Expert’s Corner with Gretchen Precey - Children's Mental Health

Clare Jerrom talks to Independent Social Worker Gretchen Precey about children’s mental health.

The care system is not always geared up to address the mental health needs of children and young people, an Independent Social Worker has warned.

While one in 10 children have a diagnosable mental health disorder – the equivalent of three children in every classroom – this figure rockets to 50 per cent of children in care.

ISW Gretchen Precey warns that when children come into care, the threshold has been met for them to be removed from living with their parents and they enter care with many worries and uncertainties. However, this can be exacerbated by the care system and children having numerous social workers and placements, potentially having to change school, experiencing the whole stigma of being care, having identity issues and generally feeling ‘different’ to the rest of the population.

“The care system doesn’t always do children any favours,” said Precey, adding that even when children are in foster placements, they may be living alongside their foster parents’ birth children and experience feelings of being inferior.

The government announced this month new pilots for children entering care to receive high quality assessments of their mental health. However, Precey warns that it may not be the best time to assess their mental health given that they will be “in the middle of experiencing trauma, separation, anxiety and generally all over the place”.

While there may be a need for a ‘baseline’ assessment, it is critical that children in care receive ongoing assessments once they are more settled, she adds.

‘Their home life was exacerbating their mental ill health’

Gretchen came from her native America in 1971 with her English husband having grown up in a children’s home with her parents and two younger brothers as her father was the live-in supervisor of a large children’s home in Detroit. Precey studied a degree in sociology at Leeds University before the CQSW and Diploma in Applied Social Studies and started out as a social worker at the Department of Child and Adolescent Psychiatry at St. James Hospital in Leeds.

“It was a social work team which acted as a pre-cursor to CAMHS, with a day unit and a residential unit,” said Precey. “We had far more resources available then compared to now. Children were referred to us with mental health problems and we had a big team with social workers, occupational therapists, play therapists, psychiatrists.”

“We saw a lot of different issues. Some of the children needed to be away from their families and would stay in the residential unit which had a school within it and there were other children with behavioural problems or eating disorders who would attend the day unit,” she adds.

Precey’s role was going out into the community and working with the families of the children attending the unit because, as she said, “their difficulties didn’t arise from nowhere”. Sometimes their home life may have been exacerbating their mental ill health or the children was acting out to try and get their parents’ attention.

Precey held a number of social work and senior practitioner posts in the children and families field during her career and specialised in child protection and Child Sexual Abuse. She currently works as an Independent Social Worker where she carries out parenting and special guardianship assessments, assesses contact between parents and children, supervises and assesses complex child abuse cases and carries out specialist investigative interviewing with disabled children.

Drug-induced psychosis

While Precey does not carry out direct work with children and young people with mental health problems, she experiences many of the issues first hand while carrying out assessments and conducting child protection work. She explains that she is currently working with a 16-year-old mum of a five month old baby. The girl was “living feral” from the age of 13 having been abused at the hands of her older brothers. Prior to having her baby, she experienced mood swings and was diagnosed with bipolar disorder and linked to CAMHS. She also heard voices that were very critical of her. Now she has a child of her own, she is no longer hearing voices but still experiences mood swings although this is not directed to the baby at all. However, as Precey explains, this situation can go one of many ways now. Will her own mental health be compromised by looking after her baby? While she is currently living in a mother and baby unit, she cannot be in that situation forever and will at some point need to cope on her own. Will the pressure of that precipitate the voices returning?

Further, had the 16-year-old been assessed on entering care, by her own admission she was “a mess, drinking, taking drugs, hearing voices”. “If we had assessed her then, it would be a very different person to the person she is today,” said Precey.

In a separate case, Precey is working with a four-year-old child who has been living with both parents for three years but has never been set any boundaries and as a result he is exhibiting challenging behaviour. Precey explains that the child may have an ADHD or autistic diagnosis in the future, but he is currently living with his grandmother and thriving. “It makes you wonder how much is organic and how much is a result of his parental treatment?”

Precey outlines how she sees a lot of depression and self-harm particularly in adolescents although this is increasingly happening at a younger age. In the younger children she tends to see more behavioural problems which again may be ADHD or autism or may be down to the parenting they have experienced. However, she warns that she is seeing a surge in drug-induced psychosis, particularly in under 18 year old boys. “They are taking increasing amounts of drugs like ecstasy because they become accustomed to the potency and need more and more to create the same effects. However it is leading to persistent mental health problems, especially psychosis. I am aware of a mental health ward at the moment where there are 10 beds and seven people out of those 10 are there for a connection with drugs,” she explains.

Exam factory

The high levels of mental distress among children and young people is no surprise given the pressure on children from a young age, says Precey. Some children are being neglected with parents being glued to their phones, creating problems around attachment and generally not attending to their children which, Precey says, “is storing up a big problem for the future”.

Some schools are like an “exam factory”, she adds, while some children from affluent families face further pressure to do well academically with promises of what they will receive if they do well, with a focus on what they can produce rather than who they are and “not all children can produce academically”. Indeed a recent study by Goldsmith’s University found children from affluent backgrounds had excellent housing, a nutritious diet, first-class educational opportunities and access to a range of enrichment opportunities, yet their home environment lacked emotionally-nurturing parenting behaviours.

Furthermore Precey explains that there is huge pressure around body image to be thin and beautiful which often manifests in eating disorders. “It is a very tense, high pressure existence and some children crumble under that pressure,” she said.

Self-harm epidemic

It can often take time for a mental health to become recognised in children as “sometimes it takes a while to work out whether it is bad parenting or a diagnosable mental health problem,” said Precey, adding that with bigger classrooms, and exam pressure in schools, the sense of the whole child can be lost and you miss what the child is needing.

Once a mental health problem is diagnosed, there is a postcode lottery on waiting times. There is currently variation across the country in terms of waiting times from four weeks to 100 weeks for the time from referral to treatment. The average wait is 12 weeks. However, Precey warns that often that is the time to see someone initially and then the child has to wait a further six months for treatment. Not only can this exacerbate the mental health problem and the anxiety for both the child and parents, but Precey highlights that children are influenced by peers and can then get caught up in an epidemic of self-harm, drugs or alcohol or going on social media which can have a negative effect or even pro anorexia/bulimia or suicide websites which could implant strategies they would not perhaps have thought of.

The cuts to local authority budgets have also seen thresholds for intervention – whether that is going into care or receiving specialist support – rise meaning children’s problems are often entrenched and severe before they access help. Many of the preventive work in groups, youth work and counselling have been cut and resources front-loaded into the care system.

High thresholds

Precey says schools are “absolutely” ideally placed to pick up on mental health problems early and increasingly schools are playing the welfare and safety role previously met by children’s services prior to cuts. “Many schools play a pastoral, nurturing role with children in a way they didn’t before.”

She highlights the case of a boy aged five who is presenting as potentially transgender and wanted to be identified as a girl. The school in question were supportive and enabled him to wear a girl’s school uniform and use the gender neutral disabled toilet while providing a member of staff he could seek out if he was experiencing difficulties or needed support. “Had the school reacted in a different way, the result could have been a depressed and conflicted child. This school did a good job whereas others perhaps couldn’t and it could easily have resulted in the boy experiencing mental health problems,” said Precey.

The parents of the boy tried to get him a referral to the Tavistock and Portman Foundation NHS Trust in London which has a dedicated Gender Identity Development Service which leads the way in this arena. “Even with the challenging behaviour he was exhibiting, he didn’t meet the thresholds,” said Precey illustrating how high thresholds are today. “It makes you wonder who meets the criteria needed for support. And that was in London, what would happen in rural Cumbria?”

We need a culture where we can talk

Schools are very much a focus within the government’s green paper on children and young people’s mental health and a key recommendation is creating a Senior Designated Lead on Mental Health within schools who would have a role incorporating the oversight of the whole school approach to mental health, support the identification of at risk children exhibiting signs of mental health problems, have knowledge of and links to local mental health services, co-ordinate the mental health needs of pupils and have oversight of the delivery of interventions, support staff and raise awareness of mental health among staff and oversee the outcomes of interventions.

“The success of the designated leaders will depend on whether they are equipped to have a knowledge base on what the contributing factors towards mental health problems are and how to work with young people. You cannot heap that onto the SENCO who is already over-stretched. Schools are often where problems are first identified but identifying someone as a lead does not necessarily mean they will do the job the government expects them to. They will need resources. Plus the lead may need their own support and supervision as they will be dealing with difficult situations. It is not enough for a person to just assume the duties outlined next week,” said Precey.

The green paper also suggests introducing Mental Health Support Teams to work with the designated leads and more specialist services and to provide early intervention to children with mild to moderate mental health problems.

Precey says there needs to be an environment where children can talk about their feelings and emotions. “We are beginning to see more tolerance for people with mental health problems and Princes William and Harry opening up about the impact of losing their mother, and celebrities talking about mental health shows the positive side of social media.”

She outlines the case of a young boy age 15 who was an immigrant and lived with his mother and younger brother and was trying to support them both and work for his GCSEs. “He drank a bottle of bleach and died. The pressure was too great. The school was completely banjaxed, he had been a bright and popular pupil. We need to create a culture in schools where children can talk more rather than do something like that.”

In order to meet the government’s third recommendation of reducing waiting times for specialist treatment, Precey says more resources and staff are necessary. In order to treat children and young people with mental health problems, professionals need to be creative. “You need to think, under which circumstances can this child be best helped. It might not be traditional talking therapy but art, drama or music therapy as children don’t always have the words to express what’s troubling them,” she concluded.

Transforming Children and Young People’s Mental Health Provision: a Green Paper

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