Children’s Mental Health in Wales

Author: Dr Rhian Croke

Published: February 2022

There’s a long history of inadequate focus, funding and prioritisation for children’s mental health in Wales. While recently there has been some progress as new legislation and policy has been introduced, there is still some way to go until every child’s right to the highest attainable standard of mental health is properly respected, protected and fulfilled in Wales.

1. Legislation relevant to children’s mental health

Since 1999, health provision – including mental health – has been a responsibility devolved to the Senedd Cymru or Welsh Parliament) previously known as Cynulliad Cenedlaethol Cymru or National Assembly for Wales). Mental health law in Wales is primarily set out in the Mental Health Act 1983,  (go here for information on the Act, the Act is currently under review) the Mental Capacity Act 2005  (go here for information on the Act) and the Mental Health (Wales) Measure 2010.

The Mental Health (Wales) Measure focuses on primary mental health support services, making it a legal requirement for local authorities and health boards to work together to expand and strengthen mental health services at primary care level across Wales for people of all ages, including children. Local authorities and their mental health partners have a duty to provide local primary mental health services in accordance with – (a) a scheme for their area or (b) a scheme for their area determined by the Welsh Ministers.

Since 2011, Welsh Government Ministers have also had a legal obligation to have due regard to Part 1 of the United Nations Convention on the Rights of the Child (UNCRC) and its First and Second optional protocols in the exercise of all their functions. This obligation is set out in the Rights of Children and Young Persons (Wales) Measure 2011. There are many articles of the UNCRC that are relevant to children’s mental health. Some of these articles are summarised below.

Article 2 of the UNCRC: children must be protected from all forms of discrimination. Children must not be discriminated against (e.g. on basis of age, race, language, gender identity, religion or disability) when accessing health services and facilities. If children have a mental health condition or additional learning needs, they must not be subjected to any discrimination. Children who are most vulnerable for example, children in care, in police custody, unaccompanied or homeless children

must always be protected and provided with mental health care and support.

Article 3 of the UNCRC: In all actions and decisions concerning children, the best interests of the child must be a primary consideration.

Article 4 of the UNCRC: Governments must do everything to implement the rights set out in the UNCRC to the maximum extent of their available resources.

Article 6 of the UNCRC: Governments must recognise that every child has the right to life and must ensure they are able to survive and develop to the maximum extent possible.

Article 12 of the UNCRC: Children have the right to express their views in all matters affecting them, and their views should be given due weight in accordance with the child’s age and maturity.

Article 19 of the UNCRC: Children have a right to be protected from all forms of physical or mental violence, injury, abuse, neglect, mistreatment or exploitation, including through the provision of social programmes that provide necessary support for children and for those who care for them.

Article 24 of the UNCRC: All children have the right to the highest attainable standard of health and to health care services that help them to attain this, including mental health. 

Article 27 of the UNCRC: Government should ensure that every child has a standard of living which is adequate to allow them to develop fully – physically, mentally, emotionally, spiritually and socially. Whilst recognising the responsibilities that parents have, governments must ensure that they provide assistance to families to ensure that children’s essential needs are met- in particular, nutrition, health, clothing, housing, education and safety.

Article 37 of the UNCRC: No child should be subjected to cruel, inhuman or degrading treatment or punishment. Children who commit offences should not be imprisoned for life. The arrest, detention or imprisonment of a child should be used only as a last resort and for the shortest appropriate period of time. Every child deprived of liberty should be treated with humanity and in a manner that takes into account his or her needs. Children in custody should be kept separate from adult prisoners and they have the right to maintain contact with their family. Every child deprived of liberty has the right to prompt legal advice and other assistance.

Article 39 of the UNCRC: Governments must take all appropriate measures to promote physical and psychological recovery and social reintegration of a child who is the victim of any form of neglect, exploitation, or abuse; torture or any other form of cruel, inhuman or degrading treatment or punishment; or armed conflicts. Such recovery and reintegration must take place in an environment which fosters the health, self-respect and dignity of the child.

Article 42 of the UNCRC: Governments must make the UNCRC known to children and adults. Children are then better able to claim their rights in relation to mental health and adults are better able to empower children to claim them.

The UN Committee on the Rights of the Child in its General Comment No. 15 on the child’s right to the highest attainable standard of health, makes it clear that all health services (this includes mental health services) must always be available, acceptable, accessible and of high quality:

Availability of services: there should be functioning children’s health facilities, goods, services and programmes in sufficient quantity.

Accessibility of services: services should be financially and physically accessible, without discrimination.

Acceptability of services: health-related facilities, goods and services must be designed in a way that takes full account of and is respectful of medical ethics as well as children’s needs, expectations, cultures, views and languages, paying special attention to certain groups, where necessary.

Quality of services: health-related facilities, goods and services should be scientifically and medically appropriate and of good quality.

The Social Services and Well-being Wales Act also requires any persons exercising functions under the Act must have due regard to Part 1 of the UNCRC. However, health boards and health services in Wales are not under the same duty.

The Well-being of Future Generations (Wales) Act 2015 aims to make public bodies act more sustainably, including demonstrating how they are maximising their contribution to ‘a healthier Wales’ and ‘a more equal Wales’. The Well-Being Objectives however do not make the right to health a legal right.

Additional Learning Needs and Education Tribunal (Wales) Act 2018 and associated Transformation Programme are intended to support a more coordinated approach to meeting additional learning needs. Consequently, if a health body determines that a CAMHS treatment or service they could provide is likely to be of benefit in addressing a child’s or young person’s additional learning needs then CAMHS will secure that provision.

In 2021 the Curriculum and Assessment (Wales) Act, embedded a whole school approach to children’s mental health.

2. Policy

In 2009, the review into Services for Children and Young People with Emotional and Mental Health Needs set out to establish whether services were adequately meeting the mental health needs of children and young people in Wales. The Healthcare Inspectorate Wales (HIW) and the Wales Audit Office jointly undertook the review, supported by Estyn and the Care and Social Services Inspectorate Wales (CSSIW).

The overall conclusion of the review was that services are failing many children and young people. Breaking the Barriers: Meeting the Challenges. Better Support for Children and Young People with Emotional Wellbeing and Mental Health Needs (2010) was the Welsh Government’s action plan in response to this report. In 2012, the Together for Mental Health Strategy (all ages strategy) was published by the Welsh Government.

However in 2014, the National Assembly’s Children and Young Peoples’ Education Committee launched an Inquiry into CAMHS because there were still serious concerns regarding effective mental health provision for children. For example,  Welsh Government data referenced in the Inquiry report showed that £82.75 was spent per head on general mental illness compared to only £13.94 per head on child and adolescent mental health. This suggests that children were not being prioritised within health budgets.

Following concerns raised regarding children’s mental health provision the Assembly’s Children, Young People and Education Committee agreed in 2016 to undertake a further inquiry. In their report, Mind over matter: a report on the step change needed in emotional and mental health support for children and young people in Wales (2018). Committee members said that not enough was being done to support the mental health of children and young people. The report called for a “step change” in mental health service provision:

We state that the urgent challenge now lies at the front end of the care pathway – emotional well-being, resilience and early intervention – and that addressing this should be a stated national priority for the Welsh Government.

Lynne Neagle AM, (then) Chair of CYPE Committee

3. Policy and legislative developments

The Mind Over Matter report made 27 recommendations; these can be summarised very broadly into three key themes:

• The Welsh Government to make emotional and mental health a national priority, and ensure services receive sufficient resources.
• Focus to shift towards prevention and early intervention.
• Increase and improve collaboration between relevant services such as health, education, social services, advocacy services, youth services, police and others.

The report identified the key role that schools play in emotional resilience and called for whole-school approaches to good mental health. This was taken on board by the Welsh Government in their response to the report.

One of the main areas the Committee report focused on was the group of young people who need mental health support, but who do not need or meet the criteria for help from specialist services. The Welsh Government responded by highlighting the Together for Children and Young People programme T4CYP (an NHS-led programme to improve mental health support available to children and young people) and one of its workstreams – early help and enhanced support.

This multi-agency service improvement programme considers ways to reshape remodel and refocus the emotional and mental health services provided for children and young people in Wales, in line with the principles of Prudent Healthcare.

T4CYP reported it was aiming to finalise the early help and enhanced support framework and prepare for implementation by March 2021. An independent evaluation of the T4CYP is reported as a key milestone in the Mental Health Delivery Plan (2019-2022). There have been concerns expressed by the Royal College of Paediatrics and Child Health at the short-term nature of the T4CYP funding model and there have been requests made for Welsh Government to explain their long-term thinking.

Young people have also been campaigning for improvements in mental health support for children. In 2016, young people working in partnership with several organisations (including Hafal and the Observatory on the Human Rights of Children) conducted research and wrote a report called ‘Making Sense: a report by young people on their mental health and well-being’ and made several recommendations on children’s mental health, including creating high quality support provided by non-mental health professionals, embedding healthy coping mechanisms into the curriculum and reforming CAMHS referral systems and practice within CAMHS.

Following its establishment in 2018, the Welsh Youth Parliament engaged with young people to determine its priorities. Their top priority was the emotional and mental wellbeing of young people. Their report Let’s Talk About Mental Health made ten recommendations focused on two central themes – information and awareness, and barriers to, and quality of support for children’s mental health.

The Children’s Commissioner for Wales (CCfW) critical report ‘No Wrong Door’ also focused on the importance of children’s mental health and emphasised that:

‘children and their families who seek support for a range of needs often find that they have to navigate a very complex system, may fall through gaps where there are no services to meet their needs, or be on a waiting list for a long time only to be told that they were waiting in the wrong queue, or have been knocking on the wrong door all along’.

From the findings of the research, CCfW made several recommendations regarding the importance of early intervention and prevention and the critical importance of services being more coordinated. CCfW have also promoted the importance of statutory advocacy for children in health care settings.

Progress was made in the last Senedd, in particular with regards to providing mental health support for children and young people through education. There has been more funding dedicated to school-based counselling and a CAMHS in-reach programme. Furthermore, the publication of the framework for embedding a whole school approach, and the amendment to the Curriculum and Assessment Act, has placed a greater priority on children’s mental health. The Senedd Children and Young People Education Committee described the planned reform of the curriculum in Wales as a ‘once-in-a-generation opportunity’ to embed well-being into children’s lives.

The Welsh Government’s Mental Health Delivery Plan lists a number of actions to be met on children and young people’s mental health, demonstrating an increased prioritisation on children.

The Senedd Children and Young People and Education Committee’s scrutiny of Welsh Government, as well as consistent campaigning by children, the Children’s Commissioner for Wales, the third sector and health and education professionals, has certainly been central to achieving changes on this agenda.

4. Change for children: Not quick enough

In the Senedd Children and Young People Committee’s follow up report, Mind over Matter: two years on (2020),  the Committee concluded that:

• While progress has been made, change has not happened quickly enough.
• Services are still not working collaboratively enough to address the problem.
• The Covid pandemic has impacted the lives of children and young people greatly and has made action now even more imperative.

Whilst significant progress has been made on the education recommendations made by Mind Over Matter and its follow-up reports, the progress on those relating to providing mental health support through service provision has been criticised as being slower.

In March 2020, the Royal College of Paediatrics and Child Health, reported that they were concerned that inpatient provision and community settings for CAMHS patients was comparatively lower in Wales compared to other nations across the UK. Wales has:

‘the lowest number of psychiatrists and the second lowest number of community mental health nurses and psychologists (6 and 8 per 100,000), implying lack of capacity as a reason for its low activity rates among both inpatient and community-based care.’

As emphasised by the Royal College for Mental Health Expert Advisory Group

‘at the front end’ of the care pathway, there needs to be an additional focus on the lack of provision for children and young people who need more specialist support, those with complex needs, and those who need help in a crisis. Specialist services have long experienced staff and resourcing shortages’.

Barnados Cymru commented that children far too often have to reach crisis point before accessing the support that they need and Hafal Cymru reported that there needs to be improved access and waiting times for children with acute needs as well as appropriate transition to adult services.

The statistics on child mental health are concerning:

• Three children in every classroom have a diagnosable mental health condition.
• Half of all mental health problems are established by the age of 14, with levels of stress, anxiety and self-harm rising.
• Suicide as a leading cause of death amongst children 15+ is also increasing.

This evidence is compelling and concerning. It is totally inadequate that historical underfunding and under-resourcing of children’s mental health services in Wales has continued over a decade since the Wales Audit Review 2009 pointed out these issues.

The Covid-19 Pandemic

Action to support children’s mental health cannot come soon enough. The Covid-19 Pandemic has amplified challenges to accessing mental health service provision while at the same time children’s mental health has deteriorated.

In April 2020, the UN Committee on the Rights of the Child expressed concerns about the physical, emotional and psychological effect of the COVID-19 pandemic and associated lockdowns and other measures on children. The pre-existing deficits in service provision for children’s mental health in Wales have become more noticeable, with many children’s mental health affected by the pandemic (breach of Article 24 of the UNCRC).

In submissions to the Welsh Parliament, Children and Young People and Education Committee Covid19 Inquiry, paediatricians and psychiatrists expressed their concerns regarding the ‘collateral damage’ of the pandemic on children. They also noted that services for children were being redistributed to adult services to respond to the pandemic. The Senedd Children and Young People and Education Committee’s Inquiry into Covid-19 in 2020, was conclusive regarding the negative impact of the pandemic on children’s mental health.

The Royal College of Paediatrics and Child Health have also published data that illustrates that there has been a significant increase in the proportion of inpatient beds being taken by children and young people due to being admitted for mental health reasons.

The link between the Covid pandemic and the mental wellbeing of young people was also highlighted in a report by Mind Cymru: The mental health emergency: How has the coronavirus pandemic impacted our mental health?. The survey found that three quarters of young people said their mental health was worse in the early months of the pandemic, while a third of young people who tried to access support were unable to do so. The Mind Cymru research also reported that there has been a greater negative impact on young people from different ethnic minorities and those living in families where there is low or insecure income. The links between child poverty and mental health are fully acknowledged. The pandemic has plunged many families into poverty and food insecurity (breach of Article 27 of the UNCRC) which will have long-term negative impacts on children’s mental health.

The links between abuse and children developing mental illness are fully evidenced. NSPCC reported on the unprecedented demand across the UK for their Child Line Service during lockdown with child abuse calls to NSPCC rising by 20%. Reports of physical abuse of children rose by 53% during the first lockdown. Furthermore, between March and June 2020, the police recorded 259, 324 domestic abuse related offences in England and Wales. The challenges of no longer having school as a safe sanctuary from potential abuses in the home kept some children invisible, with limited scope for accessing help. Children’s increased time at home also resulted in children’s increased time online, and pressure to do 24-hour online networking, is likely to have resulted in greater on-line bullying. Of further serious concern, many adults time online also increased with the Internet Watch Foundation reporting that 8.8 million people in the UK accessed images of child sexual abuse in just one month. This is evidence of serious breaches of Article 19 of the UNCRC.

Evidence that children were more vulnerable to violence, abuse and sexual exploitation is supported by research undertaken for the European Network of Ombudspersons (ENOC) in 2021. Increased levels of abuse have certainly impacted on children’s mental health. According to Royal Colleges of Paediatrics and Child Health, with regards to ‘Adverse Childhood Experiences (ACEs), there needs to be ‘ongoing scrutiny of work to develop ‘trauma informed’ and recovery and reintegration programmes to ensure that key stakeholders are working in a joined-up way, particularly given the changes and challenges to youth services over the period of the pandemic’. This is also a requirement of the UNCRC under Article 39, which focuses on a child’s psychological recovery and reintegration.

Other issues that are likely to have affected children’s mental health, are delays in court proceedings in the juvenile justice system; (ENOC Research) and, on children in institutions who were denied their liberty for long periods of time, with limited access to lawyers and social workers, often without good reason. This is a clear breach of Article 37 of the UNCRC.

At the beginning of the pandemic, the UN Committee on the Rights of the Child, recommended that governments worldwide explore alternative and creative solutions for children to enjoy their article 31 right to play, rest, leisure, recreation and cultural and artistic activities. Evidence that children’s diminished opportunities for play due to home confinement has had a negative impact on their overall mental health is supported by research undertaken for the European Network of Ombudspersons (ENOC) in 2021. Research undertaken by Graber et al. concluded ‘play may be one of the most important areas of focus to promote children’s health and well-being.’ Play Wales recommend that any programmes that ‘support children’s physical and mental health should be scrutinised to ensure that they feature opportunities and time for self-directed play’.

Research in Wales undertaken by Tyrie et al, focused on early childhood development, has reported that the Covid-19 pandemic has had negative impact on the cognitive, emotional and social development of young children 0-5 years. There have also been consistent concerns expressed by the Royal College of Psychiatrists regarding the peri-natal mental health of mothers being affected during the pandemic.

The Royal College of Psychiatrists additionally has expressed concerns that the pandemic has created a context likely to increase eating disorders risk and symptoms and decrease factors that protect against eating disorders and exacerbate barriers to care.

Climate Emergency and Children’s Mental Health

Alongside the Covid-19 global emergency, children are also living in the context of a global climate emergency. A global survey has demonstrated that children are experiencing increasing distress, anxiety and anger due to their concerns regarding the climate emergency and the negative impact on their fragile planet. Links have also been demonstrated between exposure to air pollution and deterioration of mental health by recent research undertaken by the London School of Economics.

5. Moving forward

In February 2021, the Welsh Government announced that an additional £9.4 million would be allocated to build on previous investments to improve child and adolescent mental health services (CAMHS) and also to support the whole-school approach to improve mental health and wellbeing in schools. The Welsh Government has also produced a Young Person’s Mental Health Toolkit via the Hwb platform which provides details of a range of resources, including helplines and websites.

Following the 2021 Senedd election, the new Welsh Government set out its Programme for Government, which included the following:

• Prioritise investment in mental health.
• Prioritise service redesign to improve prevention, tackle stigma and promote a no wrong door approach to mental health support.
• Roll out child and adolescent mental health services ‘in-reach’ in schools across Wales.

Translating this into practice takes time, however some may argue change has not happened quickly enough.

In Autumn 2021, oral evidence presented by the Children’s Commissioner for Wales to the Senedd Children and Young People and Education Committee and Mind Cymru to the Senedd Health Committee continued to present serious concerns regarding waiting times for CAMHS. Concerns have also been expressed by the Royal College for Mental Health Expert Advisory Group regarding serious capacity issues within Neuro Development services and how these services must be able to meet the demand not just for autism services but for all Neuro Development services, regardless of diagnosis.

The Royal College for Mental Health Expert Advisory Group is calling for sustainability of the neurodevelopmental work force and the mental health workforce for babies, children and their families. For far too long the Group reports, specialist services have experienced staff and resource shortages. The Welsh Government Mental Health Workforce Plan has been described as a ‘real chance to remodel current provision and create sustainable services which ensure that all people (including children) in Wales are able to access appropriate mental health support’.

The Children’s Commissioner for Wales has been continuing to advocate strongly for a ‘No wrong door approach.’ As the UN Committee on the Rights of the Child recommends, services must be available, accessible, acceptable and of high quality. Services need investment but they must also be coordinated and ready to intervene early and in a timely manner. Every child deserves services that are children’s rights compliant and adopt and embed a children’s rights approach.

CCfW working with Together for Children and Young People have developed the NEST/NYTH Framework to be implemented by Regional Partnership Boards. CCfW considers this framework has the potential to address the ‘No wrong door approach’. However, it will require sustainable support from Welsh Government with close monitoring of its implementation. The new early intervention framework will only be applied by Regional Partnership Boards from 2022/23.

In December 2021, the Welsh Government announced 100 million funding for mental health. It is not yet clear what proportion of this funding will be spent on children or indeed how it will be used to support the mental health needs of children. It is a requirement of the UN Committee on the Rights of the Child, that the proportion of expenditure on children is made transparent and spending on children should be to the maximum extent of available resources (Article 4 of the UNCRC). Any allocation of Welsh Government public funds should be subjected to a Children’s Rights Impact Assessment. It can only be hoped that this new investment alongside policy being translated effectively into practice will better help children to experience their right to the highest attainable standard of mental health (Article 24 of the UNCRC).

The Senedd Children and Young People Committee must continue to scrutinise Welsh Government. The UN Committee on the Rights of the Child will soon be scrutinising the UK State party in the State Party Hearing as part of the UNCRC Reporting process. We look forward to hearing recommendations from both these commitees on children’s mental health.