The Prevalence of Children and Young Peoples Mental in Scotland

INTRODUCTION

There are several and complex developmental needs of the children, as they are going through many changes and stages of growth (Sharman, 1997). Therefore, these needs must be met for the children to attain their highest potential in each stage of the life (Health et al, 2000). Mental health is defined as a “relative state of mind in which a person…is able to cope with, and adjust to the recurrent stress of everyday living” (Anderson and Anderson, 1995 p.450) cited in (Sharman, 1997 p.1). Therefore, experiencing mental health issues may hinder children and young people from their principal life attainments (Sharman, 1997). According to Sharman (1997), most human beings if not all, will experience some form of mental health problems in their life time, particularly when we feel unable to manage and cope with the day to day life stresses, and children are no exception to this. With this in mind, it is imperative that, encouraging and dealing effectively with mental health while managing symptoms, and risks related to mental health issues is vital duty for all the professionals, working with the children and young people including social workers (Richardson and Joughin, 2002).

The role of social workers, especially those, working with the children and young people with mental health issues, is fundamental. As such social workers are duty bound to safeguard, promote and support the wellbeing of all the people experiencing mental health issues, including Children and young people in accordance to the Scottish Social Services Council (2016). These duties are laid down under S.46 of the Social Work (Scotland) Act 1968 and the Mental Health (Scotland) Act 2015. As well as with these two Acts, the social workers are also mandated under the Children (Scotland) Act 1995 to assess the needs of all the children referred to the service, as a ‘child is in need’ by conducting investigation, risk assess, and initiate contact with other agencies to ensure the welfare of children are protected.

The purpose of this report is to consider the policies relevant to mental health in Scotland for both the children and young persons and critically evaluate it in relation to the service user’s needs. The report will also consider current gaps in practice those impacts on this service user group.

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NEEDS AND KEY ISSUES FOR SERVICE USERS (Demography/context)

“Mental health is an important component of the total well-being of a child and it cannot be considered in isolation, but must be seen in conjunction with physical health and in the context of the environment in which the child lives” (Sharman, 1997 p.1). In 2016, the Scottish Government published a review, which indicated that, about 15% of the population in Scotland experience a diagnosable mental health condition, however an estimation of about two thirds of those, experiencing mental health issues and could benefit from the treatment, are not receiving the much-needed support (Erin Dean, 2017). A report by SAMH (2019) indicated that, three out of ten children and young people, referred to the main mental service in Scotland, are placed in the waiting list for over 18 weeks and one in every five referrals to CAMHS has been rejected for the past five years.

While adult mental health issues have benefited from high profile awareness, mental health issues in children and young people that has been undermined until the last few decades (Emerson et al, 2003; Audit Commission, 1999). Sharman (1997) in agreement stated that, the increase in awareness, recognition and consideration for children and young people’s mental health only started in the last 20 years cited in (Audit Commission, 1999). The change in attitudes is attributed to the increase in knowledge, gained over the last few decades (Audit Commission, 1999).

These led to the awareness of emotional and psychological development that has impact on children’s lives, and consequences of emotional and behavioural disorders (Audit Commission, 1999). Similarly, Herbert, (1993 p.95) argued that, mental health issues that originate from childhood may present “unfavourable social and personal consequences for the child”. Charities like the Scottish Association for Mental Health (SAMH) ‘It Going To Be Alright in 2017) report evidenced that, these concerns detailing half of adulthood mental health issues start form a tender age of 14 years and before they turn 16 years. This report found prevalence in high proportion of low mental health and emotional issues in 15 years olds indicating 44% of girls reporting two or more psychological health issues as compared to 21%, for boy’s age 15 years (Currie et al. 2015). This report revealed a notable gap between girls and boys of 15 years old (Currie et al. 2015). Some of the reasons cited by this report includes, self-perception of body image, social media, limited physical activity, school work pressure (Currie et al. 2015). Similarly, a recent Ofcom (2018) report stated that, 90% of children and young people experienced unpleasant behaviours by their peers on social media. Additionally, the National Society for the Prevention of Cruelty to Children (NSPCC’s) How Safe Are Our Children (2018) report indicated that during 2016–2017, there has been a 30% increase of indecent online communication, experienced by children and young people. Also 1 out 8 (12%) 12-15 years olds reported face to face bullying, and 11% via social medial and 9% via messaging apps or text messages.

Policy and Legislation

Laws and policies accord the authority for intervention in any given context. However, for the sake of brevity, this report will provide a brief outline of history and some of the milestones of mental health in Scotland relevant to Children and young people’s mental health. There have been many changes in the area of mental health since the passing of The Poor Law (Scotland) Act 1845, the Lunacy (Scotland) Act 1857 and the Mental Deficiency and Lunacy Act 1913. According to Farquharson, (2017), these two Acts occupied a role of de factorather than de jureand described as “solid accretions”with the Scottish landscape. The 1960’s that saw the beginning of challenges against conventional treatment and hospital care for mental health patients led to the changes in societal and political attitudes towards mental health care in the 1970s as the public became more aware of the human rights issues surrounding the detainment of people with mental issues by the most powerful with society (Prior, 2003). Mental Health (Scotland) Act 1984 was centred on detention of mental health patients within hospital setting (Baillie, 2003). However, it was later recognised that, this approach lacked humanity. Specifically, S.17 which held on the grounds for detention was deemed as not reflective of modern practice, and led to a major policy shift (Millan, 2001).

in order to address this, in 2002 the Mental Health (Scotland) Bill was passed (Baillie, 2003), and it led to some major changes within the Scottish mental health law. These changes were to the time “the public safety agenda” within a climate of high profile homicides cases involving people experiencing mental health issues (Baillie, 2003). One high profile case was that of Christopher Clunis, a discharged schizophrenic patient, who stabbed and killed a member of the public. Although not a young person, however, the resulting inquiry outlined many failures within the system and held all inter-agencies, involved with his care responsible for what it called “catalogue of failures” (Clunis Inquiry, 1994). Thus, there is lack of communication and responsibility taken amongst those agencies involved (Clunis Inquiry, 1994). This inquiry led to the current Mental Health (Care and Treatment) (Scotland) Act 2003, implemented in 2005. The 2003 Act was rolled out to modernise mental health practises and to introduce “legally enforceable community compulsory treatment” (Ridley & Hunter, 2013 p.2). The 2003 Act became the most fundamental change to occur in 40 years and was described as both “visionary and revisionary” as it encompasses 10 key values including enforcement of community measures, safeguarding and advocacy, access to mental health tribunal, and gave new responsibilities for the health and social care authorities(Ridley & Hunter, 2013). Others like Goldie et al, (2016) described it “as one of the most advanced pieces of mental health legislation in the world, particularly with regards to respect for human right” (Goldie et al, 2016 p.18).

A review by Mcmanus Jet al. (2009) found that, although numerous part of the Act in terms of implementation worked well, however there were still some remaining problems six years after implementation. Mcmanus J et al. (2009) cited in (Goldie et al., 2016) criticised that, some areas of the 2003 Act were unreliable in terms of it independent advocacy, the lacked of clarity in terms of the Named Person Policy and the lack of opt out option as well as the limited legal representation accorded to the patient. The 2003 Act was thus revised in 2015 by the Mental Health (Scotland) Act 2015 and complemented by the good practice guidance, Mental Health Welfare Commission as well as the Code of Practice (2005) (Guthrie, 2018). For children and young persons, additional legislation includes the Children (Scotland) Act 1995 that is influenced by the UN Convention’s principles on the Rights of the Child. This act makes it clear that, the wellbeing of the child must be absolute in any consideration pertaining a child (Millan, 2001), with S.22 outlining the duties of social work to promote and safeguard the welfare of children in need.

The current Mental Health Strategy 2017- 2027 recognises that, mental health issues affect every individuals in Scotland and while almost all mental health issues are treatable, and can lead to a complete recovery or manageable condition and the people to live a happy, healthy and productive lives, this is not materialising (The Scottish Government, 2017). The focus of this strategy is to prevent and make treatment accessible for those, experiencing mental health issues, through integration of the services. This is implemented through a multi-agency approach including working alongside, schools, the national health services and child and adolescent mental health service (CAMHS). CAMHS is the main mental health assessment and treatment service for the children and young people in Scotland that will be addressed in a later section in this report (Hothersall, 2008).

Getting It Right for Every Child (GIRFEC)

In addition to these Acts, a foundation of the approach to the children and young person’s care within Scotland is the Kilbrandon Committee Report (1961). The preventative approach of addressing the child’s environment has threaded through children and young people’s welfare policies, developed in Scotland (Hothersall, 2014). One of the most influential and relevant policies to be originated from Kilbrandon report 1961 is Getting It Right for Every Child (GIRFEC). GIRFEC currently stands as the main policy, looking after the welfare of the children and young people in Scotland. Branded as "the golden thread which knits together our policy objectives for children and young people" (Scottish Government, 2010a, p.3). The vision and practice of GIRFEC is to “empower those working with children and families to operate across professional boundaries in order to identify and address needs at the earliest opportunity to prevent problems escalating” (The Scottish Government, 2017). GIRFEC underpins and provides the framework for agencies working with children and young people to provide a holistic support (Hothersall, 2014) and the required measures through the children's hearing system for children and young people in need of protection (Aldgate, 2011).

Although hailed as a positive policy GERFIC (Stalker, 2015) nevertheless it also attracted some negative public, media academic criticism over the years. According to Stalker (2015), GIRFEC neither highlighted nor accounted for the specific needs of disabled children therefore unintentionally, excluded them, from the policy at the initial stages. As a result, disabled children's needs were placed outside the principles of GIRFEC until 2009, three years after it was launched (Stalker, 2015). Critics including McKendrick, (2016) indicted the Scottish Government of developing GIRFEC and broadcasting it as best as for the children and young people to hide its real agenda of neo-liberalism and state control. One of the most contentious police to come out of GIRFEC is the Named Person Policy which was implemented to protect children and young persons from birth to 18 years of age, or beyond 18 years if still in school.

In relation to mental health for the children and young persons, the Named Person appoints someone to look after the interest of care for those treated under the mental health legislation and allowed an automatic appointee for those under 16 years of age, the appointee mainly person with parental right or primary care givers of the child (Guthrie, 2018). The policy however came under heavy criticism with the general public and the media and perceived as the government's way of interfering in family lives (Change.Org, 2016). Due to the level of public outrage, controversies and bad publicity the named person policy was suspended and place under review while other elements of GIRFEC was put in place. However, in September 2019, the Scottish government repealed named person policy (The Scottish Government, 2019).

ROLE AND FUNCTION OF SOCIAL WORK

Social workers work mostly with vulnerable people and, are mandated to protect and promote the rights and interest of service users and their carers (SSSC Code of Practice, 2016).The key role of social work is to intervene and help the maters including “accommodation, arranging community support, advocacy, referrals for further specialist treatment, and assisting with welfare procedures” (Hothersall et al., 2008).

Walton, (1999: 378) acknowledged that, “Social work in the mental health field has traditionally occupied an unstable, ambivalent and ambiguous position, caught between the dominant theoretical and professional discipline of biological psychiatry and the psycho-socially oriented theory and practice of mainstream social work”. While social workers in Scotland operates as individual key workers, and are accountable for care planning and the needs assessment of service user’s (NHS Lothian, 2010). Social work however is “only one contributing profession in the multidisciplinary mental health field that increasingly hinges on effective inter-professional working” (Adams, Dominelli & Payne, 2009 p.325). This is through effective team approach including social work and social work specialist, Mental Health Officers (MHO) plays a key role mental health intervention. Mental Health Officer (MHO) safeguards the rights of those experiencing mental health issues, by scrutinising proposal to detain and to deliberate other routes for support and treatment (Mental Welfare Commission, 2016a) and administer the Mental Health (Scotland) Act 2003 (Guthrie, 2018).However, for social work practice be effective social worker must collaborate with other professionals and service user’s (Hothersall, 2014). As argued by Tarren-Sweeney, (2013) by the social workers joining with different collaborators, builds a robust partnership, quick problem-solving, enhances a mutual pathways of support while increasing confidence and simplifying treatment. When collaboration is unsuccessful, the effect can be very serious for the Service users, and their families. Therefore, all teams must have a better understanding of their own unique contributions in order for a team approach or collaboration to be effective, (Adams, Dominelli & Payne, 2002). Based on the service user’s experience of CAMHS, it was identified that, many of the issues faced by CAMHS that were driven by lack of collaboration between multi agency professionals and CAMHS workers.

Interventions and treatment for children and young people with mental health issues in Scotland

This report will now discuss and evaluate CAMHS interventions and treatment for the children and young people with mental health issues. CAMHS was established in 2003 following the ‘Together We Stand’ health advisory service report in 1995 (Burton, 2014). As such, CAMHS is still a new specialist intervention and treatment service in Scotland as compared to the adult mental health care and treatment services.

CAMHS consists of a multidisciplinary team of experts, whose common goal is to assess, care and treat the children and young people, experiencing mental health issues. In order to distinguish between CAMHS and adult mental health models, CAMHS focuses on combination of medical and psychological interpretations, whereas the adult mental health model focuses predominantly on medical interpretation and interventions (Burton, 2014). The models, adopted by CAMHS, are medication (psychopharmacology), psychoanalysis therapy, cognitive behaviour therapy (CBT), dialectic behavioural therapy and mindfulness as well as building a therapeutic relationship with the service user and their family (Padmore, 2015).

Theories that underpin the developmental stages of the children and young people are fundamental to the practice of CAMHS. According CAMHS’s hand book, the most growth in humans is between the ages of 0-18 years in terms of physical, cognitive and social prominence (Sergeant, 2017). Therefore, CAMHS practice is influenced by the theories like Freud’s (1962) psychoanalytic child development theory, (1962), Erikson’s (1963) theory, Attachment theory and Piaget’s theory (1964), and the models utilized varies from one practitioner to another (Angela Sergeant, 2017).

CAMHS service provision is organised in a tier system that works from the bottom up, where the lower tier indicates the less complex mental health issues (The Scottish Government, 2017). As such, tier 1 level service is targeted towards primary care services provided by the general medical practitioners such as, health visitor and within schools, the school nurse. Tier 2 which works with the children and young people with more complex issues that will be overseen by a specialist CAMHS team with community based services such as primary mental health worker. Tier 3 system involves multidisciplinary CAMHS team and the final level tier 4 involves inpatient CAMHS as well as intensive community treatment (The Scottish Government, 2017).

This tiered system was recently described by Public Audit Committee’s convener, as “complex and fragmented” (Holyrood’s Public Audit Committee, 2019) as will be illustrated in the section below on the system’s limitations.

Limitations of CAMHS interventions

Given that CAMHS is the central mental health treatment and intervention for the last 16 years, it was thus concerning to find out that a quarter of the 900,000 children and young people population do not know that CAMHS is a source of mental health support (Public Audit Committee, 2019). Additionally, while figures show a 22% increase in referrals from the previous year 2017-2018, Scottish Association for Mental Health (SAMH) reported that, 7,255 of children and young people referred to CAMHS were discharged without any support (SAMH, 2019). As well as this SAMH (2019) reported that, three out of ten children and young people are placed on a waiting list for over 18 weeks, exceeding the target.

The numbers of rejected referrals have also remained stagnant for the past five years, with one in every five referrals to CAMHS been rejected (SAMH, 2019). The 2018 quantitative audit findings showed that out of the 285 rejected referrals submitted, 226 (79%) of these were from a General Practitioner with rest from school nurse, teacher, and paediatric outpatient services. As a result of rejected referral more children being given more level 3 treatments due to late intervention or intervention at crisis point.

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The Cabinet Secretary for health and sport, in her reaction to the Holyrood’s Public Audit Committee, (2019) described the current CAMH system as “completely unacceptable” and stated that the current system hinders C&YP and their families from receiving much needed support when they need it (Holyrood’s Public Audit Committee, 2019. Apart from the issues of access, the model of intervention and treatment was also criticised by Freeth (2007) and Burton (2014) as lacking person-centred approach and that it does not offer a standardised evidence based practice, as the clinicians differ in their own preferred approach (Padmore, 2015).

In term of in-patient’s care, the Mental Health (Care and Treatment) (Scotland) Act 2003 makes it a duty to local authorities to make provisions and provide appropriate service including accommodation for children and young people in need in the form of hospital admission due to mental health issues. However, in a recent review carried out by the Mental Health foundation in 2016, it found that CAMHS currently only have three main inpatient units for children between the ages of 12 to 18 across Scotland (Mental Welfare Commission for Scotland, 2018). This is despite a threefold increase from 7.1 per 100,000 between 2008 and 2009 to 21.2 per 100,000 between 2012 and 2013 in children and young people’s mental health related hospital admissions.

Without matching resources to these needs, it has been reported that, the children and young people are subsequently admitted into adult wards (Goldie et al., 2016). The alarmingly resource inadequacy is illustrated by 2018 figures, whereby 90 out of 103 admissions into adult wards were young people. Similarly, in 2017, 66 out of the 71 admissions in adult wards nationally were young people (Mental Welfare Commission for Scotland, 2018). The Scottish Government initiatives aim to improve mental health in Scotland are Choose Life, run by NHS Scotland to prevent suicide awareness. Scottish Recovery Network, to engage communities in the fight against long term mental issues through awareness and support for recovery. See program to end stigmatisation and end discrimination against those with mental health issues are raising public awareness and changing the attitudes towards people with mental health issues. Breathing Space, a phone service started in 2002, to provide confidential free telephone and online service for those experiencing low level of MH issues like low mood and depression. Finally, Healthy Working Lives, aimed to promote the understanding, knowledge and skills required by employees to employee within the work place. (Dean, 2017)

IMPACT OF POVERTY, DISCRIMINATION, OPPRESSION

Discrimination, oppression and poverty are key underlying factors relating to mental health which is protected under equality Act 2010; therefore it is important to consider how it impacts this service user group.

Discrimination, is defined as any action that directly or indirectly, authorised via law (de jure) or via norm or witness (de facto) of a designated cluster of people less favourably than others, in relations to race, colour, ethnicity, religion, gender, disability, sexual orientation or age (Parkinson, 2007). The right for a person to make an informed decision and to be in control of their daily living and other aspects that affect their personal life (SSSC Code of Practice, 2016)as it is integral to a person’s human rights.

“Anti-oppression and anti-discrimination attitudes are critical in the ongoing battle for inclusion and equality" (Thomas, 2003 p.161) and social workers must bear this in mind during practice. Also social work practice must actively look out for any barriers that restrict anyone’s ability to challenge it. Poverty has a strong link to inequality as well as poor mental health issue as argued Glasby, (2015) the levels of income are a key aspect of poorer mental health. Therefore, Government’s cuts due to austerity has also led to unequal treatment happening within a wider social context in which universal and freely accessible public services are in decline including access to CAMHS. In terms of children a report in 2010 for Behaviour in school-aged Children in Scotland, indicated a link between socio-economic inequalities, (Levin, 2014). Levin (2014) while drawing attention to the Children and young people from the rural areas in Scotland and the prevalence of poorer mental health and wellbeing as compared to Children and young people within the urban depending on the levels of deprivation (Levin, 2014). Over the years, it has been noted by various sociological researchers of how a certain group within society including those experiencing mental health issues. In relation to some terminologies used by professionals such as ‘disorder' that can also present as stigmatising for those with mental health issues (Burton, 2014). More so as argued by Pilgrim and Rogers (2010), that even how service users are portrayed as ‘Patients' or sometimes as ‘objects' of clinical gaze by mental health professionals, they are not empowered well (Tarren-Sweeney, 2013). In terms of cultural competency in social work, there is an overwhelming evidence to suggest that black and minority ethnic (BME) communities experience mental health services in a very different way as compared to white people (Glasby, 2015). The most affected within this group are people from African-Caribbean, African, and mixed heritage as they are over-represented within the mental health service (Glasby, 2015). Stalker (2015) stated that BME communities have the most limited research conducted in terms of their views and experiences in Scotland in relation to mental health. A research conducted by Glasgow's Anti-Racist Alliance in (2010) also identified that, many agencies serving disabled service users including those with mental health-related disabilities had limited or no contact with people from BME community of any age, and had diminutive target in provision for this group (Stalker, 2015).

Conclusion

The current models of intervention for the children and young people’s mental health are multi-disciplinary including social workers and other agencies. This can impact on practice in a number of ways which will now be discussed. While Social work in Scotland provides an “excellent social services delivered by a skilled and valued workforce which works with others to empower, support and protect people, with a focus on prevention, early intervention and enablement” according to (Foot & et al, 2014.P.5). This report identified that, while CAMHS is the main mental health treatment and intervention for the children and young people in Scotland, the service is not well known to this population. While figures show a 22% increase in referrals during 2017-2018, many of these referral were rejected or discharged without further support (SAMH, 2019). In terms of it inpatient units it was found that despite a threefold increase children and young people been admitted for mental health issue CAMHS currently only have three main inpatient units for children between the age of 12 to 18 across Scotland (Mental Welfare Commission for Scotland, 2018). As a result, many of this population are hospitalised within adult mental health units. In addressing this and other issues, the new health and social care integration under the Public Bodies (Joint Working) (Scotland) Act 2014introduced by the Scottish Government has a vision to encourage interdisciplinary agencies to work together for a common good. This new integration approach has been praised as the most significant in the health and care sector in over 60 years since the creation of Nation Health Service (NHS) in 1948. The main emphasis of the integration service is to provide proactive and preventive care and support for the service users and their families. This mirrors the agenda of the Scottish Government to make care and wellbeing of Children and young people’s mental health in Scotland, a key area of focus. As the Government promise to make Scotland the best country in the world for the Children and young people to live, social work practice is a central in making this a reality along with the new Mental Health Strategy 2017-2027 and the additional pledged of £35 million to fund additional mental health frontline workforce by 800 (Erin Dean, 2017),to drive this vision through.

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