Mental health disorders
Although it is thought that approximately 10% of young people under the age of 16 in the UK cross ICD-10 (World Health Organisation (WHO), 1992) diagnostic thresholds for mental health disorders at any one time, many of these young people are not known to specialist Child and Adolescent Mental Health Services (CAMHS) (Meltzer, Gatward, & Goodman, 2000). Research in the USA suggests that it is only 10–20% of young people with mental health disorders who are in fact seen by specialist mental health services (Costello et al., 1993). Farmer et al.’s (2003) study of mental health problems and service use over three years in 1420 young people aged 9, 11 and 13 at study entry, found that the education sector was the most common point of entry (60.1%) to mental health services and the provider of services across all ages studied. Specialist mental health services were the first point of entry for approximately a quarter (27.3%) whilst 12.9% of young people gained access to mental health services through general medical services. Of note, young people who entered the mental health system through the education system were the least likely to receive services from the other agencies and the least likely to meet criteria for any psychiatric diagnosis. In comparison, young people who entered the mental health system through specialist mental health services were the most likely to receive services from other agencies and were more likely to be severely disturbed. Overall, 45% of service users received services from more than one agency.
Several other studies from the USA (Burns et al., 1995; Leaf et al., 1996) have also found that young people with mental health disorders are more likely to contact school-based services in relation to their mental health than other agencies and it has been shown that mental health services based in schools are perceived as more accessible and used more by pupils than services located off site (Catron & Weiss, 1994; Kaplan et al., 1998).
Epidemiological research in the UK has revealed similar findings. For example, in a follow-up of the Office of National Statistics (ONS) survey, Ford, Goodman, and Meltzer (2003) found that 53.4% of the children who had a psychiatric disorder diagnosed in the original study had seen a professional by the time they were re-contacted 20 months later. In line with the USA findings, education services were more likely (43.3%) than specialist CAMHS (22.1%) to be contacted by the young person or their family regarding the young person's mental health. Indeed, in a UK-based survey on mental health needs, 80% of adolescents questioned said that they would approach a teacher for help (Clarke, Coombs, & Watson, 2003).
The likelihood of help being sought also depends on the child's presenting disorder. For example, nearly all children with diagnosed hyperkinetic disorder in the initial ONS study had seen a professional by the time they were re-contacted 20 months later, whereas the proportion of children with conduct and emotional problems not in contact with services at 20-month follow-up was considerably higher (Ford et al., 2003). Similarly, Angold et al. (1998) found that children who had depression or anxiety disorders were experienced as less burdensome by their parents than those with other disorders, and were thus less likely to be referred to specialist CAMHS.
Neurodevelopmental disorders, such as ADHD, DCD and ASD, all have associated functional impairments which impact many areas of the child's life including home and school. The importance of ensuring that a multi-agency, multi-professional perspective is obtained when assessing and managing these children is highlighted when the literature relating to co-morbidity is examined.
For example, there is clear evidence of association or comorbidity of ADHD with a number of other psychiatric conditions including oppositional defiant disorder, conduct disorder as well as depression and anxiety disorders (Barkley et al., 1990; Gittelman et al., 1985; Loeber et al., 1982; Mannuzza et al., 1993; Taylor et al., 1991). ADHD has also been associated with learning difficulties. These include specific reading difficulties (Cantwell & Scatterfield, 1978; Gilger, Pennington, & DeFries, 1992; Lambert & Sandoval, 1980, Pliszka, Carlson, & Swanson, 1999) and dyslexia (Dykman & Ackerman, 1991; Semrud-Clikeman et al., 1992). For example, in one study it was found that approximately 50% of children with ADHD were also found to have DCD (Gillberg, 1998), the symptoms of which impact on writing and ball skills, and have a long-term impact on future psychological development (Hellgren et al., 1993; Rasmussen, Almvik, & Levander, 2001).
involve children, parents and carers and the child's school …… multidisciplinary assessment which may include educational or clinical psychologist and social workers is advisable for children who present with significant comorbidity … (p.1).
It further recommends that:
a comprehensive treatment programme should involve advice and support to parents and teachers … (p.1).
In areas where there are no multi-agency agreements in place for the assessment and management of children with ADHD, schools can often only access support through education channels. Many children with undiagnosed ADHD are difficult to manage in the classroom so are likely to be referred to a pupil referral unit (PRU) and in some cases, it may only be when these specialist placements are on the verge of failure that a medical referral is made (Keen, Olurin-Lynch, & Venables, 1997). Place et al. (2000) looked at prevalence rates of psychiatric disorder within a primary school for emotionally and behaviourally disturbed children who were all in receipt of a statement of Special Educational Need (SEN) from the Local Education Authority (LEA). Using DSM-IIIR criteria (American Psychiatric Association (APA), 1987), the authors found that 70% of the children fulfilled diagnostic criteria for ADHD.
Further evidence of the need for greater collaboration between health and education comes from an Australian study which suggests that a significant number of pupils who are excluded, either for a fixed term or permanently, may in fact have a condition that is amenable to medical treatment, such as ADHD (Bain & Macpherson, 1990).
The importance of multi-agency collaboration in the assessment of children with neurodevelopmental disorders is not restricted to those with suspected ADHD. For example, Moore et al. (1998) emphasise the necessity of integrating both the health and the educational components of the assessment of children suspected of having an ASD. They propose that health-based ASD assessment services liaise closely with educational services to reduce the risk of any conflict occurring between the assessment of a child's educational needs and the diagnostic assessment. They recommend the incorporation of classroom assessments by educational staff into the health-based diagnostic process. In line with this, the Department for Education and Skills and Department of Health (2002) have produced a document entitled Autistic Spectrum Disorders Good Practice Guidance which recommends the development of multi-agency models for identification of ASD. The latter are also proposed in The National Autism Plan for Children (National Initiative for Autism: Screening and Assessment (NIASA), 2003) and the Autism Exemplar published as part of The National Service Framework for Children, Young People and Maternity Services (DoH/DfES, 2004), both of which set out a vision for what a good service for the child with suspected or diagnosed ASD should look like.