Tower above it all

11th January 2008 at 00:00

If a child has mental health problems, early recognition and support can make all the difference. There is help out there, you just need to find it, says Barry Wright.

Have you got a child in your class with mental health problems, but you don't know where to seek help?

I had thought this was unusual and that all teachers would know where to get support. But then I read articles in The TES before Christmas describing child mental health services that seemed exceptionally limited. I was left wondering if our service in York was unusually comprehensive - or if contributors (including teachers) simply did not know what was available.

The emotional and psychological welfare of children and young people is the responsibility of everyone - primarily parents, of course, but also teachers and other professionals such as GPs.

In York, GPs are supported by eight primary mental health workers (PMHWs). These are usually former community nurses or children's social workers. Each one covers two secondary schools and all the feeder primaries. They discuss any child where concerns are raised by a professional. Our team of eight deals with about 2,000 children a year, in many cases referred by school-based professionals.

What sort of problems are referred? For example, Arthur's parents worry about his development, but he is their first child and relatives reassure them that nothing is wrong. In reception, the teacher notices that Arthur doesn't play with other children, has a range of preoccupations and uses very little gesture in communication.

The teacher consults the primary mental health worker, who gives advice, and carries out a screening questionnaire for autism that triggers further concerns. Arthur is assessed by a psychiatrist or psychologist who carries out a long interview with the parents and a play-based assessment with Arthur in their home.

The teacher and educational psychologist discuss Arthur, observing him in the class and playground. The multidisciplinary autism team discuss Arthur with the professionals and they agree on a diagnosis of autism and make an intervention plan. A clinical psychologist helps the parents manage difficulties such as poor sleep.

The parents attend the local training programme run by the specialist team called ASCEND (Autism Spectrum Conditions - Enhancing Nurture and Development). The autism specialist teacher and educational psychologist assess Arthur for school support and arrange a meeting with the parents. Throughout Arthur's childhood, he will be monitored by the community paediatrician. In-patient services are available for severe difficulties, but the team tries, whenever possible, to make sure that children are supported in their homes.

There are other problems that can be detected. A school nurse is worried about Mary, a 12-year-old girl, who is dieting excessively. The primary mental health worker may advise her or facilitate a PSHE session about nutrition.

What if that doesn't work? The PMHW could arrange to meet Mary and her family and refer her on to a clinical psychologist or community mental health nurse. The family would receive advice about how to put down clear boundaries for good nutrition in a healthy and positive way.

The psychologist offers Mary cognitive behavioural therapy, where they examine together beliefs about eating, nutrition, growing up, sexuality and self-esteem.

If that still doesn't work, Mary could see a specialist eating disorder service and attend family and individual therapy, with advice from a dietician. Things usually improve at one or all of these stages. But if Mary continues to pursue thinness to the point where her life is in danger, she could then go to a specialist in-patient service for more intensive therapy.

However, once she is firmly on the road to recovery, Mary can go home and the support she has had will continue in the community.

What is offered in York is in line with government guidelines. If the service in your area differs radically from this, either in the coverage or the range of services offered, you may be able to bring about improvements. Each locality has a commissioner and a Child and Adolescent Mental Health Services (CAMHS) strategy and an action plan highlighting what is happening now and future plans.

Find out who your local authority lead for child and adolescent mental health is, and start talking to them. Remember: good child mental health services are keen to work closely with families and schools to improve the lives of the children in their community.

Dr Barry Wright is a child and adolescent psychiatrist in a multidisciplinary CAMHS in York.

The Way it Works

Tier 1: Any professional giving day-to-day support to children, eg, teachers, educational psychologists, GPs, social workers, health visitors and school nurses.

Tier 2: Clinical psychologists, child psychiatrists, community mental health nurses, occupational therapists, mental health social workers, psychotherapists, creative therapists (art, music, drama). Therapies such as cognitive behaviour therapy and support for parents.

Tier 3: Specialist out-patient teams. In York we have teams for looked- after children, eating disorders, attentional problems, autism spectrum conditions, learning disabilities, bereavement and palliative care, support for sick children (paediatric liaison), groupwork, family problems, attachment and parenting, young people who self-harm.

Tier 4: Specialist in-patient services - more intensive treatment.


R Williams, G Richardson, P Bates (1995) Together We Stand: The Commissioning Role and Management of Child and Adolescent Mental Health. London: HMSO

DfES and Department of Health (2004) "National Service Framework for Children, Young People and Maternity Services." London: DoH.

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