Response 3471761

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Joanna Barrett

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NSPCC Scotland

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1. Our framework sets out 8 priorities for a new Mental Health Strategy that we think will transform mental health in Scotland over 10 years. Are these the most important priorities?

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If no, what priorities do you think will deliver this transformation?
We are delighted to see that the proposed strategy will place significant emphasis on perinatal and infant mental health. We feel strongly that increased priority and investment in these areas will contribute significantly to tackling the intergenerational transmission of trauma and improve mental and physical health in Scotland. Priority 1: a focus on prevention and early intervention for pregnant women and new mothers Depression and anxiety affect up to 20% of women during pregnancy and in the first post-natal year (perinatal mental illness). Without the right kind of support, perinatal mental illness can become long-term and may inhibit a mother's ability to provide her baby with the sensitive and responsive care that s/he needs. This, in turn, may have an impact on the child's emotional and cognitive development, potentially creating a trans-generational cycle of poor mental health and wellbeing. To lessen the impact of perinatal mental illness on mothers, babies and their families, we need to provide timely, safe and evidenced-based interventions which explicitly address the mother's own mental health and wellbeing and their interactions with their babies; supporting mothers, fathers and families to give babies the physical and emotional care they need to thrive together. Over the past few years, there has developed a wealth of evidence that Scotland must do better to support the mental health of pregnant women and new mums. Data from the Growing Up in Scotland study reported significant association between early exposure to maternal mental health issues and poorer child outcomes. Last year, we published research on community perinatal mental health provision which found that services were hugely variable; only five out of fourteen health boards have a community perinatal mental health team. The National Confidential Inquiry found mental illness was the leading cause of maternal death in the UK. Most recently, the Mental Welfare Commission’s themed review of perinatal mental health care found a third of mothers who required hospital care were unable to access specialist Mother and Baby Units. These reports highlight why the needs of mothers, babies and families are best served by developing specialist services. By prioritising perinatal mental health we can protect two generations at once - we can improve maternal health and child development outcomes - while also placing mental health policy in the wider context of early intervention, the early years and prevention. Priority 2: a focus on prevention and early intervention for infants, children and young people Children's wellbeing relies on the quality of caregiving relationships from the earliest days: that is, infant mental health. We believe that to address effectively poor mental health outcomes at a population level, it is imperative that we recognised the fact that mental health issues develop in infancy as well as in later childhood and adolescence. This applies particularly to children who have experienced maltreatment. The Infants Suffering Significant Harm study found that, by age three, almost half of infants who had suffered maltreatment in the first years of life had acquired developmental or behavioural difficulties . Both this Strategy and the Child and Adolescent Health and Wellbeing Strategy must be explicitly underpinned by an understanding of the impact of adverse childhood experiences on health outcomes, complex trauma and issues of intergenerational transmission. Evidence from the US, replicated in studies in England and Wales, has shown that adverse childhood experiences, including abuse and neglect, are associated with a range of poor mental and physical health outcomes throughout the life course, including physical disease, mental illness and early death . The more adversities experienced, the higher the risk of poorer outcomes. This has implications not only for the child but across the generations. Children need safe, nurturing and consistent care in order to thrive. Children who have experienced significant early adversity, such as maltreatment, can develop complex trauma, due to prolonged exposure to traumatic events. The implications of complex trauma for the individual can be devastating in terms of the child’s cognitive and emotional development, which can result in pervasive difficulties in adulthood, and in parenthood. These difficulties can manifest themselves in a range of health harming behaviours, including substance misuse. However, in our experience parents with this kind of presentation can have difficulties accessing mental health services, despite trauma having a significant impact in all domains of their lives. These difficulties can impact on their ability to provide the responsive and nurturing care their own infant child needs, impacting on the attachment relationship for that child and so that child’s development and future outcomes. It has been suggested that childhood adversity and attachment experience may be linked to Scotland’s ‘excess mortality’ . This is an issues which demands further exploration. There is also emerging evidence from the US that the premature mortality experienced by those who have experienced childhood maltreatment applies only to women. To really improve public health in Scotland, we need to understand much more about the mechanisms of inter-generational transmission of trauma, the impact of abuse, and how can best intervene. It is vital that we seek to prevent childhood maltreatment, and intervene at the earliest point to promote children’s recovery when they have experienced abuse and neglect. Child maltreatment in the early years can cast the longest shadow but effective intervention at that time can also promote the greatest potential for recovery. This is why infant mental health must underpin the Scottish Government’s long-term mental health strategy. The NSPCC’s It’s Time campaign seeks to ensure that children are able to get the support they need to recover from abuse. For very young children, this requires services to be informed by an understanding of parent-child relationships, attachment and complex trauma, and a clear care pathway from universal to specialist services for infants who have experienced maltreatment, which explicitly includes the role of adult mental health services. There is a wealth of evidence about the economic and societal benefits to early intervention . Over the past few years a rich policy framework has developed which emphasises the importance of early intervention and prevention , however we have struggled to translate these aspirations into reality. Having infant mental health as a key priority of the national mental health strategy, and developing the necessary skills and expertise in both universal and specialist services to support vulnerable young children and their families, will go some way to delivering on these broader policy goals.

2. The table in Annex A sets out a number of early actions that we think will support improvements for mental health.

Are there any other actions that you think we need to take to improve mental health in Scotland?
Priority 1: a focus on prevention and early intervention for pregnant women and new mothers We warmly welcome steps being taken by the Scottish Government to establish a Managed Clinical Network for perinatal mental health. We need provide a nationally-coordinated, systemic approach to developing high-quality and consistent specialist perinatal mental health services across the country. A clinical network should provide leadership for this. It must consider both service development and succession planning, to ensure the sustainability of specialist services. It is imperative that the position of maternal and infant mental health services is clarified in relation to the local integration of services. The UK Government has ring-fenced spending for perinatal mental health service in England . The Welsh Government has also committed resources to improved provision . We feel strongly that Scotland should follow suit and make specific investments in specialist community perinatal mental health teams, and in improving access to psychological interventions in the community provided by both statutory and third sector services. Where admission to hospital is required, health boards should ensure that women are admitted with their babies to a specialist Mother and Baby Unit, unless there are compelling reasons not to do so. The Mental Welfare Commission for Scotland’s recent recommendations for improving standards of care provided to new mothers who require inpatient admission for mental health difficulties must be implemented by every health board. The Scotland-wide clinical guideline on the management of perinatal mood disorders (SIGN 127) published four years ago, provides evidence-based recommendations to all health boards. Full implementation of this guideline would help ensure women who are at risk of, or are suffering from, mental illness are identified at the earliest opportunity and given appropriate, safe and timely expert care, and minimises the harm suffered by women and their families. Poverty and adversity place women at higher risk of developing mental health problems during this time. The way we provide help must reflect the needs of parents living with adversities, including maltreatment and trauma in their own childhood, and who therefore are likely to require additional support in parenthood. Developments in perinatal mental health must recognise the clear links between maternal mental health and child outcomes. A healthy, secure parent-child attachment is the most important protective factor for infants and a strong predictor of good outcomes. We are aware of some very good practice in individual health boards in upskilling their universal services workforce to identify issues, and promote and support infant-parent attachment. We think there is still more to do to ensure early identification and support by universal services is for both maternal and infant mental health. Priority 2: a focus on prevention and early intervention for infants, children and young people NSPCC analysis of infant mental health policy in Scotland identified the range of promising recommendations in national reports, with the potential to be transformational, that have not been acted upon . We would suggest that it would be timely to undertake a comprehensive review of provision and delivery. The current Local Delivery Plan Standards and new Improvement Standards for access to specialist CAMHS does not effectively address support for our youngest children, because in most of Scotland there is no service provision for them to access. Most CAMHS teams do not provide a service to children under five. In addition, as far as we are aware, most operate exclusion criteria for child protection cases, thereby depriving access to specialist services to the most vulnerable children, whose mental health may already be at risk. NSPCC’s Glasgow Infant and Family Team routinely encounters unmet mental health need in young children aged 0-5 years. In our view the extent of complex and severe difficulties in very young children is being overlooked. The new strategy must address the gap in availability of CAMHS provision for this 0-5 age group. We would like to see clear actions from the Scottish Government to ensure that all CAMHS services are adhering to their responsibility to include the needs of infants, with an emphasis on attachment and the parent-child relationship, in the overall configuration of services. These services should provide for a full range of provision for this age group, from mild to moderate difficulties, including anxiety and mood disorders (early intervention CAMHS services) to tier 3 & 4 services. This help must be available to the most vulnerable young children, including those who have experienced neglect and maltreatment and have either been, or are presently being looked after, including young children in foster care. To this end, while we very much welcome recognition that an MCN for perinatal mental health is required to provide leadership and to coordinate and develop provision, we would also call for an MCN for infant mental health to be developed to drive the policy aspirations we have had in this field for a decade or more. However, we must also look outwith specialist services. Local areas must have clear pathways to supporting children's emotional wellbeing across every tier of service provision. This should also include access to appropriate adult mental health services for parents who require support and intervention. We welcome that one of the actions listed is to utilise universal services, especially health visiting. Midwives, health visitors and GPs have the potential to play a crucial role as a preventative mental health service. Infant mental health care, comprising primary, secondary and tertiary interventions, should be an essential part of universal service provision. In particular, our health visiting workforce should be enabled to spend time with families, and have skills and expertise in observing and understanding parent-child interaction and supporting this relationship, as part of the refreshed Pathway. We are keen to find out more about the SNP's election manifesto commitment to train all individuals who work with children in attachment . The upskilling of the universal children's workforce, in relation to child development, attachment relationships, and recognising and responding to the signs of maltreatment is a vital part of a national approach to improve mental health in Scotland.

3. The table in Annex A sets out some of the results we expect to see.

What do you want mental health services in Scotland to look like in 10 years' time?
In ten years’ time we want to have seen real progress in delivering on commitments to infant mental health and early intervention. To achieve this we want to see a Managed Clinical Network for Infant Mental Health, in addition to that for Perinatal Mental Health, to provide leadership in improving the quality and consistency of provision across Scotland. At a local level, in every area there should be fully integrated care pathway for children and young people’s emotional and mental health ensuring that help is available and can be accessed in a way that suits the needs of the child. Specifically, we would want to see a pathway for infants who have experienced maltreatment, including universal services and interagency identification of need and access to tier 2 and 3 CAMHS which recognise attachment and complex trauma as core clinical business. The care pathway would also include specialist infant mental health services which provide the intensive intervention required to address the impact of maltreatment on parent-child relationships, and current and future mental health. It must also ensure that there is appropriate access to adult mental health services, and that adult services have sufficient understanding and skills in child mental health and attachment. The pathway must not solely include NHS mental health services, but therapeutic interventions provided or commissioned by other agencies, with parity of esteem. It should also include specialist trauma recovery services for children and young people related to specific types of experience or vulnerability. Though outwith the scope of the mental health strategy, to effectively address the needs of infants who have experienced maltreatment, we also need to ensure that out social care and legal systems are attachment-informed and child-led in terms of focusing on children’s developmental needs and operating within timescales accordingly.