Child mental health

Introduction

Mental health is as important to a child's safety and wellbeing as their physical health. It can impact on all aspects of their life, including their educational attainment, relationships and physical wellbeing. Mental health can also change over time, to varying degrees of seriousness, and for different reasons.

And we know it's an important issue for children: 45% of all Childline counselling sessions in 2018/19 related to mental or emotional health and wellbeing (NSPCC, 2019a).

Negative experiences such as abuse and neglect can adversely impact a child's mental health. Mental health issues can also sometimes lead to safeguarding and child protection issues, for example if a child's mental health begins to put them or other people at risk of harm. 

Supporting children with mental health issues

It can be hard for adults to recognise when a child needs support with mental health issues. And it can be difficult for young people to speak out about the challenges they're facing.

So it's crucial that anyone who works or volunteers with children is able to recognise the signs that a child may be struggling with their mental health. And that they know how to take appropriate action to support children and young people in getting the help they need.

We’ve put together some information to help you recognise and respond to concerns about children and young people's mental health.

What does mental health mean?

Mental health is an individual's cognitive, behavioural and emotional wellbeing (Mind, 2020). It's something we all have - including every child and young person.

We use the term "mental health issues" to refer to mental health problems, conditions and mental illnesses. These issues may or may not be medically diagnosed.

Who is at risk?

Who is at risk?

Any child or young person can develop mental health issues. But research has shown there are some factors that are associated with children and young people's long-term mental health.

Abuse and neglect

The traumatic impact of abuse and neglect increases the likelihood of children developing a range of mental health issues – both during childhood and in later life. These include anxiety, depression, eating disorders and post-traumatic stress disorder (PTSD) (Norman et al, 2012; Spatz Widom, 1999).

Specific types of abuse may be connected to certain mental health issues. Children who have experienced emotional abuse may be more likely to develop anxiety and depression compared with children who have experienced other types of abuse (Cecil et al, 2017; Gavin 2011). One study found that almost three quarters (74%) of young people who had experienced sexual assault developed PTSD (Lewis et al, 2019).

Abuse and neglect can also make children more vulnerable to developing more than one mental health condition at one time (known as composite mental health issues) (Chandan et al, 2019).

Providing effective mental health support for children who have experienced abuse and neglect can help them recover from its effects (NSPCC, 2019b).

Additional needs and disabilities

Children and young people with additional needs and disabilities may face a range of challenges including:

  • reduced mobility
  • prejudice, discrimination and bullying.

These challenges may lead to lower self-confidence, difficulty forming peer networks and social exclusion, putting them at higher risk of developing mental health issues (Falcounbrige, Hunt and Laffan, 2019).

Adults may confuse the signs of learning disabilities with the symptoms of mental health issues. This can mean concerns aren't recognised and responded to quickly or appropriately.

Black and Minority Ethnic (BME) children

Children from black and minority ethnic groups may experience:

  • racism, discrimination and prejudice – this can be direct, indirect or institutional
  • an increased stigma around mental health issues in the community.

This can lead to inequalities and issues in accessing appropriate care and support for mental health needs (Race Equality Foundation, 2020).

Life events

Stressful or traumatic situations and experiences, such as bereavement or sudden changes in environment, can trigger mental health issues.

Living in care

Children in care are more likely than their peers to have a mental health difficulty (NSPCC, 2019c). This can be due to isolation and loneliness. Children in care may also have experienced abuse or neglect, which increases the likelihood of developing mental health issues (National Youth Advocacy Service, 2019)

LGBTQ+ children and young people

LGBTQ+ children and young people may experience:

  • prejudice, discrimination and bullying
  • a fear of or an actual rejection from family and/or friends
  • feeling excluded or like an outsider.

They may also experience gender dysphoria: the distress when someone's assigned gender does not match their identity.

These factors and experiences mean they are more likely than their heterosexual and cisgender peers to experience a range of mental health problems (Chakraborty et al, 2011; Becerra-Culqui, et al 2018).

Recognising

Recognising issues

Professionals need to be able to recognise the signs that a child may be struggling. However, it's important to remember that some mental health issues may not have visible signs. There are also factors that might make it more difficult for a child or young person to ask for help.

Some children and young people may try to hide how they are feeling or what they are doing (Theodosiou L. et al, 2020). This might be because they:

  • worry they won't be taken seriously
  • believe others won't understand
  • have had a negative experience talking about their thoughts and feelings in the past
  • feel that no one can help them
  • fear being dismissed or labelled an attention seeker or 'crazy'

(Mental Health Foundation and Camelot Foundation, 2006).

Children and young people may not always have the language or ability to communicate how they feel. They may be unsure who to talk to and how to talk about their problems.

Some signs of mental health issues may also look like normal child behaviour. For example, tantrums in younger children or teenagers keeping feelings to themselves.

Children who have experienced abuse or neglect

Children who have experienced abuse may be reluctant to talk about how they are feeling, particularly if they haven't yet told anyone about the abuse. They may feel that something is wrong with them or that things may get worse if they talk about it.

Identifying and responding to mental health concerns may be one way of helping children who are experiencing abuse to get the support and protection that they need.

> Find out more about barriers to disclosure of abuse 

Signs of child mental health issues

There are ways you can identify if a child needs support with their mental health.

By being attentive to a child or young person's mood and behaviour, you can recognise patterns that suggest they need support.

Common warning signs of mental health issues include:

  • sudden mood and behaviour changes
  • self-harming
  • unexplained physical changes, such as weight loss or gain
  • sudden poor academic behaviour or performance
  • sleeping problems
  • changes in social habits, such as withdrawal or avoidance of friends and family.

These signs suggest that a child may be struggling, but there could be a number of different explanations for them.

Don't attempt to diagnose mental health issues yourself or make assumptions about what’s happening in a child's life.

Recognising that a child or young person may be struggling with their mental health is the first step in helping them. The next step is to respond appropriately.

Responding

Responding to child mental health issues

All children and young people should have someone they can talk to about whatever they’re going through, regardless of whether they have a mental health condition.

Children may not want to talk specifically about their mental health, but about the struggles and issues in their daily lives (Mental Health Foundation and Camelot Foundation, 2006).

If you are concerned that a child may be struggling, it's important not to wait for them to talk to you before trying to start a conversation. Encourage them to talk with you or with other trusted adults.

Talking with a child about their mental health

If you're talking with a child or young person about their mental health and wellbeing, be prepared that conversations may not be easy or straightforward. There are things you can do to make these conversations as easy as possible.

> Read our information and advice on how to have difficult conversations with children

The following principles will help you discuss mental health and wellbeing sensitively.

Use the right language

When talking with a child, use language that they understand. This will differ according to their age and stage of development. Avoid using technical or diagnostic language which children might find unfamiliar, confusing and distant from their experiences.

Make sure you understand the language the child is using and how they are using certain terms. For example, a child may use the word "anxiety" to describe a feeling of general nervousness or as a way to describe severe anxiety attacks.

By paying attention to the language children use to describe their feelings, you can reflect the terms they use in your own language. This will help them feel listened to.

Some children may have difficulty communicating, for example if they have additional needs or disabilities (Fuggle and Redfern, 2019). Make sure you give these children the time and support they need to talk.

> Find out more about how to have difficult conversations with children and young people 

Create an open environment

It's important to create an open and safe environment where children and young people are comfortable speaking about their mental health. Make sure children and young people know who they can talk to — and make this pool of people as wide as possible.

In schools, for example, discussions about mental health and wellbeing can be integrated into the curriculum and put on an equal footing with physical health.

Some children with mental health problems will have experienced abuse. An open environment will help them talk about the challenges they are facing and may help them feel able to tell you what’s been happening to them.

> Use our resources to find out how you can let children know you’re listening if they tell you they have experienced abuse 

> Find out how to recognise and respond to abuse 

Promoting mental health and wellbeing

Anyone who works with children and young people has a responsibility to promote their mental health and emotional wellbeing. This can include:

  • helping with online wellbeing
  • encouraging exercise
  • maintaining routines.

> Get tips on promoting children and young people’s mental health and wellbeing

Understanding

Understanding thoughts and feelings

Mental health moves back and forth along a continuum, it's always changing. This can happen over a period of time or quite quickly. So it's important to have conversations with children and young people so you can best understand how they're feeling - and any mental health issues that they are experiencing.

Doing OK – Struggling – Unwell – In Crisis

When you speak to a child for the first time, or during ongoing conversations, you may find it useful to think about whether they're doing OK, struggling, unwell or in crisis.

This continuum is based on a model used by Childline counsellors, alongside other tools, that helps them understand how a child is feeling at that particular point in time. You can use it to better understand a young person’s mental health and wellbeing.

It’s important to remember that a person’s mental health changes continuously – so you should refer to this continuum regularly.

Doing OK

  • Communicates effectively with others
  • Seeks help when needed
  • Can focus on specific issues
  • Has healthy relationships
  • Identifies and tries to solve problems
  • Uses healthy coping strategies

Struggling

  • Struggles communicating with others
  • Is unsure how to access help
  • Relationships are beginning to suffer
  • Begins to use unhealthy coping strategies
  • Has some sleep issues, low energy and fatigue
  • Is able to engage well in some areas

Unwell

  • Feels overwhelmed and isolated
  • Struggles to focus on specific issues
  • Struggles to access and/or engage with services
  • Has disturbed sleep
  • May have suicidal thoughts
  • Relies on unhealthy coping strategies
  • May already have a mental health diagnosis
  • Is ambivalent towards change

In crisis

  • Has made recent suicide attempts
  • Is distrustful of support services
  • Mental health symptoms are unmanageable
  • Has escalating self-harming behaviours
  • Distress may not reduce when talking
  • Not engaging at home or school
  • Is resistant to change

Using scaling techniques

Our Childline counsellors sometimes use "scaling" questions to help them understand how a child or young person is doing.

A counsellor gives the child a clear scale – from 0 or 1 to 10 – and asks where they think they sit in relation to a specific question. For example:

  • If 1 is your mental health at its worst and 10 is at its best, how are you doing at the moment?
  • If 0 means that you are having a panic attack and 10 means that you feel completely calm and confident, how would you rate the way you feel before going to school?

Counsellors may be able to find out what support children would like by asking how they can move up the scale. For example:

  • What is it that puts you at a 5 rather than a 6?
  • What can we do to help you move from a 3 to a 4?

Using the continuum and scaling techniques can help you better understand how a child is feeling so that you take appropriate action to help and support them. 

Taking action

Taking appropriate action

Mental health issues indicate that a child or young person needs support. If possible, discuss with them what help could be put in place.

What if a child doesn't want to talk to me?

If a child isn't able to engage with a discussion about their mental health you should still consider what support can be put in place for them.

Follow your organisation's procedures to share any concerns you have about a child's wellbeing. For example, you could talk to the person who is responsible for pastoral care in your school or organisation.

Safeguarding and child protection issues

You must always consider whether you need to take any action to protect a child or those around them from harm.

If you identify a safeguarding or child protection issue, you must follow your organisation's policies and procedures.

Safeguarding issues include:

  • a child being in immediate and/or significant danger
  • someone else being in immediate and/or significant danger
  • a child being at risk of or experiencing abuse.

> Find out more about responding to safeguarding and child protection concerns 

Confidentiality

If a child is confiding in you about their mental health they may ask you not to tell anyone what they've said. But if you're concerned about someone's safety and welfare you must share this information with relevant professionals.

You should never promise to keep what a child tells you a secret. Explain from the outset that you might have to talk to someone else who can help. 

Getting support

Getting support

There are lots of different types of support available for children with mental health issues. These include the following.

Contacting a GP

GPs may be able to diagnose mental health conditions, suggest next steps and provide medication.

>There is information on the Childline website about visiting GPs 

Child and adolescent mental health services (CAMHS)

Across the UK, CAMHS is a free NHS service for children and young people that aims to help with mental health problems such as depression, anxiety, self-harm and eating disorders.

Teachers, social workers, GPs and parents can refer a young person to CAMHS. Services differ from area to area.

In England, you can find CAMHS services in your area through the NHS CAMHS webpage.

Counselling and therapeutic services

Counselling services are available to help children and young people with their mental health. Services can include helplines, one-to-one counselling sessions in person, online or by phone, and online chats and forums.

These services are available through a range of fee-paying and free services including schools and the NHS.

Childline

Children and young people can get free, confidential support from a Childline counsellor via online chat, email or phone.

Childline will listen and provide advice to any concerns about topics, ranging from exam stress to depression and suicidal thoughts.

Childline offers a range of resources for children and young people, including:

  • Art box to write or draw about their feelings
  • Calm zone with breathing exercises
  • Games to help relax and de-stress.

Childline also has dedicated resources for under 12s.

Download or order Childline posters and wallet cards to display across schools, encouraging children to contact Childline if they need to talk.

NSPCC services

We provide therapeutic services help children, young people and families get their mental health back on track after abuse.

Hear and Now 

Hear and Now is a therapeutic service that aims to address behavioural and emotional issues faced by children who have been affected by sexual abuse.

Letting the Future In

Letting the Future In is a play-therapy service that helps children who have been sexually abused.

The Lighthouse 

The Lighthouse is a multi-agency service that provides guidance and support to help children and young people recover from sexual abuse.

Life Story Work 

Life Story Work is a direct support service that works with children in care to help them understand and accept their personal history.

Consent for treatment

It's best practice to get parental consent for children's therapeutic and medical treatments. But there may be times when a child or young person does not want their parents to know. In this case, you should assess whether the young person has the capacity to make this decision for themselves.

The Gillick competency and Fraser guidelines help professionals assess whether a child is mature enough to make decisions.

> Read our information about Gillick competency and Fraser guidelines

Legislation and guidance

Legislation and guidance

Key legislation

In England and Wales, the Mental Health Act (MHA) 1983 covers the assessment, treatment and rights of people with a mental health condition. It applies to all children and young people under the age of 18. The Act allows for people to be detained in hospital if they need treatment for a mental health condition. It gives children the right to appeal against detention.

The Mental Health Act 1983 was amended by the Mental Health Act 2007. This strengthened children's safeguards, for example adding a duty to ensure an age-appropriate environment for children and young people.

In England and Wales, the Schools (Mental Health and Wellbeing) Bill is currently in its second reading in the House of Lords. This will set out how schools should promote the mental health and wellbeing of the pupils.

In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 applies to all those with a "mental disorder", including children and young people. It contains specific safeguards for under 18s regarding mental health treatment, including on named persons, promoting wellbeing and the welfare of children.

The Mental Health (Scotland) Act 2015 amended provisions relating to children and young people in the Mental Health (Care and Treatment) (Scotland) Act 2003, specifically on named persons and providing services and accommodation for mothers.

In Northern Ireland, the Mental Health (Northern Ireland) Order 1986 is the main mental health legislation which applies to children and young people under 18. It covers the assessment, treatment and rights of people with mental health conditions.

Guidance

In England, from September 2020, the Department for Education (DfE)’s statutory guidance for schools, highlights that child mental health problems may be an indicator that a child has experienced abuse or neglect. The guidance includes information on how schools and colleges should support children and young people’s mental health (Department for Education, 2020).

Public Health England (PHE) provides guidance on Improving the mental health of children and young people. This describes the importance of children’s mental health and summarises what works in improving their mental health (PHE, 2016).

PHE has also produced guidance for health commissioners and professionals on Measuring the mental wellbeing of children and young people (PHE, 2015).

In Northern Ireland, the Department of Health has published a Mental Health Action Plan, which is comprised of 38 actions and commits to producing a mental health strategy (Department of Health, 2020).

The Guidelines and Audit Implementation Network (GAIN) have also published Guidelines on the use of the Mental Health (Northern Ireland) Order 1986 (GAIN, 2011).

In Scotland, the government has produced guidance on the mental health and wellbeing of disabled children, young people and their families (Scottish Government, 2019).

It has also provided a CAMHS national service specification, outlining the available CAMHS provisions for young people and their families (Scottish Government, 2020a).

The Scottish Government has also published guidance on Access to counselling in secondary schools. This provides a framework on developing access to counsellors within schools for education authorities (Scottish Government, 2020b).

In Wales, the government has produced a strategy for Mental Health and Wellbeing (PDF).This covers children and young people as well as adults (Welsh Government, 2012).

The Welsh Government has also published non-statutory guidance on Collaborative working between CAMHS and the counselling service. This outlines how services are organised and includes case studies on collaborative working (Welsh Government, 2016).

References

References

Becerra-Culqui, T. A. et al (2018) Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Paediatrics, 141(5). 

Cecil CAM, Viding E, Fearon P, Glaser D, McCrory EJ (2017) Disentangling the mental health impact of childhood abuse and neglect. Child Abuse & Neglect, 63, pp. 106–119.

Chakraborty, A et al (2011) Mental health of the non-heterosexual population of England. The British Journal of Psychiatry, 198(2).

Chandan, J. S. et al (2019) The burden of mental ill health associated with childhood maltreatment in the UK, using The Health Improvement Network database: a population-based retrospective cohort study. The Lancet Psychiatry, 6(11). 

Department for Education (DfE) (2020) Keeping Children Safe in Education. London: Department for Education.

Department of Health (2020) Mental Health Action Plan. Belfast: Department of Health.

Faulconbridge, J., Hunt, K and Laffan, A (ed) (2019) Improving the psychological wellbeing of children and young people: effective prevention and early intervention across health, education and social care. London: Jessica Kingsley.

Fuggle, P and Redfern, S (2019) Positive mental health and wellbeing in children and young people. Totnes: Research in Practice Suggestions for Practice.

GAIN (2011) Guidelines on the use of the Mental Health (Northern Ireland) Order 1986

Gavin, H. (2011) Sticks and stones may break my bones: the effects of emotional abuse. Journal of Aggression Maltreatment and Trauma, 20(5): 503-529.

Lewis S, Arsenault L, Caspi A et al. The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. Lancet Psychiatry 2019; 6 (3): 247–256.

Mental Health Foundation and Camelot Foundation (2006) Truth hurts: report on the national inquiry into self-harm among young people. London: Mental Health Foundation.

Mind, 2020 Mental health problems – an introduction. [Accessed 05/03/2020].

Nanni, V et al (2012) Childhood Maltreatment Predicts Unfavorable Course of Illness and Treatment Outcome in Depression: A Meta-Analysis. The American Journal of Psychiatry, 169(2).

National Youth Advocacy Service (2019) Looked After Minds: Prioritising the Mental Health of Care-Experienced Children and Young People (PDF). [s.l.] National Youth Advocacy Service.

Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T (2012) The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis.

NSPCC (2019a) Childline annual review 2018/19. London: NSPCC.

NSPCC (2019b) Transforming mental health services for children who have been abused: July 2019 (PDF). London: NSPCC [Accessed 08/04/2020].

NSPCC (2019c) Looked after children: statistics briefing. London: NSPCC Knowledge and Information Service.

Public Health England (PHE) (2016) Improving the mental health of children and young people. London: Public Health England.

Public Health England (PHE) (2015) Measuring the mental wellbeing of children and young people. London: Public Health England

Race Equality Foundation (2020) Racial disparities in mental health: Literature and evidence review. London: Race Equality Foundation.

Scottish Government (2019) Supporting disabled children, young people and their families: guidance. Edinburgh: Scottish Government.

Scottish Government (2020a) Child and Adolescent Mental Health Services: national service specification. Edinburgh: Scottish Government.

Scottish Government (2020b) Access to counselling in secondary schools: guidance. Edinburgh: Scottish Government.

Spatz Widom, C (1999) Posttraumatic Stress Disorder in Abused and Neglected Children Grown Up. The American Journal of Psychiatry, 156(8).

The Children’s Society (2016) Poor Mental Health The links between child poverty and mental health problems (PDF). London: The Children’s Society.

Theodosiou L. et al (2020) Children and young people's mental health: early intervention, ongoing support and flexible evidence-based care. Pavilion: West Sussex.

Welsh Government (2012) Together for Mental Health: A Strategy for Mental Health and Wellbeing in Wales. Cardiff: Welsh Government.

Welsh Government (2016) Collaborative working between CAMHS and the Counselling Service. Cardiff: Welsh Government.