Prevention and early intervention
- Every child and young person to have appropriate access to emotional and mental well-being support in school.
- Appropriate, evidence-based, parenting programmes should be available across Scotland.
- Evidence-based interventions to address behavioural and emotional issues in children and young people should be available across Scotland.
- Mental health support and treatment for young people involved in offending who have mental health problems should be available across Scotland.
- Mental health training for non-mental health staff should be available across health and social care services.
- Training in first aid approaches for mental health should become as common as physical first aid.
Prevention and early intervention are key to minimising the prevalence and incidence of poor mental health and the severity and life time impact of mental disorders and mental illnesses. Prevention and early interventions must be a focus of activity and funding.
Along with literacy and numeracy, health and wellbeing is one of the three core areas that are the responsibility of all staff in the school. All adults who work in Scotland's schools have a responsibility to support and develop the mental, emotional, social and physical wellbeing of pupils, as part of what is referred to as 'Responsibility of All'. To support this responsibility, Education Scotland provides training and professional development, as well as promoting good practice on positive relationship and behaviour approaches.
Making sure that children and young people are included, engaged and involved in their education is fundamental to achievement and attainment in school. That means ensuring that schools provide a positive culture for all students' social, emotional and mental wellbeing, and that appropriate pastoral care and access to educational psychologists is available. The school environment can then help children to feel secure, resilient, confident, supported, and ready to learn.
- Action 1 : Review Personal and Social Education ( PSE), the role of pastoral guidance in local authority schools, and services for counselling for children and young people.
- Action 2 : Roll out mental health training for those who support young people in educational settings.
Actions to support children and their families
A child or young person's wellbeing is influenced by everything around them, and by the different experiences and needs they have. The vision and practice of Getting it Right for Every Child ( GIRFEC) empowers those working with children and families to operate across professional boundaries to provide support and to identify and address need at the earliest opportunity to prevent problems escalating. The eight SHANARRI indicators can be used to identify what help and support a child or young person may need in order to improve their wellbeing and their mental health. 
For a child, good relationships, starting with early attachment, create the setting for good mental health and resilience. A key factor is the quality of the parent-child relationship. The Scottish Government has supported the roll-out of evidence-based interventions that support children and their families with behavioural issues, through the Psychology of Parenting Programme ( POPP).
To build on the success of POPP there is a need for a range of solid, evidence-based interventions for emotional, behavioural and/or conduct issues where a child would not be diagnosed with a mental illness, but could be helped by a psychologically-informed approach. This should include interventions to support children's parents or carers.
- Action 3 : Commission the development of a Matrix of evidence-based interventions to improve the mental health and wellbeing of children and young people.
- Action 4 : Complete the rollout of national implementation support for targeted parenting programmes for parents of 3- and 4-year olds with conduct disorder by 2019-20.
Adverse childhood experiences, including sexual abuse
Understanding and addressing Adverse Childhood Experiences ( ACEs) is important to children's current and future mental health and wellbeing. Universal services - for example, health visitors, midwives, and school nurses - can play a role in helping to reduce the incidence and impact of ACEs and in supporting good mental health, prevention and early intervention, especially for vulnerable children and families. This role can be maximised by ensuring the workforce are ACE-informed and confident in the early identification of risk factors and of symptoms of mental ill-health.
The Scottish Government has commissioned NHS Education for Scotland ( NES) to develop a National Trauma Skills and Knowledge Framework and a National Training Plan for practitioners. Prevention of future abuse and increasing the safety of those currently affected by abuse and trauma - both adults and children - will be a central theme of both of these pieces of work.
Children and young people may be affected by parental substance misuse. The Scottish Government will fund a response to the recommendations of "Everyone has a story" which supports innovation and good practice in supporting children and young people affected by this issue.
It is crucial to consider the mental health needs of disabled children and young people. Some will be disabled because of mental health conditions that impact on their lives, while others will experience poor mental health as a result of their physical impairment or long-term condition, including where that is not a disability. Children with physical health conditions may experience four times greater anxiety, low mood and psychological distress than others and are at greater risk of mental health difficulties.
Appropriate treatment and facilities, as well as support for families and those caring for them, are vital. The Scottish Government will ensure that its Framework for Supporting Disabled Children, Young People and their Families makes clear links to the ambitions in this Strategy, and that mental health issues for disabled children, and for young people and their families and carers, are given consideration during the engagement and development process for that Framework.
It is important to note that amongst infants, children and young people, the highest rates of mental ill-health occur in those with learning disabilities and those with autism. Unless appropriate treatments and services are available then health inequalities will widen. Integration Authorities and Local Authorities will therefore need to understand the mental health and wellbeing inequalities experienced in their areas and plan the delivery of local services to reduce those inequalities, to remove barriers to health, and to ensure improved outcomes. 
Looked after children
NHS boards are required to provide all children and young people who become looked after with a health assessment within four weeks of notification. Alongside this, it is important to respond appropriately to the emotional distress linked to both the circumstances that led to the child becoming looked after and the experience of being looked after in any setting.  Professionals working with looked after children and young people should have the necessary knowledge and skills around issues linked to trauma and attachment. Consideration should also be given to the transition period from being looked after to being established as an independent adult.
There are particular issues for young people on the edges of, and in, secure care to ensure that systems work well together for the child at the heart. It is crucial that mental and emotional health and wellbeing needs are considered throughout those systems to help improve outcomes for children and young people.
- Action 5 : Ensure the care pathway includes mental and emotional health and wellbeing, for young people on the edges of, and in, secure care. 
Children involved in offending
Children and young people involved in and/or at risk of offending may have mental health problems, but not necessarily a mental illness. Work to address offending must take account of, and address, mental health issues as part of improving outcomes.
The youth justice strategy "Preventing Offending: Getting it Right for Children and Young People (2015)" identified a need to improve understanding and enhance capacity in relation to mental health and trauma, through practice development and supporting services for young people - all as part of a preventative approach to reducing offending. Work on this will be supported by partners including the Centre for Youth and Criminal Justice, and the Youth Justice Improvement Board. It will include work to support practitioners who are managing children, as well as early intervention approaches.
- Action 6 : Determine and implement the additional support needed for practitioners assessing and managing complex needs among children who present a high risk to themselves or others.
- Action 7 : Support an increase in support for the mental health needs of young offenders, including on issues such as trauma and bereavement.
In the 2011 Census, 4% of young carers said they had a mental health condition; this compares with 1% of non-carers. When Integration Authorities and Local Authorities prepare the young carer statement as part of the Carers (Scotland) Act 2016, (which will be commenced in April 2018), they should take into account the mental health and wellbeing of young carers.
Understanding Child and Adolescent Mental Health Services
Child and Adolescent Mental Health Services ( CAMHS) are usually planned and provided around a 4-tier model, as illustrated in Figure 1. A characteristic of the model is that child and adolescent mental health specialists will usually offer consultation and support to the teams and individuals working in the generalist and community-based tiers.
Figure 1: CAMHS Tiers Diagram
It is extremely important that services and staff are available to treat our most unwell children and young people. At the same time, children and young people who have mental health problems but are not ill, or who have behavioural or emotional issues, may benefit from preventative or less intensive services. Improved support at tiers 1 and 2 could have the potential to tackle such issues earlier and stem the flow of referrals to the more intensive tiers 3 and 4.
Work on child and adolescent mental health, and work on progressing Child and Adolescent Mental Health Services, must address both elements. There is therefore a need for a multi-agency, whole system approach to planning and service provision so that the different tiers function together effectively. The Integration Authorities or Local Authorities working with their NHS Board, as appropriate, will be well placed to do this.
- Action 8 : Work with partners to develop systems and multi-agency pathways that work in a co-ordinated way to support children's mental health and wellbeing.
Part of improving support at tiers 1 and 2 is having a workforce that is confident in dealing with mental health issues. To help this, mental health-informed training programmes should continue to be offered. Taking part in such training can, for example, build the confidence and capacity of front line staff in non-mental health services (such as health visitors, midwives, school nurses and teachers) to support good mental health and wellbeing, and can help to ensure that their responses to distress are sensitive and well informed.
Accessing treatment in Child and Adolescent Mental Health Services is discussed in the following chapter.
Further and Higher Education
Students of further and higher education face some unique challenges, but we want to ensure a consistent level of support for mental health across the country. These education settings also provide opportunities to help address stigma and discrimination, and support efforts towards self-management.
Working with the NUS, we've supported their 'Think Positive' project and we will work to explore how this can be developed and built upon in the coming years, particularly for the most vulnerable students
- Action 9 : Support the further development of 'Think Positive' to ensure consistent support for students across Scotland.
Mental Health and the Justice system
This Strategy does not just focus on traditional mental health services. In comparison to the general population, the prevalence of mental health problems among those in contact with the justice system is high. Mental health issues commonly co-exist with problem substance use (alcohol and drugs), chronic physical health conditions, learning difficulties, and homelessness. Relationships with families and other supports may be limited or absent. The transition from prison back to the community is a particularly high risk period for people's mental health, and continuity of care is important.
There are many opportunities to develop and improve actions that promote good mental health for people who come into contact with the justice system as a result of their offending behaviour, or who contact the police in distress. The Justice Strategy, due to be published shortly, explicitly frames the challenge of the 'relatively poor mental health and wellbeing of those in the justice system', making reference to the prevalence of mental health and addiction problems for those in police custody, in prison and leaving prison. It makes clear that justice agencies are commonly dealing with situations where the main issues are mental health and distress where no offence, or only a minor offence, has been committed.
In response to this challenge the Justice Strategy sets out a priority to 'work with others to improve health and wellbeing in justice settings, focusing on mental health and addictions' and more broadly describes a partnership and prevention approach to supporting those with mental health problems. The Justice Strategy identifies the need to learn from and build upon the innovative approaches such as Community Triage, THRIVE and Distress Brief Interventions that are currently underway in this area in order to deliver improved, evidence-informed responses in the future. The Justice Strategy also acknowledges the need to ensure that interventions for victims and offenders are informed by understanding of the impact of trauma.
In the 10 year Strategy for policing in Scotland (to be finalised in Summer 2017), Police Scotland has highlighted that it will work with partners to intervene early to address high impact issues such as mental health problems. The following examples illustrate some of the improvement work already underway:
- Police Scotland Safer Communities, in partnership with NHS Health Scotland, has developed mandatory training packages for officers and staff to raise awareness of mental health distress and suicide intervention. Police Scotland is also the first police force in the UK to introduce mandatory mental health awareness training for its workforce.
- The Community Triage service provides police officers with out-of-hours telephone access to Community Psychiatric Nurses, who offer professional support to both police officers and to those in distress. It was piloted in Glasgow and Edinburgh and is gaining ground elsewhere.
- The National Co-ordinating Network for Healthcare & Forensic Medical Services for People in Police Care will be consulting on draft guidance in 2017 with a view to improving the quality of mental health services for people detained by the police.
- The National Prisoner Healthcare Network works closely with partners in Health, Justice and the Third Sector to support the health inequalities agenda and to reduce re-offending. 
- Action 10 : Support efforts through a refreshed Justice Strategy to help improve mental health outcomes for those in the justice system.
Responses in emergency care and in the Blue Light Services
Adverse experiences can lead to poor mental health, and people in distress often present to frontline services, such as the police and at Emergency Departments. In 2016, the Scottish Government launched a Distress Brief Intervention programme, to test out a new approach to provide better support to people presenting in distress but who do not require further emergency service involvement. A national host is working with a small number of pilot sites across Scotland. A development year is underway, with service provision to begin from Summer 2017.
Integration Authorities and their partners also have a major role to play through the provision of services which can protect against adverse experiences occurring and help to mitigate their effects when they do occur.
- Action 11 : Complete an evaluation of the Distress Brief Intervention by 2021 and implement the findings from that evaluation.
Good Mental Health For All
We have endorsed Good Mental Health for All, published by NHS Health Scotland in 2016. Integration Authorities, Local Authorities, NHS Boards, the Third Sector and other community planning partners can use that document and plan partnership action to tackle the determinants of mental health and the causes of inequalities in mental health.
If inequalities are to be tackled successfully, it will be important that local partnerships use good data about the make-up of their communities and ensure appropriate targeting of actions to address issues for those most at risk. As an example, in-work poverty can contribute to inequalities, which affect people's mental health. Promoting Fair Work and the real Living Wage can contribute to tackling in-work poverty. We will continue to work with COSLA and other partners to promote Fair Work and the real Living Wage.
The challenge presented by isolation is keenly felt by many in our rural communities. The National Rural Mental Health Forum has been established to help people in rural areas maintain good mental health and wellbeing.
This forum will help develop connections between communities across rural Scotland, so that isolated people can receive support when and where they need it.
- Action 12 : Support the further development of the National Rural Mental Health Forum to reflect the unique challenges presented by rural isolation.
Stigma and discrimination
Where people do not feel welcomed, or do not see themselves represented, it can be hard for them to open up about mental health problems or to believe they will be listened to. Differences in ethnicity, sexuality, or gender identity, for example, should not be barriers to receiving high quality services to treat mental health problems.
The SeeMe programme has proven vital in efforts to promote anti-discrimination and we will ensure that it continues and develops.
Mental Health and Housing
Evidence shows there is a strong link between poor mental health and people experiencing housing problems and homelessness. Poor quality housing may also affect people's wellbeing. Housing services alone cannot prevent homelessness or address housing need. Early preventative mental health interventions are needed and Integration Authorities and Local Authorities have significant opportunities to develop joined-up policy and service provision in this area.
To help staff in housing - and staff in other groups who may be the first point of contact for vulnerable people - it's important that staff feel confident in dealing with mental health problems, just as they might with a physical health problem. That means knowing what to do and what their limits are. Training such as 'first aid' in mental health can help here.
We will also ensure that the provision of evidence-informed, quality assured training programmes on mental health, for non-health workforces is supported and continues.
Tackling inequalities in unscheduled care
Research shows that people with a mental health problem are more likely than others to have the maximum wait of four hours in Emergency Departments breached.  Pulling Together, the National Review of Primary Care Out of Hours Services, declared that psychiatric urgent care and emergencies must be prioritised no less than physical health presentations.  Too often, people with mental health needs experience longer waits in out of hours services than people with physical health needs. This is unacceptable and is a basic issue of parity in healthcare. Addressing it will help in delivering against the right to the highest attainable standard of health, as well as delivering on non-discrimination and equality in a human rights-based approach, and helping to achieve both parity of esteem and treatment.
Some mental health services are community-based, so improvements in the response to unscheduled care presentations need to focus on the community as well as on hospital sites.
- Action 13: Ensure unscheduled care takes full account of the needs of people with mental health problems and addresses the longer waits experienced by them.
- Action 14: Work with NHS 24 to develop its unscheduled mental health services to complement locally-based services.
The Third Sector
The Third Sector plays a crucial role in supporting people, in providing services, in developing research, and in policy development. Support to the Third Sector can also help in achieving, for example, Participation and Empowerment in a rights-based approach, because of the role that the Third sector often plays within communities, at the local strategic planning level, and in national policy development and legislation. The Scottish Government will consider how its support to the Third Sector can help build capacity in local areas for effective partnerships between Third Sector bodies, between the Third Sector and public authorities, a strong mental health Third Sector Interface, and to support continuing development of recovery-oriented services.
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