School-aged Years

Why the School-aged Years are an important period

The Chief Medical Officer and Professor Sir Michael Marmot⁵⁰ have highlighted the importance of giving every child the best start in life, and reducing health inequalities throughout life. They recognise the importance of building on the support in the early years, and sustaining this across the life course for school-aged children and young people, to improve outcomes and reduce inequalities through universal provision and targeted support. There will be challenges within a child’s or a young person’s life, and times when they need additional support. Universal and targeted public health services provided by health visiting and school nursing teams, are crucial to improving the health and wellbeing of all children and young people.

Over the past 10 years, there has been significant research emerging around young people’s brain development. Puberty is a time of a major ‘second wave’ of brain activity, where the brain is developing its skills to make decisions, empathise and reason.51 At the same time, the body is developing its potential for fitness, physical strength and reproductive capacity.⁵²

What is the local picture?

The most recently compiled and published data is compared with other local authorities of similar deprivation, unless stated otherwise, as of April 2021.

Table 3: The School-aged years in Central Bedfordshire⁵³

School-Aged Indicator	Previous Period [Comparator IMD 2019] (Date)	Most recent available period [Comparator IMD 2019 or England] (Date)
Reception children age 4-5 overweight and obese (%)
	20.7 [22.6, England] (2018/19)	20.9 [23.0, England] (2019/20)
Year 6 children overweight and obese (%)
	28.6 [34.3, England] (2018/19)	29.7 [35.2, England] (2019/20)
Smoking prevalence at age 15 – current smokers (%)
	NA	7.1 [8.2, England] (2014/15)
School pupils with social, emotional and mental health needs (%)
	2.70 [2.36] (2019)	3.22 [2.60] (2020)
Hospital admissions: mental health conditions, under 18 years (Rate per 100,000)
	112.0 [101.5] (2018/19)	94.2 [100.7] (2019/20)
Hospital admissions: alcohol-specific conditions, under 18 (Rate per 100,000)
	24.4 [31.1] (2016/17-18/19)	37.3 [31.8] (2017/18-19/20)
Hospital admissions: substance misuse aged 15-24 (Rate per 100,000)
	111.7 [69.7] (2016/17-18/19)	120.8 [74.5] (2017/18-19/20)
Rate of hospital admissions caused by injuries in children (0-14 years) (Rate per 10,000)
	84.6 [87.5] (2018/19)	83.8 [81.4] (2019/20)
Hospital admissions as a result of self-harm in children aged 10-24 (Rate per 100,000)
	465.2 [446.2] (2018/19)	534.0 [457.9] (2019/20)
MMR vaccination coverage for two doses (5 years old) (%)
	90.7 [85.3] (2018/19)	92.1 [88.0] (2019/20)
Hospital admissions for asthma (under 19 years) (Rate per 100,000)
	99.3 [125.7] (2018/19)	104.9 [109.9] (2019/20)
First-time entrants to the youth justice system aged 10-17 (Rate per 100,000)
	94.1 [240.9, England] (2018)	118.3 [208.0, England] (2019)

Excess weight

Children with excess weight (either overweight or obese) are more likely to become overweight and obese adults, and have a higher risk of poor health, disability and premature mortality in adulthood. There is also a link between obesity and poor mental health in teenagers, with weight stigma increasing vulnerability to depression, low self-esteem, poor body image and maladaptive eating behaviours. Nationally, by the age of 11, almost a third of children are overweight or obese, and this proportion is predicted to rise if concerted action is not taken.⁵⁶

The National Child Measurement Programme (NCMP) measures children’s weight and height in their first year at school (Year R) and again in Year 6. The NCMP is used to identify children who are underweight, overweight and obese so that they can be offered support, as well as the data being used to monitor national and local trends.

In Central Bedfordshire, 20.9% of Year R school children were overweight or obese (‘excess weight’) in 2019-20 (similar to the England rate).57 In school Year 6, 29.7% of children were of excess weight (significantly better than the England rate).⁵⁸

In 2019-20 in Central Bedfordshire, there were 245 4-5 year olds, and 910 10-11 year olds identified who were living with overweight or obesity levels.

The impact of obesity on a child’s health, now and in the future
Obesity has a profound effect on children’s physical and mental health. It can frame children’s life chances – not just their health, but also their employment, opportunities.

Once established, obesity is notoriously difficult to treat. Children with obesity are 5 times more likely have obesity as an adult and are more likely to develop cardio-metabolic disease, some cancers and musculoskeletal conditions in adult life.⁵⁹

The causes of obesity are complex and multi-faceted driven by biological factors such as genetics, social factors such as the built environment and transport systems; values, culture and norms around eating; leisure centres and green space; education and schools; and poverty. Finally, obesity is influenced by commercial factors such as the production, supply, marketing and sale of high calorie sugar and fat foods. The combination of these things can lead to obesity.

As well as helping children and young people maintain a healthy weight, there is increasing evidence of the mental health benefits of exercise in children and young people. Regular activity helps children and young people to feel good about themselves and to concentrate better, as well as bringing physical health benefits.

Health inequalities
There is a strong association of deprivation with childhood obesity and being overweight. Families living in deprived communities experience multiple, interacting exposures to material, psychosocial and behavioural risks for childhood obesity across the life-course. Obesity prevalence is highest amongst some of the most deprived wards in Central Bedfordshire. This is consistent with the national pattern where children in the most deprived parts of the country are more than twice as likely to be obese as their peers living in the least deprived areas are.⁶⁰ This is sowing the seeds of adult diseases and health inequalities in early childhood.

What are we aiming for?
Nationally, the Government have committed to halving childhood obesity and reducing obesity inequalities by 2030.⁶¹ With the recent spotlight on obesity due to COVID-19, key actions include work on sugar reduction, food labelling, calorie and sugar reduction, restrictions on advertising and food promotions as well as the ‘Better Health’ campaign to help people lose weight, get active and eat better after COVID-19 ‘wake-up call’.⁶²

The causes of excess weight are complex and multi-faceted, driven by: biological factors; built environment and transport systems; norms around eating and physical activity; access to leisure facilities and green space; education; poverty; and the commercial and fiscal systems, which affect these. Tackling excess weight requires a whole systems approach to change the environment in which we are born, live, learn, play, work and age. Working with multiple partners including health colleagues, local planning teams and education the council has already begun to follow a whole system approach to identify ways we can change the local obesogenic environment.

The approach should be complemented by local weight management services. We need to maximise attendance of these services to effectively support those living with overweight or obesity including families, pregnant women and prevention work in schools.

School aged vaccinations

The delivery of school aged vaccinations by the Community and School Aged Immunisations team was severely affected by school closures due to the COVID-19 pandemic from March 2020. Social distancing, bubbles and school closures resulted in a more time-consuming and complicated delivery of the programme. The academic year (from September 2020) has been focussing on restoration and recovery and up until May 2021, uptake of Meningitis ACWY was 71.15% and Diphtheria/Tetanus/Polio 70.80% and the team continues to offer these vaccines both in school and community clinics.

‘Flu was the most challenging programme to deliver. It has a time-limited delivery model and staff had to work around all the complexities of school closures, social distancing, bubbles, pupil absence and parental concern. Uptake in 4-10 year olds for 2020-21 was 57.4%, slightly above the East of England average

Reducing health-related risk-taking behaviours

Adolescence is recognised as the most significant time for introducing behaviours that can have long term health impacts, for example, smoking and substance and alcohol misuse. Health during adolescence is strongly linked to educational outcomes, including attainment and employment.

Whilst most research is showing that risk-taking behaviours amongst young people are on the decline, there seems to be an upward trend of children and young people experiencing poor emotional health. There is also evidence of a link between risk-taking behaviours and poor mental health

Smoking

Smoking continues to be a major cause of ill health, particularly heart and lung disease. Many people start smoking as adolescents and some will continue to smoke into adulthood. However, across England, the number of young people who reported trying smoking has fallen and is now at the lowest levels since 2003.⁶³

Local data tells us that the majority of young people do not smoke and there are fewer young smokers compared to the England average; however, there has been an increase in ‘ever smoked at least once’ and a significant number are affected by second-hand smoke. Smoking tobacco is associated with an increased prevalence of all mental disorders, with smokers 50% more likely to suffer from a mental disorder than non-smokers are and more than twice as likely to attempt suicide. It is therefore crucial that people with mental disorders have appropriate access to support services.

The Stop Smoking Service specialist advisors offer free advice and support across Bedfordshire and Nicotine Replacement Therapy can be provided to children over the age of 12.

Tobacco remains the main cause of preventable morbidity and premature death in England.64 Beyond the
well-recognised effects on health, tobacco also plays a role in perpetuating poverty, deprivation and health inequalities.

Drug and alcohol misuse

Drug and alcohol misuse can have significantly harmful impacts on young people, beyond the immediate effects. This can affect educational outcomes, employment, housing, relationships, and increase the likelihood of criminal behaviour. There is also evidence to suggest that young people who use recreational drugs and alcohol are at risk of poor mental health outcomes, including depression, disruptive behaviour disorders and suicide. Cannabis and alcohol are the most common substances used by young people,⁶⁵ although there is evidence that young people also use new psychoactive substances (NPS), also known as ‘legal highs’.⁶⁶ Young people who misuse substances may be at a greater risk of both criminal and sexual exploitation and may be more likely to be involved in criminal and gang behaviour.

Nationally, the 2018 England survey⁶⁶ reported that 24% of pupils aged 11-15 years had taken drugs at least once, ranging from 9% of 11 year olds, to 38% of 15 year olds. 9% of pupils surveyed reported taking drugs in the month prior to the survey. Of those who had taken drugs in the past year, 33% reported taking cannabis only, however, 35% reported taking two or more types of drug. Data for England also showed that there has been a downward trend in the number of young people who drink alcohol,66 however 6% of children and young people reported drinking alcohol weekly, 11% reported drinking alcohol between fortnightly and monthly and 9% reported being drunk in the 4 weeks previous to completing the survey.

The Young people’s substance misuse treatment statistics 2019 to 2020 reported nationally⁶⁵ that:

There were 3% fewer young people accessing drug and alcohol services between April 2019 – March 2020 compared to the previous year
76% of those accessing treatment reported that they started using substances before the age of 15
37% of those accessing treatment reported a mental health need; this was higher in girls compared to boys (49% compared to 30%)
22% of young people in the service were affected by others’ substance use, and 21% were affected by domestic violence
Child Sexual Exploitation (CSE) was reported by 4% of those in treatment; this was more common in girls (10%) than boys (1%)

Findings from Central Bedfordshire Children and Young People’s Substance Misuse Snapshot, 2019:68

11.5% of those young people in Central Bedfordshire drinking alcohol do so at least once a week
A similar number of young people in Central Bedfordshire are admitted to hospital for alcohol-specific conditions than the national average

Findings from the PHE young people specialist substance misuse interventions69 – executive summary
report included:

44% more young people were in treatment compared to March 2019
89% of young people in the service were affected by one or more substance-specific vulnerability and 68% by wider vulnerabilities (Q3 2019/2020).
Almost a third of young people in the service were affected by others’ substance misuse
Locally, hospital admissions due to alcohol-specific conditions in under 18 or substance misuse in 15-24-yearolds are relatively rare but are the ‘tip of the iceberg’, pointing to wider substance misuse and its impacts.

Drug and alcohol services for young people

Aquarius Bedfordshire offers a range of confidential and accessible support, information, and advice to young people aged between 5 and 18 who use drugs or alcohol, and provides support for young people affected by someone else’s use, for instance, a parent/carer’s or sibling’s use.

An evaluation was carried out in 2018⁷⁰ to identify areas of best practice, and development for drug and alcohol support for children and young people.

Aquarius also offers drug and alcohol training to schools, and provides parenting interventions, sharing
evidence-based information to widen the support network available to children and young people. Children and young people are monitored through follow-up reviews after discharge, and those with complex needs receive treatment for longer to address these complexities in a ‘needs led’ approach.
Areas of development were identified, including working closely with schools to develop targeted PSHE lessons, and support drug and alcohol policy development. In addition, enhancing joint working protocols and improving use of technology in the service were identified as important development areas.

Sexual Health

As young people become sexually active, it is important that have easy access to contraception and sexual health services. Chlamydia is the most common, curable sexually transmitted infection in the UK. If left untreated it can cause infertility in both women and men. An effective screening programme for chlamydia aims to screen young people between the ages of 15 and 24 years, to achieve a detection rate of at least 2,300 per 100,000. This ensures that the programme is effectively targeting those young people at highest risk of infection.

Areas achieving this rate should aim to maintain or increase it. Such a level can only be achieved through the ongoing commissioning of high volume, good quality screening services across sexual health services and primary care.

While the detection rate and numbers being screened in Central Bedfordshire are below those recommended by Public Health England, positivity is within the recommended range (5-12%); therefore, the local programme is an effective approach in detecting positive cases. Optimal treatment and partner notification levels result in fewer untreated infections circulating in the community.

There is support for schools around contraception and sexual health in the majority of schools in Central
Bedfordshire. Targeted outreach work is delivered to young people identified as more vulnerable; this
includes looked after children, young people from areas of high teenage pregnancy, and young people not in employment, education or training.

Teenage pregnancy

Teenage pregnancy is a complex issue, affected by personal, social, economic and environmental factors.
Under-18 conception data includes all conceptions that result in either a live birth or abortion. Since 2009, there has been a 58% reduction in under 18 conceptions across England (2019).

The Integrated Contraception and Sexual Health service (iCaSH) provides an integrated contraceptive and sexual health service for all ages, including services specifically for young people.

To support young parents, there is a Support Pathway for Parents Under 20 in Central Bedfordshire. The
pathway offers all pregnant women under the age of 20 a range of support to improve their own outcomes, their partner’s, and their child’s.

LGBT+

As part of growing up, all young people will spend time exploring their identity and developing a sense of who they are. This will include thinking about who they are attracted to (their sexual orientation), how they feel about their gender (their gender identity), and the different ways they express their gender.⁷¹
LGBT+ (lesbian, gay, bisexual, trans and those questioning their sexual or gender identity) children and young people realise they are lesbian, gay, bisexual or trans at different stages in their lives, but will often know at an early age.

Growing up, LGBT+ young people face specific challenges in addition to wider factors that lead young people in general to face additional difficulties. These include homophobic, biphobic and transphobic discrimination, and a lack of support and inclusion in education, training and work.⁷² In addition, nearly half of LGBT+ young people are still bullied at school simply for being who they are.⁷³

Being LGBT+ can feel like an extra pressure for young people, particularly at school, depending on the
extent to which staff, peers and the wider school community are supportive. Creating an inclusive environment is a key part of making sure that LGBT+ young people feel welcome and valued in any environment.74 The principles around supporting LGBT+ young people are the same at any age. This includes helping young people to talk about how they feel, ensuring they are providing age-appropriate information to answer any questions they have.

Personal, social, health education (PSHE)

Today’s children and young people are growing up in an increasingly complex world and living their lives
seamlessly on and offline. This presents many positive and exciting opportunities, but also challenges and risks. In this environment, children and young people need to know how to be safe and healthy, and how to manage their academic, personal and social lives in a positive way. This is why high quality and effective Relationships Education has been made compulsory in all primary schools in England, and Relationships and Sex Education in all secondary schools; Health Education has also been made compulsory in all state-funded schools.

Mental health

Children suffering from mental ill health are at risk of poor physical health outcomes, poor educational
attainment, and are at greater risk of unhealthy behaviours such as taking up smoking.

There is relatively little data about prevalence rates for mental health disorders in pre-school age children, but by the time they reach school age, 1 in 10 children need support or treatment for mental health problems. This means that in a class of 30 schoolchildren, 3 are likely to suffer from a mental health disorder such as depression, conduct disorders, anxiety, and hyperkinetic disorders (e.g. Attention Deficient Hyperactivity Disorder).

Young people have been uniquely impacted by the pandemic and lockdown, with NHS research suggesting 1 in 6 may now have a mental health problem, up from 1 in 9 in 2017.⁷⁵

A whole systems approach will be needed to address the challenge and provide care and support to local children and young people in the wake of the pandemic. Addressing the priorities therefore needs to be a collaborative programme across the commissioning and provider system, inclusive of local authorities, educational partners and the voluntary and community sector.

Improving emotional health & wellbeing & building resilience

Good emotional health and wellbeing amongst children and young people promotes healthy behaviours, good attainment and helps prevent behavioural and mental health problems.76 Most children and young people are part of happy and healthy families, and their parents or carers are the providers of their emotional support.

Sometimes children and young people need extra support. Families, schools, local health, and social care organisations have a vital role in helping children and young people to build resilience and supporting them through life’s adversities. We are aiming for children and young people to have good levels of resilience to enable healthy relationships and positive life choices

The impact of COVID-19 on school-aged children

On the 20th of March 2020, schools in England closed except for vulnerable pupils and children of key workers. National exams were also cancelled for 2020 and 2021. From March 2020, remote education was rolled out to support children and young people to continue their learning at home. Remote learning became statutory from mid October 2020 for any pupils unable to attend school or college due to the pandemic.

During the coronavirus pandemic we have seen both increasing numbers and increasing acuity of children and young people suffering crisis, whether it is due to mental ill health, or related to learning difficulties and /or autism. This has included an unprecedented surge in the numbers of children and young people presenting with eating disorders.

There has been increasing pressure on CAMHS (Child and Adolescent Mental Health Services) Tier 4 beds, our local hospital paediatric beds and the CAMHS crisis teams. Young people are often admitted to a paediatric ward whilst awaiting admission to a Tier 4 unit. They also frequently present at A&E and are admitted to a paediatric ward in the event of a social crisis, family or placement breakdown. As well as being unsuitable environments for these young people, this also causes immense pressures on the acute paediatric staff. Due to the lack of Tier 4 beds we have also recently seen children and young people admitted inappropriately to adult mental health beds.

GPs are also seeing an increased number of children and young people with mental health difficulties and have less capacity to support these young people. Schools are similarly challenged with decreased resilience in the teaching and support staff leading to increased stress in the pupil populations.

Following the first lockdown there was a surge in mental health referrals when children and young people went back to school. It is expected this surge will continue, adding further pressure on services across the system that are already extremely stretched.

The national lockdowns in 2020-21 have led to children and young people losing their usual routines including walking to schools, clubs, PE and school meals and some are spending more time doing sedentary activities including an increase in screen time, consuming more calories and eating unhealthier food.

The significant reduction in face-to-face meetings, appointments and contact with professionals has led to fewer safeguarding concerns being raised and a potential increase in child sexual exploitation (which has become hidden) and online exploitation due to increased regular use of technology.

Priority areas we should continue to build on:

Schools must continue be supported to achieve good health, wellbeing and resilience for all pupils, including the most vulnerable, through a whole-school approach that includes high quality and effective Personal Social & Health Education, Relationships & Sex Education, Health Education and Physical Education.
Support parents, carers and families to access services to help build emotional resilience in children and young people particularly at transition points to develop the healthy behaviours that will continue in adult life.
Ensure that the details of services that support children and young people, parents and carers are clear, accessible and effectively communicated to all.
Create environments that promote physical activity and healthier lifestyle choices, and use the NCMP data as a measure to focus outcomes to tackle excess weight in children and young people.
Ensure excess weight is everybody’s business by working in partnership, and by developing a workforce, which is confident and competent in addressing excess weight.
Continue to use evidence from local validated surveys with young people to inform commissioning and provision of services.
Ensure easy access and promotion of contraception and sexual health services.
Ensure effective implementation of the Support Pathway for Parents under 20.
Children and young people are supported to transition between into educational stages and into employment and training.
Strengthen non-CAMHS offer, be clear about what’s available, increase capacity, and communicate clearly to primary care, schools and families.

Priority actions to deliver better outcomes:

Empower and educate communities to develop programmes to help tackle risk-taking behaviours.
Encourage co-production with young people (and their families and schools) in order to explore issues related to health and wellbeing and the impact that COVID-19 on access to services and support.
Adapt the CAMHS models to focus on higher risk young people and to provide more intensive community support – this may mean raising thresholds.
Rapidly explore the potential for step up and step down beds, intensive day care, inpatient provision and local bed management. This is a potential solution for the increased number of CYP needing intensive support for eating disorders.

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