1.   Samaritans Cymru welcomes the opportunity to respond to this inquiry into the Emotional and Mental Health of Children and Young People. Since launching our bilingual emotional health resource for schools in Wales in 2014, we have worked extensively on policy areas surrounding the emotional health of children and young people. Young people are a high-risk group for mental illness and suicide, and in Wales, we are witnessing a significant rise in precursory factors such as self harm, admissions for eating disorders and referrals to the specialist Child and Adolescent Mental Health Service (CAMHS) which can contribute to suicidal ideation or intent in adolescents. In 2016, there were 16 suicides in the 15-19 age group in Wales; the highest rate in 5 years and second highest in 12 years.


2.    Specialist CAMHS        


2.1.      Despite the welcome additional investment from Welsh Government for CAMHS in Wales, the overall strain on mental health services in Wales is increasing; 2012-2016 saw a 100% increase in demand for CAMHS.[1] Following the initial announcement, we were pleased to see a push to make CAMHS more responsive by placing an emphasis on expanding access to psychological therapies.


2.2.      We believe that swift and timely access to psychological therapies can enable and improve recovery, and act as a form of early intervention which can reduce the need for secondary services. Despite the cross-party support and focus on access to psychological therapies in the Together for Children and Young People Programme (T4CYP), Together for Mental Health and the Mental Health (Wales) Measure, access to psychological therapies is still a problematic issue in Wales.


2.3.      Children and young people’smental health can deteriorate significantly during lengthy waiting times for psychological therapies. Putting Mental Health on the Agenda, a collaborative manifesto which Samaritans Cymru supported, states that “lengthy waiting times can lead to absence from education and work, hospitalisation or even homelessness. Early access to psychological therapies can prevent deterioration and avoid the need for more acute services, benefiting the person and the public purse”.[2]


2.4.      Although there has been a reduction in the number of children and young people waiting between 4 and 26 weeks following the 2015 Welsh Government announcement, there were still more than 1,000 young people out of 18,000 referred to mental health services in 2016 who waited more than six months for a first appointment.[3] This initial reduction in waiting times was observed by reviewing board papers for each Health Board, reviewing Referral to Treatment Times published on the Welsh Government website and by directly requesting the information from Health Boards as opposed to routinely collected data. We believe this lack of central data is one the critical barriers for the improvement of CAMHS in Wales.


2.5.      Despite the highly welcome introduction of a 56-day waiting time target for primary care interventions in the Measure, which has since been reduced to 28 days, there is no statutory requirement for health boards to collect specific waiting time data for psychological therapies. As this data for psychological interventions is not routinely collected or published, it is difficult to measure the scale of the problem. National data is recorded in relation to first appointments and does not include the length of time people are waiting in total (from referral to treatment). The data is also not broken down by Health Board area. In order to access a true reflection of specialist CAMHS in Wales, it is vital that waiting time data and patient outcome data are routinely collected and published.


3.    Post-hospital support


3.1.       It is also crucial that health boards in Wales collect and publish data for post-hospital support for patients following admissions for self-harm or a mental health crisis. According to Mind Cymru, as of April 2017, there is only one health board in Wales that records how many people get timely follow up contact after they’ve been discharged. The lack of data for post-hospital support in Wales is a major concern. A survey of over 850 people with mental health problems about their experiences after leaving hospital in Wales showed those who weren’t followed up appropriately (after seven days or not at all) were twice as likely to attempt suicide and a third more likely to harm themselves compared to respondents who said they were followed up within seven days of being discharged.[4]


3.2.      Research by the NSPCC found that 1,193 young people were admitted to A&E departments in Wales because of self-harm in 2015. That number has increased by 41 per cent in the past three years.[5] National suicide prevention strategies recognise that Accident & Emergency services have an important role in treating people who have self-harmed or have made a suicide attempt. At least half of people who die by suicide have a history of self-harm and one in four have attended hospital for self-harm in the preceding year.[6]Given the particularly high suicide risk of people who attend hospital and A&E after harming themselves it is essential that rapid follow-up care is always available. It’s essential that anyone having self-harmed is treated with respect, given a proper assessment and follow-up care. 



4.      Links with Education (emotional intelligence and healthy coping mechanisms)


4.1.      Following the Donaldson review and announcement of the new curriculum in Wales, we have been lobbying extensively for real change which these education developments could create. As a core purpose of the new curriculum and as one of the six Areas of Learning and Experience (AoLE), health and wellbeing have risen up the agenda for education in Wales. We have welcomed this focus but continue to emphasise the importance of implementation and the potential of this AoLE.


4.2.      Currently in Wales, Personal and Social Education (PSE) is compulsory for all students at Key Stages 1,2,3 and 4 (5-16 years old) and covers an extensive and wide range of topics including sex education, spirituality, healthy eating, careers advice and online safefy.  Lesson plans which focus on emotional health and wellbeing, or mental health, are also freely available to schools within this remit . However, with increasing pressure on schools to deliver such a robust PSE framework, emotional and mental health lessons are often excluded.


4.3.      In August 2017, we made a second campaign call for emotional and mental health lessons to be mandatory in Wales. This September, we have welcomed the announcement of a two-year Welsh Government trial which will allow pupils with mental health problems at more than 200 schools in Wales to access early help from onsite CAMHS practitioners. Whilst this kind of linking up between education and health services is essential, we would like to take this opportunity to emphasise that our call for action continues to be placed further downstream and in the primary context of early intervention through building resilience.


4.4.      Whilst we welcome any initiative to help young people experiencing mental ill-health in Wales, our primary focus is to decrease the likelihood of mental illness developing in the first instance. In order to deal with and manage periods of low mental wellbeing, pupils need to develop and build their emotional resilience. Building resilience can help children and young people to view failures and mistakes as lessons to be learned from, and as opportunities for growth instead of viewing them as a negative reflection on our abilities or self-worth. Developing resilience increases the likelihood of people feeling committed to their lives and their goals, and having a compelling reason to get out of bed in the morning. Evidence shows that being taught about emotional health can reduce specific mental health problems and help with communication skills, social skills, cooperation ,resilience, a sense of optimism, empathy, a positive and realistic self-concept and problem-solving skills. We also know that children with higher levels of emotional, behavioural and social wellbeing have, on average, higher levels of academic achievement and are more engaged in their education.


4.5.      Being taught about emotional health helps people become less prejudiced which reduces the stigma surrounding asking for help.  A major concern for Samaritans is the stigma which children and young people will experience in school when needing to access support for low mental wellbeing or specific mental health issues. During our time working with the Cardiff Healthy Schools team, we discovered that one of the key reasons pupils don’t access support through their counselling service is because of stigma. We are also aware that it is this reluctance to seek help, teamed with a lack of knowledge surrounding emotional health and healthy coping mechanisms, that can worsen a child’s mental health and eventually lead to an unnecessary CAMHS’ referral for the pupil and an over-referral to CAMHS’ nationally. It is imperative that we don’t medicalise emotional distress in children and young people’s formative years. Whilst we advocate for parity of esteem for physical and mental health in Wales, it is importance to identify the wider societal and cultural aspects of today’s modern society which impact negatively on the mental health and wellbeing of children and young people.


4.6.      Children today are born into a complex world which we can struggle to understand, one where social media, internet use, information and communication technology is embedded in their early development, childhood and subsequent maturation. There is increasing evidence that social media may be causing loneliness and depression in teenagers. In a recent US study on the effect of social media use on feelings of social isolation, the University of Pittsburgh found that more than two hours of social media use a day doubled the chances of a person experiencing social isolation.[7] In September 2017, a government-funded study found that one in four girls in the United Kingdom is clinically depressed by the time they turn 14, a startling figure which once again has been attributed to increasing pressure and loneliness caused by social media.[8]  


4.7.      We must embed a public health approach to mental health by placing a primary focus on prevention rather than cure alone.  Investment in prevention and early  intervention can reduce human, social and economic costs. With half of all mental health problems beginning by the age of 14, the case for this approach is clear; school years are the crucial opportunity to equip children and young people with the skills they need to face the modern society they find themselves in.  Emotional health programmes in schools should be viewed as a form of promotion, prevention and early intervention which could reduce pressure on CAMHS, reduce specific mental health problems and increase academic achievement.


4.8.      We are concerned to hear the recent announcement that the introduction of the new curriculum in Wales will be delayed. However, we hope this phased roll-out will provide more time for the opportunities within Health and Wellbeing AoLE to be realised. We believe lessons in emotional and mental health should be mandatory for all secondary schools in Wales and should form part of the new curriculum under the Health and Wellbeing AoLE. For the 2016/17 academic year, we have worked with five schools in Cardiff to help them implement our own emotional health lesson plans (DEAL – Developing Emotional Awareness and Listening) into their curriculum. We look forward to assessing the evaluation of this project and are pleased to already hear that the schools will continue to use it in the future.


5.      Teacher Training

5.1.      We would also like to highlight the training gap in emotional and mental health for teachers in Wales. This is another growing concern which could be addressed during the phased roll-out of the new curriculum. We believe existing teaching staff across all schools in Wales should be provided with basic emotional and mental health awareness to increase confidence in teaching the subject. We should also be equipping new teaching staff with the confidence and skills they need by embedding emotional and mental health awareness in Initial Teacher Training (ITT). We are pleased to see the ‘upskilling of teachers to recognise and deal with low level problems’ included in the recent announcement of the £1.4m mental health project in schools. However, we must ensure consistency across all educational settings in Wales and make sure teaching staff are equipped to deal with emotional and mental health. During our training session for the Cardiff DEAL Pilot, the most frequent concern raised was the lack of confidence the teaching staff had in dealing with difficult questions. Of the five schools involved, all of them raised the issue of not knowing how to respond to instances of self-harm or questions about suicidal feelings. This lack of confidence is apparent in passionate PSE staff so we must be realistic about the many other teachers in Wales who don’t have the confidence or knowledge to deal with these issues. During our time engaging with teaching staff, we have heard of many instances where pupils are referred to services because the first point of contact, the teachers themselves, do not know how to deal with them.


5.2.      It is vital that we realise the potential of the new curriculum. Its success will improve the future of public health in Wales and in turn, could save us economic, health and most importantly, human costs. Finally, we believe the potential of this change in Wales strongly adheres to the principles of the Well-being of Future Generations (Wales) Act 2015, particularly in terms of the sustainable development principle.This change would contribute to a solid foundation for the next generation; it is vital to create opportunities for every child and young person in Wales.



[1] Mental Health in Wales: Fundamental Facts 2016, Mental Health Foundation (2016)

[2] Putting Mental Health on the Agenda, Gofal & Mental Health Foundation (2015)

[3] Child and Adolescent Mental Health Services (CAMHS): Position Statement, Community Health Council (2017)

[4] Thousands left to cope alone after leaving mental health hospital - putting their lives at risk Mind Cymru (April 2017)

[5] Child self-harm figures 'frightening' in Wales, NSPCC says, BBC Wales (December 2016)

[6] How local authorities can prevent suicide, Samaritans (2017)

[7] Social Media users more likely to feel isolated, Medical News Today (2017)


[8] One in four girls have depression by the time they hit 14, study reveals, Guardian (September 2017)