Saturday, June 24, 2006

What Would Mental Health Treatment For A Million Children Cost?

2 children: slogan is that sometimes parents forget to tell the children that it is OK if they are not shining stars
I took a speed reading course and read War and Peace in twenty minutes. It involves Russia.
Woody Allen pretty much sums up the level of media coverage and examination of the recent Child and adolescent mental health report (CAMHR). We had plenty of coverage of the 400 children who were swindled out of their World Cup Experience. We've even had an intervention by the Prime Minister that resulted in a much-publicised warm fuzzy outcome. Of course, it is easier to deal with that than to attempt to resolve our imploding public services, increasing crime, poverty, poor housing, the chaos of the classroom, the scandal of our care system and the many issues that influence the mental health of children. Yes, these are difficult issues, but this government was elected because of their emphasis on these issues: or was the manifesto nothing but a catalogue for a fantasy auction of extravagant promises (I am indebted to Wat Tyler for this metaphor)?

After the dispiriting news that 1 million children in the UK have a mental health or behavioural disorder that is severe enough to warrant treatment, I have been waiting in vain for a news programme or a newspaper to cost this treatment. In addition, I haven't seen any estimate of the social and financial costs of these mental health disorders among children and adolescents. I'm assuming that there are additional medical, social, educational, looked-after (e.g., fostering, care-homes) and (for an unspecified number) criminal costs (Police Cautions and Anti-Social Behavioural Orders aren't cheap: mostly an ineffective laughing-stock but not cheap). We need to know what these costs are before we can establish a baseline against which we can assess the costs of the programmes that are currently being run, programmes that may be extended, and some innovative programmes that are yet to be implemented.

Sure Start has already spent £3 billion since 2002 but to little approbation. The complexity of estimating placement costs for children is so great the Loughborough University has developed a special calculator package to take a number of variables into account. The report tells us that 45% of looked-after children have mental health problems: these may be exacerbated by the experience of what brought them into Local Authority Care and their placement. 68% of children of looked-after children are placed into foster care. A disproportionate number of looked-after children have educational problems. Because of the mix of agencies involved in funding the care of these children, it is not feasible to find a ready summary of the costs or even an estimate.

Children with a range of learning, conduct, emotional or behavioural disorders may be statemented and eligible for a Classroom Assistant (CA). However, spending on CAs is complex because some are paid for by schools, and some e.g. bilingual instructors/assistants or Learning Support/SEN Assistants may be managed by schools, and paid for from centrally held funds. Spending on Special Schools (for children whose needs can not be met, even with support, in the mainstream) is also complex. It is not entirely clear what happens to children who may have special educational needs but have never been evaluated for a statement because their Local Authority does not have the resources to provide a timely statement or the resources to meet any recommendations.

There is a report on Special Educational Needs in England: January 2006: it contains some interesting statistics but does not supply any costings or references to where they might be found. There is a proud assertion on pg. 7 of this document that the report is from National Statistics and is
produced to high professional standards set out in the National Statistics Code of Practice. They undergo regular quality assurance reviews to ensure that they meet customer needs. They are produced free from political interference.
Sadly, they are also produced free from grammar checks. See also on pg. 7
Pupil numbers shown in the tables are rounded to the nearest 10, therefore totals may not always equal the sum of there [sic] component parts.
Misplaced pedantry? Certainly, but assertions like that invite it and raise questions about the quality of the quality assurance reviews.

What do we learn about children with special educational needs (SEN) in England? In January 2006:
  • 1,293,300 (15.7% of)pupils with SEN across all schools do not have statements
  • 236,700 (2.9% of) pupils across all schools had statements of SEN
  • the incidence of pupils with SEN but without statements is greater for boys (approx. 1 in 5) than it is for girls (approx. 1 in 8)
  • the incidence of pupils with statements of SEN is substantially higher for boys than it is for girls
  • approximately 1 in 37 boys has a statement compared to 1 in 100 girls.
These are distressing statistics: for some of the schoolchildren involved, it is probably a distressing reality. What is the cost of the support that is provided? What is the cost of doing nothing, both for these children and their classmates?

Not all children with SEN will have mental health problems, and the reverse holds true; however, there may be a substantial overlap. For example, the CAMHR finds that:
60 per cent of all looked after children had some difficulty with reading, mathematics or spelling. Those with mental health problems were twice as likely to experience problems: in reading, 37 per cent of children with mental health problems experienced difficulties, compared to 19 per cent of children with no mental health problem. In mathematics, the figures were 35 per cent compared to 20 per cent, and for spelling, 41 per cent compared to 24 per cent. (p.g. 15)
Multiple agencies exist to address these problems and there is the perception that a lot of help is available: a lot of money is spent on these agencies although it is difficult to find a collated figure. There seems to be significant regional variation in resources. It is invidious to play off one group of needy children against another but there is the frequent criticism that it is the better-informed, more articulate parents who are the ones who can obtain a statement for their children (I don't know where people obtain the supportive statistics from, so I would be grateful for any pointers).

CAMHR tells us about the miserable overlap between educational problems and involvement in crime.
Although not a precursor to criminal behaviour in later years, there is a positive correlation between time lost from education and crime, with half of all male prisoners having been excluded from school. Many of these children suffer from conduct disorders and there is evidence that they may also exhibit problems with social understanding, and disorders on the autistic spectrum. However, these disorders often remain undetected...These children are therefore not receiving the necessary treatment...(pg 16)
The remainder of the paragraph tails off into the usual pieties without addressing the issue of whether or not there is an agreed treatment programme, and whether there are sufficient resources to deliver it.

Somebody, somewhere, on a relevant think-tank or committee, must have come up with an approximate cost of a portfolio of mental health interventions for children. There has been a lot of publicity about The Depression Report: A New Deal For Depression And Anxiety Disorders (pdf) that claims 16 one-hour sessions of cognitive-behavioural therapy (CBT) would cure half of all those with severe agoraphobia, obsessive-compulsive disorder, depression or anxiety, at a cost of £750 per person. There is even a summary of the proposal and its costs.
The report proposes a highly structured programme with 250 teams of specially trained clinical psychologists and psychological therapists. (Counsellors don't get the same results.) To reach the 800,000 who would benefit would take seven years and cost £600m; the money would be recouped from incapacity benefit savings.
The costs are crude, because at the examplar and examplary 50% success rate, the cost is presumably £1500 per successfully treated patient. And the costings/savings pre-suppose that the person is not working and in receipt of incapacity benefit.

However, at least the above is an attempt at costing a large-scale mental health intervention and discusses an implementation time-scale. I would like to see a comparable attempt at costing appropriate mental health interventions for children and a discussion of the time-scale of such a programme. The statistics in CAMHR indicate that children with mental health problems tend to live with adults with medical, mental health or social problems. A guess-timate would be that the child and at least one other family member may need a mental health intervention (let's ignore the issue of whether the CBT initiative would be appropriate here): so, that would be £1500, albeit the statistics indicate that the intervention would fail for one of them. Not all families would need 2 interventions, some would need more, others only the one; this is a working guess-timate. So, that would be an investment of £1.5 billion to offset against continued ill-health and the loss of revenue from children who go on to be unemployed, under-achieving, low-waged or otherwise living in poverty (it leaves out the savings from children who don't get involved in crime).

The SEN costs are harder to guess-timate. According to the NUT briefing on the costs of inclusion and Pupils With Special Educational Needs-June 2006 (pdf), the cost of the statementing process is between £6000-8000 per child. So, that's around £7.8 billion to £10.4 billion.

What is the cost of doing nothing and muddling on with the present provision? Although teachers welcome inclusion in mainstream classes, a specially commissioned study summarised in the NUT paper reveals that many teachers report such a lack of resources that they are providing "inclusion without education" with suspicions that inclusion is done "on 'the cheap'" (pg. 6). The study also reported that:
for many teachers the 'Costs of Inclusion' proved a very personal one. The strain of coping with the demands of pupils with acute SEN in an environment where there is little additional back up or outside resources to help proved all too much. Many either changed jobs or left the profession all together. (pg. 6)
The study describes a bleak situation for the teachers who remain.
Competitive market driven policies impact on the most vulnerable children and penalise the most dedicated teachers. The most striking aspect of this study is the goodwill of teachers who believe in inclusion and try to make it work but do not find their goodwill repaid by the level of professional support they deserve. (pg 7)
I give up at this point, I can't cost this, but somebody must be able to give a ballpark for this. Presumably, there are cascade costs for the general demoralisation of schools which may have an impact on the mental health of children.

Even where children have a statement of SEN, the recurring annual costs of support and re-assessment are not clear. I would be grateful for an estimate of this. However, so far, the costs of statementing and the costs of something like Layard's proposed CBT intervention are cumulatively between £9.3 billion to £11.9 billion. And this does not include the cost of SEN accommodations, social support, care costs etc. So, this may be the equivalent of being able to say that War and Peace is set in Russia and involves Napoleon, but at least it's more of a starting point than I've seen in the general media.

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