossendale GH
Union Road
Rawtenstall
Lancashire BB4 6NE
helpline: 0870 170 4000 (from autumn 2005)
tel/fax: 01706 214 449
email: admin@papyrus-uk.org 
website: www.papyrus-uk.org
Campaigning organisation concerned with the prevention of young suicide. Information to parents, teachers, healthcare staff. Campaigns for better mental health provision for young people and better mental health education in schools. Encourages and takes part in research into young suicide, provides speakers for conferences. Contact with support groups for those who have been recently bereaved.

ParentLine Plus
helpline: 0808 800 2222 (24 hours)
textphone: 0800 783 6783 (Mon to Fri 9am-5pm)
website: www.parentlineplus.org.uk 
UK registered charity offering support to anyone parenting a child – the child's parents, step-parents, grand parents and foster parents. 24-hour freephone helpline, courses for parents, develops innovative projects and provides a range of information.

Post Adoption Centre
5 Torriano Mews
Torriano Avenue
London NW5 2RZ
tel: 020 7284 0555
fax: 0870 777 2167
email: advice@postadoptioncentre.org.uk
website: www.postadoptioncentre.org.uk 
Counselling, therapy and support for anyone involved in adoption. Individual work and family therapy. Telephone advice line. Contact and mediation service to help adoptive and birth relatives arrange contact. Birth parent and relatives drop-in, parenting skills courses.

Refugee Council
240-250 Ferndale Road
London SW9 8BB
adviceline: 020 7346 6777 (Mon, Tues, Thurs, Fri 10am-1pm and 2-4pm, Wed 2-4pm)
tel: 020 7346 6700
fax: 020 7346 6778
email: info@refugeecouncil.org.uk
website: www.refugeecouncil.org.uk 
Information service available on subscription basis. Written briefings, factsheets, research reports and leaflets in refugee community languages. Advice on education, employment, housing, health and welfare. Builds links with refugee community organisations. Residential homes for young refugees.

Re-Solv
30a High Street
Stone
Staffordshire ST15 8AW
helpline: 0808 800 2345
email: helpline@re-solv.org
website: www.re-solv.org 
Telephone enquiry service for anyone concerned about solvent or volatile substance abuse problems. Written enquiry service for professionals and others concerned with solvent and volatile substance abuse issues.

Samaritans
helpline: 08457 90 90 90 (24 hours)
email: jo@samaritans.org  
website: www.samaritans.org.uk
Telephone helpline offering emotional support for anyone in a crisis, including people who are feeling suicidal. Has local helplines and branches throughout the UK. In a crisis, write to Chris, PO Box 90 90, Stirling FK8 2SA.

Voice UK
Wyvern House
Railway Terrace
Derby DE1 2RU
helpline: 0870 013 3965 (Mon to Fri 10am-4pm)
tel: 01332 295 775
fax: 01332 295 670
email: voice@voiceuk.org.uk 
website: www.voiceuk.org.uk
Telephone support and information for adults and children with learning disabilities who have been abused, and for their families and carers. Campaigns for changes in the law and practice.

Who Cares? Trust
Kemp House
152-160 City Road
London EC1V 2NP
tel: 020 7251 3117
fax: 020 7251 3123
email: mailbox@thewhocarestrust.org.uk 
website: www.thewhocarestrust.org.uk 
Telephone helpline service for young people who are or have been in care. Also for carers.

Young Minds
102-108 Clerkenwell Road
London EC1M 5SA
Parents Helpline 0800 018 2138 (Mon and Fri 10am-1pm, Tues, Wed and Thurs 1-4pm)
tel: 020 7336 8445
fax: 020 7336 8446
email: enquiries@youngminds.org.uk
website: www.youngminds.org.uk
Information and advice for people concerned about the mental health or emotional wellbeing of a child or young person. Helpline for parents. Information about mental health issues and details of local and national advice services. Leaflets, consultancy service for health, education and social services to develop services for children with mental health difficulties.

References

[1] Office for National Statistics, 2004, Social Trends, 33.
[2] National Statistics Online (www.statistics.gov.uk/cci/nugget.asp?id=716).
[3] The Stationery Office. 2000, Mental health of children and adolescents in Great Britain.
[4] Goodman, R. 1997, 'Child mental health: who is responsible?', BMJ, 314, 813-814.
[5] National Statistics Online (www.statistics.gov.uk/cci/nugget.asp?id=853).
[6] The Stationery Office. 2000, Mental health of children and adolescents in Great Britain.
[7] Green, R. 2002, 'Mentally ill parents and childen's welfare', NSPCC Information Briefing.
[8] Singer, J., Tang, S. and Berelowitz, M. 2000, 'Needs assessment in the children of parents with major psychiatric illness', in P. Reder, M. McClure and A. Jolley (eds), Family matters: interfaces between child and adult mental health, Routledge, London.
[9] Youngminds, 'Children's needs in the Mental Health Bill' (www.youngminds.org.uk).
[10] Almost all hospital inpatients are under a Consultant who is responsible for their treatment, and their period of care under a Consultant is called a "Consultant Episode". A "finished consultant episode" is one that finished before midnight on the last day of the statistics year (31st March).
[11] Written answers, Hansard, 17 June 1997.
[12] Children accommodated in secure units, year ending 31 March 2000: England and Wales, Statistical Bulletin, Department of Health. (www.publications.doh.gov.uk/pdfs/sb0015.pdf)
[13] Dimond, B. 11 April 1997, 'Major problems with minors', Health Service Journal.
[14] Anderson, P and Montgomery, J. 11 April 1996, 'What about me?', Health Service Journal.
[15] Youngminds (www.youngminds.org.uk/responses/).
[16] Department of Health. 2004, NSF for children, young people, and maternity services: Standard