Mental health and the pandemic: the growing crisis facing children

Nicola was in a local shop with her friends when she got a phone call from a health worker asking her to describe the most difficult experiences of her life.

After years of crippling anxiety and depression, the 17-year-old was on a months-long waiting list for help from NHS Child and Adolescent Mental Health Services (CAMHS). Struggling to cope, she had requested a crisis call.

In tears, she described plunging her hand into iced water to deal with the urge to harm herself. She says she had struggled with thoughts of suicide, but had not taken any steps to follow through.

“From that, I guess they decided that I was coping,” says Nicola, who asked not to use her real name. “CAMHS came back to me saying they couldn’t do anything. I was shocked . . . I shouldn’t have to be on a ledge to get help.”

While spending on mental health in the UK through the NHS has increased over the past five years, there has been a reduction in other public services that support teenagers and their mental health — many of which were focused on prevention.

The underfunding of these services during a period of austerity is now colliding with pent-up demand from the Covid pandemic and increasingly widespread psychological problems. The result is that young people in crisis are sometimes waiting months for help, or failing to make the threshold for accessing support at all.

“The bar to access CAMHS support has become extremely high. There was a government commitment to increase capacity, but prevalence has way outstripped it,” says Olly Parker, head of external affairs at Young Minds, a charity.

“‘Suicide attempt’ is a trigger word people feel they have to use to get help. In some parts of the country even that’s not enough.”

At the heart of the crisis is a rise in demand for mental health help that dramatically outstrips supply.

Government figures show one in six young people aged 6 to 16 had a probable mental health condition in late 2021, up from one in nine in 2017. At the same time, spending is unevenly distributed: last year, only half of local NHS authorities met the government target of spending 1 per cent of their budget on children and young people’s mental health.

The problems created by the pandemic are particularly acute among young people. While rates of mental ill health in adults and children are roughly comparable, figures from the Local Government Association suggest local NHS groups can spend up to 14 times more on adult’s than children’s mental health services. 

“There is growing need. We’re hearing right around the country from parents and children that this is a very difficult situation and demand is far outstripping supply,” says Dame Rachel De Souza, the Children’s Commissioner.

Life after lockdowns

The rapid rise in need in the UK predates the pandemic but has been worsened — and complicated — by lockdowns. It is a trend that has been seen across much of the developing world.

Between 2017 and 2020 the number of young people referred to mental health services increased almost 60 per cent, to 539,000. But the following year referrals fell to just short of 500,000.

The fall is not a result of reduced need: according to the Centre for Mental Health, an additional 1.5mn under-18s will need new or additional help as a result of the pandemic. Instead, a lack of contact with GPs, teachers and other essential services meant problems simply went unchecked.

Now, authorities are facing what Parker describes as an “explosion” in numbers as children who were unable to access help in lockdown and are now beginning to reach out. Parker believes the rise is a “lagging indicator — we’ve not quite seen the crest of that wave”. 

Whether they were seeking help before lockdown or after, the consequences of the overstretched services are twofold for young people.

Waiting lists for NHS help remain stubbornly long: in March, the Children’s Commissioner reported that over a third of children accepted on to waiting lists for mental health treatment were still waiting for their treatment to begin. The average national waiting time between a referral and second contact with CAMHS last year was 32 days, but in the worst performing areas average wait times were more than 80 days, and maximum wait times stretched to many months.

And many children do not make it on to waiting lists at all. Many of those working on the front line argue that the threshold for being successfully referred to CAMHS is moving higher, so young people — like Nicola — are frequently told they do not qualify for support even when they are in crisis.

“In all of our work last year we’ve talked to practitioners, the instances they’re seeing are becoming more frequent and more extreme,” says Anne Longfield, a former Children’s Commissioner who now chairs an independent commission on vulnerable young people.

In practice, this means children’s mental health worsening after they are told to wait for help.

In a survey of 1,000 GPs by charity Stem4 last month, 95 per cent said they believed mental health services for children and young people were critically failing and had worsened in the past six years, and many described the services as “dangerous” or “unsafe”.

Two-thirds said they were afraid their young patients would come to harm as a result of a lack of treatment. Five per cent of GPs said they stopped referring young patients altogether.

One GP who responded to the survey said a 12-year-old patient was found to have a rope in his room, but was told the referral threshold was not met because he had no marks on his neck. Another said a child who had been stopped from jumping off a building earlier in the day was rejected for assessment on the same day, forcing the doctor to direct him to A&E.

“The thresholds are set so that if someone would benefit from the support of a CAMHS service they should be referred on to it,” says Sebastian Rees, the author of a report for think-tank Reform calling for schools to teach mental wellbeing and resilience to combat the problem. “They clearly aren’t.”

Eric Haines, director for London and the South at mental health charity Place2Be, says local CAMHS services are “very good at crisis response” where children are in “imminent danger”. But he says there are variations between local authorities and, outside of the starkest emergencies, waiting times were often up to 15 weeks.

De Souza, who until 2021 ran a multi-academy trust, says she would see children with profound challenges struggle to get support. “Practically as a headteacher you’ve got children who’ve made one or two suicide attempts at school and are still not getting the support they need,” she says. “There isn’t any slack to take [cases that are seen as] maybe — there are serious financial pressures.”

Parker says it was not unusual for parents to spend the night outside children’s doors “worrying about how they’re going to make it through the night”, after being placed on waiting lists despite young people being at risk of suicide.

“Imagine living with that for two years and then getting up in the morning and having to go to your job, sometimes caring for people yourself,” Parker adds. “Then the parent’s mental health begins to suffer too.”

School support

Large numbers of children stuck on waiting lists or failing to hit the threshold for help has an impact on other services. First on the frontline are schools.

Nicola says it is not uncommon for queues of several young people to be waiting at the office of the head of year, a senior staff member with informal responsibility for the wellbeing of pupils. As well as appointments with a school-based counsellor Nicola continues to depend on ad hoc support from these meetings, which she refers to as “top-ups”.

“They’re what keeps my head above the water, I’m so close to going under,” she says. “The amount of people I’ve seen waiting outside of his office is scary. He’s basically triaging without a mental health training background.”

Chloe Lowry, a former teacher and now a researcher at University College London’s Institute of Education, says teachers have always been the most common source of support for children suffering mental distress.

But more teachers are finding themselves giving emotional and social support to more children with more serious problems, thanks to young people’s needs increasing and “not being met elsewhere”. Some teachers were struggling with their own mental health as a result.

“There’s a mental health crisis among teachers — what I suspect is they’ve got a bit of a vicious cycle,” says Lowry. “We know there’s a link between the mental health of students and their teachers.”

Counsellors employed directly by schools and independently by charities say they are dealing with more severe mental health issues as those children who in a properly functioning system would be quickly referred are pushed down to less urgent parts of the system.

“The actual needs the young people are coming with are at a higher level than the intervention we have,” Rachel Ward, a mental health practitioner working for Action for Children in north-west England, says. “That’s because the services are not there . . . There is nobody to pick them up and it comes back to us.”

Lack of funding

The worsening problems of the children workers like Ward meet are part of a larger vicious circle of underspending on preventive measures and a failure to stop problems escalating, experts say, resulting in children seeking help when things become much worse.

Cutbacks in early intervention services such as youth centres have for more than a decade left young people struggling to get help with minor problems, resulting in their mental health worsening until they are forced to get help in what is often a crisis intervention.

Longfield says the system has for years failed to provide early support that could have prevented the current increase in demand. “A lot of children end up with a level of mental health need that requires clinical intervention but if they could’ve got help before it may not have got to that point,” she says.

With rates of mental ill health requiring crisis care increasing, it seems unlikely that acute care can expand to meet need, she adds. “What we’re seeing is a system that was creaking anyway but is now really under pressure . . . with little hope of catching up.”

According to a report by Pro Bono Economics, a think-tank, annual spending on children’s services was £325mn in real terms lower in 2019-20 than it was in 2010. With the number of young people increasing, this pushed spending per young person down by nearly 7 per cent in the decade before the pandemic.

Cuts in spending, however, fell exclusively on early interventions such as children’s centres, youth clubs and informal counselling. Spending on these preventive services fell 48 per cent in the decade. On late interventions such as youth justice services, looked-after children and safeguarding, it increased by 34 per cent.

Now mental health crises post-pandemic are resulting in more imbalance towards emergency services, Parker says. “When you put cash into a system it tends to flow to where there are burning buildings and right now the burning building is in the post-pandemic backlog of people being referred to CAMHS.”

But while charities recognise more funding for emergency services will alleviate the pressure on their own services, they also know additional support is needed to stop situations reaching that crisis point.

“Real conscious intervention and early support needs to be put into our young people now,” says Ward, at Action for Children. “It’s not an instant answer, but if we take action to give people the skills early on now, you’re not going to have the same people on that list in five years’ time.”

Action for Children is expanding courses to equip young people with skills to manage their own mental health. Teenagers are invited to attend the course if they score above a baseline for mental health risk in an assessment: since the pandemic, the proportion considered eligible has risen from 34 per cent to 45 per cent. In one school nearly 70 per cent of pupils were eligible.

To begin to alleviate the pressure on CAMHS more investment is needed in early help such as mental health teams in schools, says Longfield. “It can’t just be a very shiny service that is there to provide clinical treatment — it has to work much more robustly and with other partners.”

An NHS spokesperson said: “Children and young people’s mental health is a top priority for the NHS, with over 649,000 children and young people supported by NHS funded services in the year up to January, up from 534,238 pre-pandemic. The mental health workforce had increased by 40 per cent over the past three years.

The Department of Health and Social Care said: “We recognise the profound impact the pandemic has had on children’s mental health and it is vital they are able to access appropriate support early.” It had invested £79 million in children’s mental health services last year – providing around 22,500 more children and young people with access to community health services and boosting coverage of mental health support teams in schools and colleges.

A ticking time bomb

After more than half a year of waiting, Nicola is now on course to attend a counselling session with CAMHS. But as she approaches her 18th birthday she is worried about the transition to adult services.

She is also traumatised by being told she was not unwell enough to receive help even when she had reached crisis point, leaving her feeling that managing her own mental health meant she was “not bad enough” to get help.

“The scariest time in my life was two days when I was at crisis point and the idea that people will only help if I get there again — that’s really scary,” she says.

“The fact that you can get help but it’s forever just beyond your grasp makes it harder. You do everything you can and it’s not good enough . . . it makes me think there’s no point in trying — that there’s no one helping and no one cares.”

Frontline workers interviewed by the FT believe the situation for young people is likely to get worse before it gets better. A lack of community, socialising and support during the pandemic has given way to even greater pressure at school, as teenagers prepare for exams under a government push to catch up.

Government efforts to address the deficit in early intervention include dedicated mental health support teams who give help for mild-to-moderate mental health issues across schools. But Rees is sceptical as to whether the efforts go far enough.

“It’s a ticking time bomb in terms of the long-term effects,” Rees says. “It’s an economic failure to not get on top of this, but it’s always harder to focus on prevention.”

Parker believes problems run deeper than how and where young people can access counselling. “Young people are seeing a conveyor belt of life. They’re the next ones up getting a job, employment, a house and they see the next generation struggling to get those things and it seems to be getting harder,” Parker says. “There’s a sense of a future that’s not really built for them.”