Education CommitteeWritten evidence submitted by the Children and Young People’s Mental Health Coalition’s

1. The Children and Young People’s Mental Health Coalition (Coalition) brings together a variety of third sector organisations to campaign on behalf of and with children and young people to effect change in policy and practice that will improve their mental health and wellbeing. Zurich Community Trust has funded the Coalition, whose core members are Mental Health Foundation, Rethink Mental Illness, Right Here, Royal College of Psychiatrists, Place2Be, The Prince’s Trust, YoungMinds, Youth Access, Youth Net, NSPCC and The Tavistock Centre for Couple Relationships.

2. Executive Summary

2.1. Sure Start Children’s Centres (SSCC) continue to be important services for families and their children. The Children and Young People’s Mental Health Coalition (Coalition) generally welcome the Core Purpose, but we still have some concerns. SSCC s are key to the early intervention of mental health problems in both the parent and the child. We believe that the Core Purpose should include relationship support within the section on universal services, as it is not only “families in greatest need” who can be helped by relationship support.

2.2. The lessons from literature on evidence based interventions indicate that it is not just what you make available, but also the way that you make evidence-based programmes available (Fixsen, 2005; Centre for Mental Health, 2012). For instance engaging people and preventing them from dropping out of the service is vital; you need high quality staff; more integrated inclusive single needs assessment and outcome setting involving all key partners; and you need stable funding.

2.3. Children often communicate emotional or developmental distress through their behaviour; and research shows that early behavioural problems have a huge impact on later outcomes. Therefore, behaviour should be tracked just as you would track hearing or other developmental progress. There are a number of relevant NICE guidelines and other evidence based/informed practice that could be implemented in SSCC to help these children. There are some well validated tools, which will help SSCC measure children and families outcomes.

2.4. We are concerned that Early Intervention Grant (EIG), which can be used to fund SSCCs, has been reduced already, and there are plans to hold back money from the EIG to fund free nursery provision. SSCCs are part of the local provision to support children and their families. We know that SSCCs and other services are facing cuts, and this will result in some children and their families not being able to access early intervention services when mental health issues first arise. If these problems are not tackled early on, they are likely to become chronic and entrenched and continue into adulthood. So cuts to these services do not make clinical or economic sense.

3. Core Purpose

We generally support the Core Purpose for Sure Start Children’s Centres (SSCC) and are particularly pleased to see that promoting child development and mental health is included in the overall aims of SSCCs.

3.1. Overall SSCC’s should focus on social and emotional learning outcomes in order to underpin the school readiness aspect of the new core purpose. For example if parent child attachment issues are resolved by the reception year, attendance at school is likely to be a less traumatic event. Also, if children have developed a calm behaviour they are more likely to tolerate the demands of structure and focus at school and be able to engage successfully with teachers and other children.

3.2. Parental, particularly maternal mental health is known to impact on child behavioural outcomes. Where SSCC have good multi-agency working and strong use of the Common Assessment framework they are in a good position to identify parents with mental health needs linked to pregnancy. For instance, if they identified perinatal depression, they could start engaging the mother and her children, with the SSCC services as soon as possible. Family Action does this through their volunteer befriending based Perinatal Support Project, which is located in West Mansfield children’s centres. Islington Council has a First 21 months strategy whereby a range of relevant health professionals for example midwives are based in all their children’s centres. Given the importance of the first two years in child development a focus on parental mental health and well-being would boost SSCC outcomes overall and in social and emotional learning and boost uptake in respect of the two-year old offer.

3.3. The overall focus of the core purpose is on disadvantaged children, the higher flows of disadvantaged children through the two year old offer, and the expectation that councils will link SSCCs to the Troubled Families Programme would suggest increased engagement with families with multiple complex needs. This will mean that SSCCs will need to provide a range of services—including intensive, outreach and group-based- that can support parental and child mental health and well-being. This is particularly important given the expectation of the core purpose that SSCCs should increasingly function as community hubs and that disadvantaged parents should engage with activities and participate in the running of the centres. Better parental mental health will need to support these levels of participation.

3.4. We believe that the Core Purpose should include relationship support as one of the bullet points under point 1 (ie the Core Purpose). Relegating relationship support to the section on targeted interventions for families in greatest need—as the document currently does—will do nothing to change the culture around relationship support, something which is one of the Government’s own objectives (http://www.education.gov.uk/childrenandyoungpeople/families/relationship/a00212569/relationship-support-first-time-parents-trial).

3.5. After all, it is not only “families in greatest need” who can be helped by relationship support. Focusing only on “parenting aspirations, self esteem and parenting skills” as the means to improve child development and school readiness will mean that the opportunity for services that help parents whose relationship is running into difficulty before such problems become entrenched (http://tccr.ac.uk/policy/policy-briefings/273-relationship-difficulties-tccr-policy-briefing) will be missed, with all the negative consequences that parental relationship distress, conflict and/or breakdown can have on children’s emotional, social and cognitive development (http://tccr.ac.uk/policy/policy-briefings/267-impact-of-couple-conflict-on-children-tccr-policy-briefing)

4. However, there are some omissions in the current terms of reference. The lessons from literature on evidence based interventions indicate that it is not just what you make available, but also the way that you make evidence-based programmes available (Fixsen, 2005; Centre for Mental Health, 2012). So:

4.1.1.Engagement and stopping people from dropping out is key. All the literature makes it very clear that some of the most powerful factors supporting engagement with interventions are the practical facilitators (convenience of contact, crèches, ease of transport, venues etc). The Centre for Mental Health’s recent evaluation of national practice in relation to evidence-based parenting programmes highlighted that these were the areas of practice most likely to be cut by commissioners (Centre for Mental Health, 2012)—anything that interferes with your engagement and retention levels is a false economy.

4.1.2.Research highlights that you need person-centred, therapeutically skilled and highly engaging staff trained in delivery (otherwise in some instances you can make outcomes worse for children—(Scott, et al., 2008); staff need a system of ongoing coaching and supervision supporting continuous improvement and reflective practice to maximise their ability to turnaround children’s outcomes and replicate promised results. This is also important as a support for paraprofessionals (Korfmacher, et al., 1999).

4.1.3.More integrated working relies on more integrated and inclusive strategic needs assessment and outcome-setting involving all key parties (midwives, voluntary sector, health visitors, social care, speech and language therapist, EY workers, parents, CAMHS/IAPT, education, housing etc). Health and Well Being boards must play a key part in drawing together a broad range of data and partners setting clear messages about ambitions for local children.

4.1.4.Centres need stable funding in order to sustain good quality practice (Fixsen, 2005)

5. The early evaluations of the local Sure Start programmes found that often the most vulnerable children and their families were not accessing these services. This is a concern as these children are potentially at greatest risk of developing mental health problems and are likely to have negative outcomes more generally. So, it is good to hear that the most recent evaluation has shown that SSCCs are now engaging with the most vulnerable groups.

5.1.However, the national evaluation found that there were improved outcomes for parents, but not for children. So it is important that SSCCs understand what the needs of the children in their area are, and use evidence based/informed practice to improve outcomes for children as well.

6. Evidence Based/Informed Practice

6.1. Children often communicate emotional or developmental distress through their behaviour. Given what research tells us about the dramatic impact of early behavioural problems on children’s long term prospects (Fergusson, 2005); it is particularly essential to see children’s behaviour as a critical gauge for their developmental well-being (Centre for Mental Health, 2012). Behaviour should be tracked just as you would track hearing or other developmental progress.

6.2. There are a number of relevant NICE guidelines and other evidence based/informed practice that could be implemented in SSCC. Evidence-based parenting programmes focusing on supporting positive parenting have now been proven to support better outcomes for children with early behavioural problems through over 100 RCTs. They are suitable for use from three years of age, building on the important foundation of parental risk/attachment-based work highlighted above. They also form an important part of core CC provision. Some of these programmes are delivered in some areas by well-supported parent graduates.

7. There is a lot of potential for SSCCs to improve outcomes for children and their families, but it depends on what services are available, and which professionals are employed and what grade they are. We have heard anecdotally that GPs find SSCC really useful as a service to refer families onto regarding mental health problems; but some SSCC have lost their clinical psychologists. The loss of these mental health professionals from the SSCC has implications for the mental health support available within the centre, and can mean that GPs can no longer refer families who have a child with mental health issues to SSCCs.

8. Measuring Outcomes

8.1. There are some well validated tools, which will help SSCC measure children and families outcomes.

8.2. The Strength and Difficulties Questionnaire is a validated tool which tracks children’s behaviour and emotional well being in relation to norms. In Wales it is used by Health visitors as a key part of standard developmental health tests supporting children’s well being. Through this routine contact, health visitors build up a whole population picture of where children sit in relation to UK norms. They can then also work with Children’s Centres to assess to what extent these units are engaging these families (ie work out who you are not engaging). In this way, Health Visitors can also identify children and families who may need extra outreach support with parenting support or motivational help from voluntary sector or mentoring services to access broader Children’s Centre services.

8.3. Collation of SDQ data also assists Children’s Centres in Birmingham evaluate the accuracy of their outreach to vulnerable families in local communities; before using SDQ, estimates of accuracy were based on guesswork and worker perception which often proved to be unreliable (Social Research Unit, 2010).

8.4. There are other tools available. More information about relevant tools can be found in the following resources: Finding and Using Effective Measuring tools http://pelorous.totallyplc.com/public/cms/115/237/85/6728/Evaluation%20tools%2015%20Feb%202012.pdf?realName=uKkLx6.pdf and a systematic review of relevant tools from the Anna Freud Centre—http://www.ucl.ac.uk/clinical-psychology/EBPU/publications/pub-files/Mental%20Health%20Outcome%20Measures%20for%20Children%20and%20Young%20People.pdf

9. Funding and Cuts

9.1. We know that local authorities have taken a big cut in funding, and for many this has resulted in their child and adolescent mental health services (CAMHS) budget being radically cut (YoungMinds, 2011). This is likely to result in early intervention services provided by the local authority, or by commissioned voluntary sector organisations being reduced or cut. So, if a GP, for instance can’t refer a child and their parents with mental health issues to a local SSCC, it is likely that there will not be any other services they could be referred to. They are unlikely to be referred or have their referral accepted by a specialist CAMHS teams, unless the child is in significant mental distress. If what might be minor mental heath, behavioural or relationship problems isn’t addressed at an early stage they can get worse and potentially turn into chronic and entrenched mental health problems that continue into adulthood.

9.2. We know that there are already a high number of young people with mental health problems. For instance, 1 in 10 children and young people have a mental disorder; and many more have milder problems, which haven’t yet reached the clinical threshold for a disorder. Having a mental health problem can have a big impact on a child’s academic and life outcomes. For instance they are more likely to be excluded from school; more likely to leave school without educational qualifications; Children with conduct disorders and severe Attention Deficit Hyperactivity Disorder (ADHD) may be four to five times more likely to struggle to attain literacy and numeracy skills (Green, et al., 2005) (Parry-Langdon, 2008).

9.3. We are concerned about funding for SSCC and the consequences this will have for the number and range of services available. The 4Children’s SSCC Census (2012) found that there was a reduction of 281 centres since April 2010. Back then most were coping, but 10% were struggling. Funding can come from the Early Intervention Grant (EIG), but this has been reduced already, and there are plans to hold back money from the EIG to fund free nursery provision.

9.4. So it is likely that more SSCC will close or merge, and many more will struggle. Closing of SSCC is likely to mean that it is harder for some families to access these services, so those families who most need support may not access the help.

9.5. Closing SSCC is very short sighted as research has estimated that £4.60 will be generated in social value for every £1 invested in effective Children’s Centres (Action for Children and NEF, 2009).

References

4Children (2012) Sure Start Children’s Centres census 2012. London: 4Children. http://www.4children.org.uk/Resources/Detail/Sure-Start-Childrens-Centres-Census-2012

Action for Children and New Economics Foundation (2009) Backing the future: why investing in children is good for us all. London: New Economics Foundation. http://www.actionforchildren.org.uk/media/94361/action_for_children_backing_the_future.pdf

Centre for Mental Health, 2012. A Chance to Change: delivering effective parenting programmes to transform lives. Centre for Mental Health: London

Fergusson, D., Horwood, J. & Ridder, E., 2005. Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood.. Journal of Child Psychology and Psychiatry, 46:8,, pp. 837–849.

Fixsen, D. L. et al., 2005. Implementation Research: A Synthesis of the Literature, Tampa, FL: University of of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network.

Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young people in Great Britain 2004. London: Palgrave. See http://www.statistics.gov.uk/downloads/theme_health/GB2004.pdf

Korfmacher, J., O’Brien, R., Hiatt, S. & and Olds, D., 1999. Differences in programme implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: a randomised trial. American Journal of Public Health, 89(12), pp. 1847–1851.

Parry-Langdon, N. (ed) (2008) Three years on: survey of the development and emotional well-being of children and young people. Newport: Office for National Statistics.

Scott, S., Carby, A. & Rendu, A., 2008. Impact of Therapists’ Skill on Effectiveness of Parenting Groups for Child Antisocial Behavior. [Online] available at: http://www.incredibleyears.com/library/items/therapists-skill_08.pdf [Accessed 4 January 2012].

The Social Research Unit, 2011b. Preliminary Findings from Evaluation of Evidence-Based Programmes Implemented in Birmingham (updated), Dartington: The Social Research Unit.

YoungMinds (2011) Children and young people’s mental health services slashed by funding cuts. London: YoungMinds. http://www.youngminds.org.uk/news/news/430_children_and_young_peoples_mental_health_services_slashed_by_funding_cuts

December 2012