Mental health problems are the worlds’ largest economic burden (Mental Health Foundation, 2015), with mental health problems in children and adolescents being an ever-growing concern (Royal College of Nursing, 2017). It has been noted that 10% of children aged 5-19 years old suffer with a mental health disorder (Office for National Statistics, 2004; Public Health England, 2016) with approximately 850,000 children and young people in the UK having a mental health problem (Young Minds, 2016). This means that on average 1 in 3 school aged children will be suffering with a mental health disorder (Department of Health, 2015). It is also estimated that around 15,025 of Lancashire’s 5-16 year olds have a mental health disorder (Lancashire County Council, 2015). However, these national and local statistics are out of date and it is expected that these numbers will be significantly higher when the updated statistics are released.
Mental health problems in children and young people can be long-lasting and so children who suffer with a mental health disorder may go onto suffer more severely as an adult. It is also known that 75% of mental health disorders in adults began before the age of 18 (Murphy and Fonagy, 2012). Boys are more commonly affected by a mental health disorder, and the proportion of boys with a disorder was found to be 11% compared with 8% of girls, and nearly 10% of white children, 12% of black children, and 12% of Asian children were assessed as having a mental health problem (National Office for Statistics, 2004). Although boys are more commonly diagnosed with a mental health disorder, some disorders are represented more in girls, with a good example being eating disorders (World Health Organisation, 1993; PHE, 2016).
There are multiple mental health disorders that affect adolescents and children. Some of these mental health problems are eating disorders. This assignment will critically address the child development attachment theories of Bowlby (1969) and Ainsworth (1978), the social learning theory by Bandura (1986), and the sociological and psychological factors that contribute to child and adolescent mental health. Policy, legal and ethical issues will be discussed in relation to the impact that they have the mental health services available for children as well as initiatives and strategies that are in place to help and improve the mental health of children and adolescents. This assignment will focus on eating disorders, specifically anorexia nervosa.
Eating disorders are complex and serious conditions (National Eating Disorders Association, 2012; Beat, 2017; National Institute of Mental Health, 2018) that can lead to a person developing issues with their body weight and shape (PHE, 2016; Beat, 2017), and can arise from biological, emotional, psychological, interpersonal and social factors (National Eating Disorders Association, 2012). Eating disorders can cause a disturbance to the sufferers eating behaviours and attitude to food (PHE, 2016; National Institute of Mental Health, 2018). Over 725,000 people in the UK have an eating disorder (PHE, 2016; RCN, 2017), with eating disorders being on average eight times more common in girls than boys, and having an average age of onset between 16-17 years old (WHO, 1993; PHE, 2016), with symptoms in 62% of cases being first recognised before the age of 16 (Beat, 2017).
Anorexia nervosa is defined as deliberate weight loss of 15% or more of the weight for the persons age and height, which is intentional and has been both induced and sustained by excessive exercise, induced vomiting and purgation (WHO, 1993) and especially by restriction of food intake (American Psychiatric Association, 2013; National Institute of Mental Health, 2018). The disorder is associated with fear of fatness and weight gain (WHO, 1993; American Psychiatric Association, 2013) and patients view themselves as overweight, even when they are found to be severely underweight (National Institute of Mental Health, 2018). Sufferers often lack recognition of the seriousness of their low body weight (American Psychiatric Association, 2013). Anorexia is a self-harming behaviour which can lead to death, and has the highest mortality rate of any psychiatric condition seen in adolescents (Burton, Pavord, Williams, 2014).
Certain children may be at greater risk of developing a mental health disorder than others, and looking at child developmental theories may help assess which children are at the highest risk of certain disorders. Two theories of attachment and of social learning theory may be useful to look into. Attachment refers to the strong bond and personal connection that causes desire for contact and distress upon separation of an infant and caregiver (Burton et al., 2014; Crowley, 2017). The attachment theory was first mentioned by John Bowlby in 1958, and Mary Ainsworth developed upon his research in 1978 with ‘the strange situation’ study which assessed the attachment quality in 1-2 year olds. Bowlby (1969) claims that infants and small children are born with behaviours that leads them to seek close proximity to their mother or care giver. Bowlby (1973) also proposed that experiences of attachment that a child has in their early years leads them to develop their own mental representation of themselves. He concluded from his studies that prolonged deprivation of maternal care of a young child may have detrimental effects on their character and in their future (Bowlby, 1952), and so poor experiences of attachment may lead to a child developing a low self-esteem and can increase the likelihood of that child developing a mental health disorder (Lee and Hankin, 2009; Suzuki and Tomoda, 2015). The study by Ainsworth et al. (1978) which developed upon Bowlby’s theory highlighted the importance of the quality of attachment of the child to their caregiver, and how it can be affected by the parenting received. Ainsworth’s (1978) study concluded that sensitive parenting, where mother or caregiver responds to the child’s needs, will lead to the development of a secure attachment relationship, providing the child with security and confidence, while insensitive leads to the development of an insecure attachment, which doesn’t provide the sense of security for the child (Ainsworth et al., 1978). Development of an insecure attachment style in children may be detrimental to their mental health, which Canetti et al. (2008) and MacBeth et al. (2010) found, where individuals with a mental health problem display insecure attachment styles. Orzolek-Kronner (2002) looked into attachment styles between children with anorexia nervosa and their mothers and found that half of the children involved in the study claimed to have developed a closer relationship with their mothers after developing the eating disorder and showed proximity seeking behaviours. This suggests that children with insecure attachment styles may develop eating disorders to facilitate improving attachment between themselves and the parent, and incorporates Bowlby’s theory of a child being born with an instinct to seek close proximity to their parents, and the eating disorder achieves this need.
Albert Bandura developed his social learning theory in 1986 where he found that children learn and acquire new skills by observing others and imitating their behaviours, without the need of reinforcement (Burton et al., 2014; Crowley, 2017). Although not necessary, responses of others around the child towards their behaviours serve as reinforcers, which can either be negative or positive, but will also result in changed behaviour (Burton et al., 2014). Bandura demonstrated his theory in 1961 with ‘Bobo doll’ experiment (Burton et al., 2014), where children repeated violent actions against a doll after observing adults violent behaviours towards the doll (Bandura et al., 1961). Bandura’s theory may play a role in the development of a mental health disorder as a child ages, especially in young girls, as they may imitate the behaviours of role models and what they see in the media (Harrison and Cantor, 1997). Girls may also learn behaviours by watching and listening to their mothers or other family members complain about weight issues, and go on to imitate these behaviours (Canetti et al., 2008).
It is not known for sure what can cause a specific mental health disorder (Mind, 2016), but it is thought to be due to a combination of different sociological and psychological factors (Mind, 2017). An example of a sociological would be a child growing up in an unstable family, or with a single parent, which may lead to a lack of warmth and affection being shown by the parents to the child. This factor links to Bowlby’s (1969) and Ainsworth’s (1978) attachment theory as this may lead to the child developing an insecure attachment, and will not feel like they have safety or security (Ainsworth et al., 1978). If a child feels like home isn’t a safe or consistent place, they may begin to use food as a way of gaining more control over their life (Mind, 2017). Social media and cultural pressures may be a sociological factor which can contribute to a child developing an eating disorder such as anorexia (PHE, 2016; Mind, 2017). Social media and peer pressure surrounds children with ideas and images about unachievable ideas about how their bodies should look, and this can make children feel that though they are not good enough, which has a massive impact on their body image and self-esteem (Burton et al., 2014; Mind, 2017). These poor self-esteem issues are also sociological factors which can also form from insecure attachments developed during childhood as suggested in Bowlby’s and Ainsworth’s attachment theory as well as from these pressures from social media and peers, which can develop through watching other peers and family members behaviours as well as role models in the media (Harrison and Cantor, 1997; Canetti et al., 2008) which is demonstrated in Bandura’s social learning theory. Another factor that may contribute to the development of anorexia nervosa in children is their genetics as it appears in research currently being carried out that a person’s genetics can result in them being vulnerable to developing eating disorders (Mind, 2017), however there is no proof of this yet (Mind, 2016; PHE, 2016). So far research shows that your genes may impact your susceptibility of developing eating disorders (Mind, 2017), and neuroimaging shows differences in the structure of the brains of patients with anorexia nervosa (Lask, Frampton and Nunn, 2012; Burton et al., 2014). It also appears in some research that eating disorder patients have different amounts of chemicals that control hunger and appetite, such as serotonin, in their brains than others without an eating disorder, which may explain why these children will go on to develop the behaviours of an eating disorder (Mind, 2017). There are lots of theories and factors we can look at but not all children will be affected by the same thing. Each child’s mental health will be influenced differently to another child’s, and each child will go through an individual process. Every child has their own individual vulnerabilities and the tipping points for each child will be different.
Initiatives are in place in the UK to try to help improve children and adolescent’s mental health such as Place2Be which uses therapeutic interventions and works in schools to provide counselling to children during school time when they are available to get help, and have been found to be effective in recent studies (Lee, Tiley, and White, 2009). The Place2Be initiative may not address all issues though, as children who are receiving help from these services may receive labels by other pupils in school due to the stigma of counselling and mental health, and may prevent some children seeking help (Prior, 2012). This problem may be overcome with the initiatives to raise awareness about mental health disorders, with events like the annual Eating Disorders Awareness Week, run with the help of charities such as Beat and Mind.
Two policies we are currently working towards are Future in Mind (DoH, 2015) and The Five Year Forward View for Mental Health (The Mental Health Taskforce, 2016). Future in mind is a contemporary policy which looks into promoting resilience and intervention early on in development, as well as improving access to support and improving care (DoH, 2015). In the short term the policy hopes to work alongside the Department for Education to encourage the promotion of wellbeing and resilience in schools. A survey (Taggart, Lee and McDonald, 2014) found most secondary schools claim to promote positive mental health with 93% of schools fulfilling this in Personal, Social, Health and Economic (PHSE) lessons, 86% of schools having access to a qualified counsellor, and 98% of schools having pastoral care services (DoH, 2015). Although the policy proposes starting education about mental health early on in development by starting education in schools, and most schools report they are working towards this (Taggart et al., 2014), teachers are left with a lot of responsibility for promoting this policy, yet a lot of teachers are unaware of the policy (National Association of Schoolmasters Union of Women Teachers, 2017). As many as 46% of teachers claim to have never received any training on children’s mental health or how to recognise the signs of ill mental health in children, and only 24% feel that they would get the support they need from outside services such as CAMHS (NASUWT, 2017). The Future in Mind policy also looks to support parents to assist in building the child’s resilience from a young age and strengthening the attachment between them and the child, which supports the attachment theories proposed by Bowlby (1969) and Ainsworth et al. (1978), through improving health services and parenting programmes (DoH, 2015). One way that has been proposed to achieve this through the development of digital tools, allowing young people and parents access to safe and clear information (DoH, 2015). One of the digital tools is the MindEd e-portal, which can be used by children and their families to access information regarding child and adolescent mental health (DoH 2015). Another policy we are working towards is the Five Year Forward View for Mental Health, which builds upon the Future in Mind policy. This policy looks to achieve mental and physical health having equal importance to one another. One of the aims is to provide a ‘7 day NHS’ where there will be access to mental health care 24 hours a day, providing better access to support to those who need it, as the peak times for people to present an emergency with mental health crises are between the hours of 11pm and 7am, when current mental health services are generally unavailable (MHT, 2016). The Five Year Forward View for Mental Health: One Year On report (NHS England, 2017) reflects on the progress made so far in this policy, and so far, the report claims that ‘7 day NHS’ aim is not currently being met. Another aim of the Five Year Forward Policy is to fully implement the Future in Mind proposal for promoting early interventions for children’s mental health in schools and between the parent and the child (MHT, 2016).
Some of these proposals in these policies can be costly, and throughout, there is reference to needing additional funding for some of the proposals set out. Funding has been frozen or cut by as much as £600 million across local authorities’ children and adolescent mental health services (Mind, 2015; NHS Confederation 2016), which has led to about 1 in 5 children who have been referred by GP’s and professionals to be rejected from mental health treatments (NSPCC, 2015). Cuts to funding has also lead to children needing inpatient treatment having to travel far away from home, requiring families to need to travel long distances to see their children (MHT, 2016), which in turn results in the ethical dilemma of the child needing treatment losing their right to live with their families (UNICEF, 1989). Without any additional funding, it is unlikely that the proposals in these policies set out to improve children and young people’s mental health and wellbeing will be implemented, and the Five Year Forward View policy estimated that an additional £1 billion investment would be required in order to implement them (MHT, 2016).
Ethics are about working to principles and guidelines set out to keep a child safe, and Beauchamp and Childress (2009) laid out four ethical principles: Respect for autonomy, beneficence, non-maleficence and justice. Autonomy is an individual’s own choice and control over what happens to them (Beauchamp and Childress, 2009), and a patient must give consent to receiving treatment, regardless of what it may be. Consent is the voluntarily and informed decision given by an individual who has the capacity to make the decision about medical intervention for themselves (Beauchamp and Childress, 2009; Welsh Government, 2017). In the case of children’s capacity to give consent, they do not have the capacity to make the decision for themselves, then it becomes parental responsibility who has capacity to give consent to treatment (Department of Health, 2009; Welsh Government, 2017), and so in the treatment of children with anorexia nervosa, the child cannot give consent or refusal for treatment. The second ethical principle is beneficence where the best interests of the child are to be considered in relation to the Children Act (Great Britain, 2004). There is a struggle to find an ethical balance between beneficence and autonomy when it comes to children due to their lack of capacity (Koelch and Fegert, 2010). Non-maleficence is about avoiding doing harm to others (Beauchamp and Childress, 2009). Which works hand in hand with beneficence as it also considers the best interests of an individual. There are ethical dilemmas about force feeding children with anorexia as children with severe eating disorders may refuse to be given life-saving treatment, which may lead to having to use safe control and restraint techniques on the child (Royal College of Psychiatrists, 2012). Under the Mental Health Act (2007) feeding is recognised and the Mental Health Act can be applied as treatment for anorexia nervosa as a last resort, and can be done against the will of the patient as a life-saving measure (RCP, 2012). The dilemma with feeding come with the use of restrains as this may harm the child, but it is in order to do good and in the best interests of that child. Attempts are being made to improve the interventions used in the treatment of children considering both non-maleficence and beneficence (Koelch, Schnoor, and Fegert, 2007). The final ethical principle is justice and is regarding equality in the way people are treated (Beauchamp and Childress, 2009). This ties with The United Nations Convention on the Rights of the Child with the right for a child to not be shown discrimination or to be treated differently on any basis (UNICEF, 1989).
Treating anorexia nervosa in children and adolescents is complex and there are many policies, legislations and guidelines that you have to follow as well as considering the ethics around the treatments being given. As a society we are progressing with the treatment of anorexia nervosa with initiatives to promote positive mental health and awareness about the disorder. Looking at the risk factors of anorexia and the child development theories that could explain why children develop the disorder, such as insecure attachments and learnt behaviours, we can try and reduce the negative outcomes in these and lower the number of children affected by the anorexia, and lower the burden that the disorder has in society. There is still a long way to go with budget cuts still occurring and services being stretched, but if we strive to follow the policies set out for the next few years, we can hope to achieve better mental health in children in the UK.