Memorandum submitted by YoungMinds (MH 17)
1. Executive Summary
1.1 This evidence is given in support of Clause 24 - Children and Young People.
1.2 The evidence is based on YoungMinds' experience as the only national charity exclusively concerned with the mental health and emotional well being of children and young people under the age of 25. YoungMinds has a track record of research amongst children and young people about their experiences of receiving - or not being able to access - mental health services at every level including in-patient care. YoungMinds researchers first detailed the difficulties of young people experiencing in-patient care in 2002, and most recently in 2007.  Our most recent research published in 2007 has been on behalf of the Office of the Children's Commissioner to create the report Pushed into the Shadows,2 which presents a damning picture of the lack of treatment and care experienced by many young people on adult wards. YoungMinds has also received independent anecdotal evidence from parents, young service users and professionals about the disturbing consequences for mentally ill children who are inappropriately placed on adult wards. The evidence we have received has led us to conclude that the rights of children and young people to age appropriate care must be protected in legislation, that policy is not enough.
2. Why does YoungMinds support the age appropriate clause?
2.1 Despite clear Government policy in the NSF for Children and Maternity Services, the safeguarding children policy in the Children Act 2004, the UNCRC undertaking that under 18 year olds should not be detained with adults unless such detention would benefit the child, and an understanding in the current Code of Practice that the admission of an under 18 year old to an adult ward is an exceptional event, under 18s are admitted as a matter of routine to adult wards.
2.2 Unfortunately, because the numbers are not recorded, we have to rely on educated estimates by the Royal College of Psychiatrists which suggests that around 1000 children a year are being treated on adult wards.
2.3 From April 2003 to October 2006, the Mental Health Act Commission (MHAC) received 1308 voluntary notifications of children under the age of 18 detained on adult wards, approximately one per day. Although over half of the notifications were for 17 year olds, with most of the remainder being 15 or 16, the MHAC received notifications of 22 14 year olds, three 13 year olds and two children under 12, one of whom was 10 years old.
2.4 A recent report by the Healthcare Commission, Mental Health Act Commission and National Institute for Mental Health in England showed that 55% of patients are placed on wards which are mixed sex, and the figures from the MHAC showed that within the group of detained young people they had recorded 75% of girls as being held on mixed sex wards.
2.5 Quite simply, Government policy that seeks to prevent this practice, is not working.
3. What is the effect on children and young people of being placed inappropriately on an adult ward?
3.1 Adult wards, and in particular, psychiatric intensive care wards, are not yet the safe therapeutic haven detailed in the Mental Health Policy Implementation Guide.4 Children and young people witness and experience verbal, physical and sexual abuse. They are often denied access to education, and any activities which are appropriate to their age group.
3.2 Two weeks ago YoungMinds was contacted by B, who wished to remain anonymous but asked us to pass on the following statement:
3.3 'My daughter spent three and a half months on a mixed adult psychiatric ward at the age of 16 following an overdose in May 04. Prior to this she was receiving treatment for her eating disorder from the Tier 4 CAMHS.
3.4 They recognised the high level of risk she posed to herself and had allocated her the next non emergency bed but were powerless to admit her to an emergency bed as these were reserved for under 16's.
3.5 Adult psychiatric wards are scary places as they accommodate people who can be deeply disturbed, violent and sexually disinhibited. Early in June 04 my daughter was sexually assaulted by an elderly male patient on the ward. The incident left her so distressed that she left hospital and returned home. Unfortunately she 'coped' with the incident by self-harming to the extent that she required arterial stitches, so returned to hospital.
3.6 Sadly her stay in hospital did not address her problems and left her institutionalised within adult mental health services. Although she started at 6th form soon after her discharge she dropped out about a month later. Her peers abandoned her, which could be linked to the difficulty they had being allowed onto the ward. Fortunately, she has since spent a year in a therapeutic community which has had a dramatic positive effect. However a large proportion of her friends are now in the mental health system.'
3.7 B made inquiries into protocols for placing children on adult wards with Schedule One offenders, but was told no such protocol existed and in consequence under 18 year olds were on the same wards as convicted paedophiles.
3.8 This is not an isolated case, YoungMinds has been contacted by parents and lawyers for advice about how to safeguard under 18 year olds held on wards with sex offenders.
3.9 Lois was admitted at 16 years old. She told us 'I was treated like an animal. I wouldn't go back to an adult ward out of sheer fear'.
3.10 Another parent, J sent an email about her son who has Asbergers and Attention deficit disorder. He became suicidal at 16, but his parents were told 'unfortunately there were no places available in the Mental Health wards for 16-18yr olds - so what were we supposed to do? Keep him at home and just wait for the inevitable? Well it happened-almost. We went out for the day leaving Ben at home, he didn't want to come, he'd been quite settled for a couple of weeks so we agreed to leave him'
3.11 They arranged for a relative to pick him up and take him out:
'I phoned him at lunchtime to see if he was ok. He said he'd cancelled (the trip), instead he was going to hang himself. Well we were an hour & half away, and he knew that, I tried my best to talk him out of it, trying to keep him on the phone, but he hung up and wouldn't answer again. So we phoned the police who were at the house within 10 minutes, and they got in and found him hanging unconscious from the banister.
3.12 They cut him down, brought him round he was taken to hospital and when we got there, once again discharged. They said there was no place suitable for him. If he was put on an adult mental health ward it would cause more harm than good, and he was too old for a children's ward (he was 16years old)'.
3.13 Eventually their son was sectioned 'but unfortunately to an adult ward which they kept saying to us was not appropriate but there was no-where else for him. We thought at least now he would be given the help he desperately needed. But no, the person who was supposed to assess Ben was either off sick or on holiday so he was just left bored out of his mind with nothing to do on an adult ward, which must have been really hard for someone with Aspergers' & ADD. He appealed against his section and won. We wonder why, was it because there wasn't an appropriate place for him? I hope you can use our experience to help highlight the problem and that hopefully in the near future places will be available for these children who are in crises.'
3.14 Denied the right to see an advocate, many young people such as Antonia do not know they have a right to education, to fresh air, to information. She said 'Just because children and young people with mental health problems might not have any physical illness or disability, the support and treatment they get should still be provided by people who have specialist understanding and awareness of young peoples difficulties.'
3.15 Young people, parents and clinicians have reported to YoungMinds that young people are so traumatised by their experiences on adult wards that they disengage with services. One psychologist reported ' We were called out by parents to a boy in crisis. He had already had one admission to an adult ward, and realised he was experiencing the same symptoms as his first psychotic episode which had led to his admission. Eventually he told his parents, but when he realised they had called the Early Intervention Psychosis team, he hid in the loft and wouldn't come out. We only persuaded him to accept treatment by giving him a promise in writing he wouldn't go back to the adult unit he so feared. Because we were able to persuade him to receive treatment, we prevented an admission. If we hadn't been able to get to him early enough, if he had hidden his symptoms for a little bit longer he would have been too far gone and would have been admitted, under section, probably with the police involved back to that adult ward'.
4. Are adult wards ever acceptable for under 18 year olds?
4.1 Yes, where the young person is developmentally at a stage where an adult ward is the most appropriate environment, placing him or her within a child and adolescent ward would not meet their needs. However, the assessment of where is most appropriate needs to be done by a practitioner who has been trained to understand the developmental needs of children and young people. CAMHs psychiatrists are trained as adult psychiatrists first, and then they have specialised CAMHs training. Adult psychiatrists are not sufficiently trained in assessing the needs of children or adolescents.
5. The law in Scotland includes an 'age appropriate' clause, yet the numbers of children on adult wards has risen. Does this mean that placing this clause within the law rather than policy has failed?
5.1 The Mental Health (Care and Treatment) (Scotland) Act 2003 is still relatively new and Health Boards and clinicians are in the early stages of implementation of the Act. Clinicians in Scotland have advised YoungMinds that overall the effect of an age appropriate clause has been beneficial. They support the wording of the clause in particular as it acknowledges young people for whom it is therapeutically appropriate to be treated on adult wards rather than a total ban on all under 18s on adult wards.
5.2 Interpreting the increase in numbers on adult wards as a failure of the Act does not take into account the poor recording of numbers prior to the Act, so the increase may reflect more robust counting. Neither does it acknowledge that, in a landscape with serious under provision, an increase might indicate simply that access to services is improving. It also reflects the very small numbers of beds in Scotland and the knock on effects of closing beds due to sickness or a need to refurbish some beds. In any event, Scotland has a better awareness of numbers than England and Wales, where the numbers of under 18s and their age profile are not officially recorded anywhere and our estimations have to be based on research or by voluntary notification to the Mental Health Act Commission.
5.3 CAMHs services in Scotland are provided at a lower baseline than in England and Wales, so the problem of children on adult wards is even greater, with a very limited number of dedicated beds. There are similar problems as in England caused by the decision to require CAMHs teams to cover 16 and 17 year olds without an equitable transfer of funding, leaving many CAMHs teams even more stretched to deal with older adolescents previously dealt with by adult services. It would be fair to say that the manner in which the law is interpreted differs in some areas, and that a differential approach can cause problems. Scottish colleagues have suggested that the interpretation of the clause needs to be explored in training and implementation. However, the Act has now required services and service planners to face these issues. CAMHs clinicians have been able to use the clause to ensure that the Scottish Executive Mental Health Delivery Plan and local Health Boards now include plans for more in-patient provision, with ambitious targets for reduction of the numbers on adult wards. Colleagues in Scotland report that older adolescents are now being given places on CAMHs wards, and that where under 18s still need to be accommodated on adult wards because it is the only place where the young person can receive treatment, that adult clinical teams are more aware of the need to support and protect the child and to liase with CAMHs services.
5.4 The problems in England regarding children on adult wards are magnified in Scotland, but placing a legal requirement to meet the needs of the child on the Bill has done more to improve the safety of children in Scotland than years of attempts by CAMHs clinicians and the Mental Welfare Commission to encourage good practice through the route of policy, good practice and common sense. In the words of one Scottish Clinician consulted by YoungMinds : 'How it could be argued that English adolescents mental health needs would be adequately catered for without this (legal framework) beats me!'
6. Could this clause prevent young people from being admitted to hospital because appropriate care is not available?
6.1 Although the Government may have already introduced a partial requirement for age appropriate services to be provided by default by its introduction of the new "appropriate treatment test" into the criteria for detention under section 3, related sections of Part 3 and the corresponding criteria for renewal and discharge, the use of the current appropriate treatment test holds potential dangers that a child's interests may not be met.
6.2 Arguably, in the case of a child or young person under the age of 18 for whom an adult placement is not appropriate, the criteria to detain cannot be met 'unless medical treatment is available to the patient in question which is appropriate taking account of the nature and degree of the patient's mental disorder and all other circumstances of the case.
6.3 The test requires that appropriate treatment is actually available for the patient. It is not enough that appropriate treatment exists in theory for the patient's condition.'
6.4 However, the effect of this clause under section 3 could be that a young person, who should be placed under compulsory treatment for safety, could not be detained if a PCT refused to fund appropriate care in a CAMHs unit and the adult unit was not deemed safe, because appropriate treatment was not available. Relying on this section to seek appropriate treatment ignores the needs of those admitted under section 2, or those admitted on a voluntary basis.
6.5 The age appropriate clause places PCTs or Health Boards under a duty of care to provide treatment and accommodation - whether this be in a CAMHs unit or by requiring more explicit and definite division of accommodation from adult wards is not defined by the clause, as this would be a matter for discussion between individual clinicians, providers and commissioners. There is no need for the care of children to be delayed, but there is a need for commissioners to plan carefully to ensure they have adequate services which meet most needs, and plans to deal with exceptional cases.
6.6 The duty is in relation to how the service is provided, i.e. an adult ward which can offer a well supported place and addresses issues such as family access can be regarded as Act compliant. This might even be the case if there was no arrangement for CAMHS input. For example an early onset psychosis team admitting a 17 year old may well provide an Act compliant service.
7. Does placing a clause giving a specific age group differential rights on a Health Bill set an unhelpful precedent?
7.1 YoungMinds would argue differently - that there are multiple laws in which the rights of under 18 year olds are differentiated from adults, of which the current Offender Management Bill is the most recent example, which sets out differential custodial arrangements to meet the needs of under 18 year olds. Children are under the protection of a range of laws such as the Children Act 1989 and the Family Law Reform Act, so inserting a clause detailing their rights and needs would bring the Mental Health Act into line with other Acts rather than the other way round.
8.1 YoungMinds recommends that the House of Commons Committee uphold the rights in the UN Convention on the Rights of the Child for children and young people under 18 to receive accommodation and services to meet their needs, assessed and supervised by professionals with appropriate expertise. It is YoungMinds view that leaving this issue to policy and good practice will fail to safeguard vulnerable young people and perpetuate an unsafe system of care and treatment which has harmed and will harm young people in the future.
8.2 YoungMinds recommends an urgent review of transition services and continued investment in adolescent outreach teams and early prevention teams to support young people and prevent unnecessary admission.
8.3 YoungMinds recommends that the numbers of children and young people under 18 who are mental health in-patients should be counted, their circumstances recorded and their progress monitored.
8.4 YoungMinds recommends outcome monitoring research to identify what happens to young people who are placed on adult wards after they reach 18.
 Street, C. (2000). Whose crisis? Meeting the needs of children with serious mental health problems. London: YoungMinds. See http://www.youngminds.org.uk/whosecrisis/YoungMinds_WhoseCrisis.pdf
 Office of the Children's Commissioner (2007). Pushed into the shadows: young people's experience of mental health facilities. London: Office of the Children's Commissioner. See https://www.childrenscommissioner.org/documents/Pushed%20into%20the%20shadows%20report%20final.pdf
 Healthcare Commission, Mental Health Act Commisson & National Institute for Mental Health in England (2007). Count me in: results of the 2006 national census of in-patients in mental health and learning disability services in England and Wales. London: Healthcare Commission. See http://www.healthcarecommission.org.uk/nationalfindings/nationalthemedreports/mentalhealth/countmein/2006.cfm
 Department of Health (2001). Mental health policy implementation guide. London: Department of Health. See http://www.dh.gov.uk/assetRoot/04/05/89/60/04058960.pdf