Science1 publisher3 min readPublished
England's mental health services reach under a fifth of children in care or on protection plans
A Cambridge team counted every child referred to NHS mental health services in England across five years. Children on protection plans or in care reached services two to three times more often than their peers, and still only 9% to 18% of them did in a year.
The Scientist · Science desk
What happened
- Cambridge researchers, writing in Child and Adolescent Mental Health, analysed NHS Digital records for every child in England referred to or supported by mental health services between April 2016 and March 2021.
- Those same children were still two to three times more likely to be in contact with services than peers who were not known to child welfare services.
- The dataset did not record a primary reason for referral in 67% of cases, and where it did, anxiety at 13% and "in crisis" at 10% were the commonest entries.
- Almost 2 million children and young people were in contact with mental health services across the five years, with the annual figures rising throughout.
Compiled by The ScientistSomething wrong?How this is made
Why it matters
- constraint With two-thirds of referral reasons unrecorded, this dataset cannot say whether children in care were refused at the door or never referred at all, so it cannot tell a commissioner which part of the pathway to fix.
- exposure When CAMHS declines a referral on complexity grounds, the clinical need does not disappear; child welfare services and families absorb it without clinical resources.
- decision A service reporting the two-to-threefold elevation can show that it reaches this group more often than average; the same service reporting the 9% to 18% rate against prevalence has to explain a shortfall in the tens of thousands.
- precedent If "too complex" and "related to social situation" hold as grounds for refusal, the criteria filter out first the children whose adversity is best documented.
Nearly 50,000 children in England are on child protection plans and 84,000 are in care [5]. Put the two groups together and you get 134,000, though the study does not say how many children appear in both counts [1]. If up to half have mental health problems at a clinically significant level, as earlier studies suggest [6], that is about 67,000 children [2]. A contact rate of 9% to 18% covers roughly 12,000 to 24,000 of them [3]. The difference is between about 43,000 and 55,000 children a year [4].
The same dataset includes a comparison that runs the other way. Children on protection plans or in care reached services two to three times more often than their peers [4]. Divide the 9% to 18% range by that multiplier and peer contact lands near 3% to 9% [5], against a national estimate that 18% of children have a probable mental health disorder [7]. Need in the care group, at up to half, is up to 2.8 times the national figure [6], and the contact multiplier of two to three sits in the same range. Measured against need, this analysis does not show children in care being reached worse than everyone else: the largest absolute shortfall sits in the group with the most need, inside a system that refers fewer than half of all children with a probable disorder [8].
The data cannot locate the point where children drop out. A primary reason for referral was not recorded in two-thirds of cases, 67% [10]; where it was recorded, anxiety accounted for 13% and "in crisis" for 10% [11]. In a count of contacts, a child who was never referred looks the same as one who was referred and turned away.
The evidence for turning away comes from separate work by the same team, which found children in this group often rejected because their needs were viewed as too complex or as related to their social situation [13]. A 12-year-old girl in residential care, referred to CAMHS after a suicide attempt, was deemed too complex for intensive specialist support [14]. A 12-year-old boy was taken to A&E after a suspected overdose and running away from a new foster placement; his access to CAMHS was rejected because his problems were judged to relate to his social situation [15]. Professor Robbie Duschinsky, who heads the Child Health and Development Research Group at Cambridge's Primary Care Unit, said, "Through our work, we've encountered countless cases of children and young people with mental health difficulties not being offered treatment because their living situation is judged too complex or a matter for child welfare services" [16]. These are individual cases, with no rate attached.
Contact also plateaued or declined at ages 17 and 18, despite late adolescence being a high-risk period for mental illness [17]. The authors offer candidate explanations, including a lack of advocacy for young people at that age and young people who do not want to engage having their wishes respected [18]. The records do not distinguish a young person who turned down help from one who was refused it. The analysis also found children identified as Asian or Black in contact with services less often than population estimates would predict [19].
What to watch
- Whether NHS England's dataset begins recording a primary referral reason in more than a third of cases.
- Whether the Cambridge team's rejection findings acquire a denominator: how many referrals for children in child welfare are declined, and on what stated grounds.
- Whether contact data after March 2021 still shows the plateau at ages 17 and 18.