We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hello. I'm Mina Fazel, and I'm going to be talking about the networks of care for the modern adolescent. This is quite an exciting analysis that we have conducted on data from the OxWell Student Survey. And I'm presenting findings from a new publication done in collaboration with Emma Sanderson and Simon White, as well as the broader OxWell Study Team. What I'm going to do is talk through what the OxWell Student Survey is so you understand where the data came from, and then present the networks of care to you. I'll talk you through some of what we call an anchored analysis, or more focused analysis, and then share some conclusions. So first of all, what is OxWell? What do we ask? How do we run it? Why do we do it? So the OxWell Student Survey is a survey that, in 2023-- which is the fourth time we've run the survey-- asked between 200 and 350 questions. Now that difference is because sometimes if you answered yes to one question, you're then invited to ask a few more questions to clarify what you've said yes to. In 2023, over 40,000 students participated. We ask about mental health, risk behaviours, school experience. And over 180 primary and secondary schools participated in school years 5 to 13 in England, which corresponds to around ages 9 to 18 years. So this analysis will be focusing on the secondary school survey, which is over 20,000 students. We also send reports to schools. We're really keen that this data isn't just used for researchers, but is really also a value directly to the students by giving information back to schools. So we never try and identify students. It's an anonymous survey, so we don't ask names, date of birth, their addresses. We really don't want to be able to look at an individual child and say, oh, that's what they said. That's absolutely not the survey. Which is why this is the fourth wave of a repeated cross-sectional survey. It's not a longitudinal survey. We work very closely with our local authority partners. So the local authority, for example, in Oxfordshire or Liverpool, then invites all their schools to participate. And that way we hope, also at a broader level, services look at the results and make changes. And that's why the networks of care is such an important analysis for us, because it's looking and informing those things. We also run a survey for non-mainstream students. So this was the fifth wave, started on February 24th of 2025, so that's recently for me, recording right now. And this just shows with each wave, we've had a different focus and different numbers. And in 2023, the results that I'm presenting to you come from these main sites, which are mainly Liverpool, 17,000 students, Oxfordshire, 8,000 students, Berkshire, 12,000, and a few other areas. On our website, you can see some of the broader activity responses and our framework, which is, we really feel that it's really important to think about children's development and their networks of care, really. With this public mental health lens that Emma and I have written as part of what we describe as this interactional schema where children exist in an interpersonal world, a community world, and an institutional world, and our networks of care we present along these lines of what we then call informal, semi-formal and formal. And schools really lie at the heart of these three important worlds, which is why we focus so much on schools. So OxWell asks on a range of different areas I'm not going to go into in detail now. And we run the survey through the local authority working with schools and give early reports. This is what it looked like-- questions like that. And each school gets quite a detailed report on all the areas. So we use it to really encourage inquiry by providing a data platform. So everyone can look at their data, to give immediate reports to schools, to give commissioners information as part of their planning, and to inform city-wide approaches like for example, in Liverpool. So the strengths are, like I've said, that it's not trying to identify young people, so hopefully they're going to give more accurate responses than they would if they were worried they would be identified. We think this helps us get sensitive questions-- so have you self-harmed? Telling us more accurately about their mood. We can be responsive to current issues, and also to improve provision by getting data in a way that's useful for schools and for services. Our weaknesses are many, but we've been quite opportunistic in how we've developed, so never really had a good stream of funding, because we've always been more responsive. And it's cross-sectional, so we can't link to broader data. So just to give an example of how Liverpool, for example, use the survey, they asked young people-- initially, they showed them the results and said, what should we do? Really important. And then embedded it within public health, within education, broader third sector collaborations, and with mental health services and other broader health services. So finding data to be useful across the board. So this brings us to what I want to talk about today, and that's something we've called the Networks of care for the modern adolescent. It's a paper that was published in Psychological Medicine in 2024, and is a result of many years of work of us trying to understand how best to understand how young people access care, and how it can help inform provision. So in 2023, what we asked with regards to this was, in the last year, have you received mental health support from any of the following-- friends and family? So that's the first important network-- what we're calling the informal network of care, focusing on that interpersonal realm of that schema I showed you. You could take as many as you wanted within that-- parents and carers, siblings, friends, friends in person, friends online. We're also really curious about the new reality of especially young people, that there's this online world, and this in-person world. Often they intersect and interact, and sometimes they don't. So we're really trying to unpick those. So then we also asked about what we call these semi-formal networks of care. So in the last year, if you access any of the following different types of mental health support from school and community sources, and we list them. And then finally, the formal networks of care. So mental health services, other health services, social care, other thoughts of-- other sorts of more formal therapeutic work, like seeing a psychologist, maybe not as part of statutory provision. If they ticked any of these boxes, then we ask the young people, was it helpful? And they had five different options. Not helpful-- I mean, not helpful at all, not helpful enough, just about helpful, quite helpful, very helpful. And we then looked at the data like that. So this is the first main bit that I want to highlight. Well, beyond the fact that we're looking at multiple different networks-- informal, semi-formal and formal-- but we're also-- and that is about access or accessibility. Then the really important question, from my perspective, is it acceptable? So it might be accessible, but young people might not go to it. If they go to it, how do they find it? So these are all really important implementation questions. So this follow-on question, how helpful was it, is, I think, essential for us in understanding the reality and experience of young people. So I'm now going to show you our main network of care. So it's quite complicated picture, but I'll talk you through it. So this is taken from data from 23,000 secondary school students who answered this question. So in this, we split the informal, semi-formal and formal up by the shapes of the box-- the shapes. So the circles are informal. So you can see in the middle you've got carers, friends in person, friends online, siblings, and a non-school adult, and other family. So those are all your informal system of care. They're the system of care of that for millennia we've had. That's why many people invest in their friendships. That's why we keep going back to our friends, because we're a system of support. Informal support-- essential support for many people, not for everyone. Those in squares are the semi-formal. So school, peers in school, and then websites and helplines, and third sector and charities as well. So in the top here in this square, there's something called EMHP, which is an English initiative for educational mental health practitioners that are going into schools. So we've asked about this specifically, but they only mean something to the schools participating in that programme. School MH means school mental health. So we've got these different systems of care now mapped in this big network, and the hexagons here are the formal systems of care in England. We call these Statutory Provision of Social Care. CAMHS is at the bottom here, is Child And Adolescent Mental Health Services-- so that's the statute NHS provided mental health care for children and adolescents in England. So these lines between them show how often young people will-- if they say they've, for example, gone to their carer, how often they will then also go to other sources of support. And this network is mapped so that the responses that have been given most frequently are more in the centre, the ones less frequently further out. And for subsequent networks that I show you, we're going to stick to this model so that those providers will be within the same positions. So these networks show how often young people will seek support with other systems of support. And then I want to highlight the different colours. So the darker the green, the more helpful the young people who'd access that source of support have then found it. So this dark green in the middle-- carers, friends in person, friends online. The squares and then the hexagons have somewhat different shaded colours. So for example, these help lines are not being perceived as helpful as, for example, another school adult. They're also sought less, so they've gone to them less. For those that go to them, though, they're not perceived as that helpful. So this is our main network of care. So of the young people we present, 27% said that they had accessed some sort of support for their mental health care. So this is a large number. And 15% had accessed two or more types. So this is why it's important to think about provision as a network-- as interconnected systems of care. So because we have such large numbers, we can then look at these networks in different ways. So on the left here, we've got the network I just showed you, of everyone. And on the right, we've got that for girls. So it's not really that different if you just eyeball it, I think. So some things are coming out as slightly less helpful, but in a way. So the total sum was 23,000. Of those that said they sought support, 12,000 were girls. So we've got slightly higher representation of girls in the network than boys, but you can see there's not that much difference. So now I'm going to next present boys, and I'm going to present the group of young people who either didn't tell us their gender-- that's what we call gender non-disclosing-- or who identify as gender diverse. We've put those two groups together because in so many of our analyses, they fall into similar patterns of risk. So on the left here, we've got boys. About 10,000 said they'd sought some help. And then on the right, we've got gender diverse and gender non-disclosing. And I'm just going to spend a little bit of time going through this. I first want you, in a way, to think about your own conclusion about this if you look at it, and what you conclude. So if we look at boys, my conclusion is if a boy seeks help, they've-- in general, find it quite helpful. So on one level, it might not be as important to them where this help is sought. Once they seek it, once they've got over the barrier of accessing care, it seems to be relatively acceptable to them. They find it helpful. Now, with the gender diverse and the gender non-disclosing, we're presenting results from over 1,000 young people. So that's really powerful in the first instance, because that's really important data for which we're incredibly grateful to the young person for trusting us with. So we haven't really done statistical analysis with these differences, because I don't think that's necessary or meaningful. Because the eyeballing in these situations is sufficient. So everyone's going to see different things in these networks, but I'm going to tell you what I think. So the first thing that's quite interesting for me is that the lines-- these networks-- are so much more profound than if, for example, you compare it to boys. So my interpretation of this is that young people who identify as gender diverse or gender non-disclosing are seeking support for their mental health needs in many, many different places. It's not as if they're just going to one space and finding that helpful. It seems like these are individuals who are looking everywhere, but not necessarily perceiving the care they receive as health. There are some things that are clearly perceived as less helpful. So as we move into more formal provision-- so semi-formal. So if you look at the education mental health practitioners who are practitioners that go in to school, the boys find helpful when they access. The gender diverse group and not the helplines-- really not being perceived as helpful. Formal services, CAMHS social care-- again, not being perceived as helpful, actually. Really, really not being perceived as helpful for CAMHS. And the importance of friends in person and friends online for this group, who are really searching everywhere and unable to identify places that are helping them. So we can then look at this in much more detail and say, what types of support are these young people accessing? What do they find helpful? And then talk to commissioners, talk to mental health service delivery, and start thinking about well, what should we invest in? Maybe we should be thinking about different areas or focusing on certain places, because this is where they're going anyway. Look at this. Look at the charities here. This hexagon for charities is really perceived by these young people as helpful. Also, these other adults who aren't in school. And so, the importance of these community networks for populations who might not be perceiving more mainstream provision that acceptable. We could also look according to neurodivergence, which I won't go into detail, but we put this in-- if we publish it, we look according to whether you feel you belong to your school, because we're quite interested in understanding belonging and its relationship with mental health. So if you feel you belong at school, how you basically might perceive most systems of support as helpful. And if you don't feel like you belong in school, how actually these informal networks are so important. And as we head towards more formal, semi-formal, formal provision, they're perceived as less helpful by young people. And in the paper, we present according to ethnicities, in different year groups we've split up by key stages, so we're able to really sit and understand. We want to really improve services for this group. What can be done? So the last analysis I'm going to show you is what we're calling a focused analysis, or our anchored analysis. So what we did for this is we looked at the answers to the question. For those that said that they had gone to their carer, and they had perceived their carer as helpful, we asked them-- we looked at what else they found helpful. So a lot of people looking at this, and thinking about the importance of attachment relationships with this. But we can look at it in many ways. And this is really for adolescents, so it's understanding this. But basically here, if you perceive your care as helpful, it seems like perceiving most of the network that you might also access as helpful. Look at the perceptions of formal provision-- these hexagons of therapists, GP, CAHMS, are being perceived much more helpful. The network also isn't that strong, so perceiving care as helpful, it might be that you're better able to perceive the nexus of support, and that might be sufficient. Then we've done an analysis where if you went to your carer-- so many young people might even go to their care because they know-- before they've even gone, they might not see them as helpful. But for those that go to their carer and don't perceive them as helpful, we then look to the network to see what they then saw as helpful. So if you went to your carer and you didn't perceive them as helpful-- look at this network. It's is very, very different. So basically, like most people are-- and other providers are not being perceived as helpful. Friends take on a really important role here. Look at this-- this box of school adults. So this is not formal provision of mental health support in schools. So not the partial care worker, not the EMHPs. These are other adults in the school. So this is like the individual that young person chooses they want to talk to. There might be a teacher they like, or some other member of school staff. Then, how important it is, when we're thinking about provision, to think about the whole network. We can't just say, OK, we're going to reinforce the mental health counsellor at school, and that's going to address all our problems. No. Because actually, if we look at vulnerable populations, they're seeking help in different places, and in different ways, and we really need to respect that. And look at the importance of friends for these groups. So what I take away from this is two things-- one is, what are we doing for parents of adolescents to help them be perceived by their kids as helpful? Because that's something that they might need support for. And then, well, what are we doing to provide support for young people who don't want to go through formal systems of care, but still require access? So what provision are we giving to young people who don't want their parents to know, or to be involved? What support are we giving to the friends, who are basically the biggest system of support in schools? Are we providing support? Are we saying, we're not going to ask them to identify the friend they're worried about? If you want to come and talk, we're available to you. So we've done this for those that find school support helpful, and school support-- school mental health support not helpful. What else did they find helpful? And look, these friends are important. And then here, this anonymous online support then shows. And again, the CAMHS. So I've got two more slides, but I'm not going to go too in detail. But just to say we've also looked at the question of where would you prefer to access mental health support. We've looked at that according to gender, and for the gender diverse population as well. We've asked about would you prefer to be seen at school, or at home, or you don't know. So we're able to look at that in more detail. And then a really big piece of what we're looking at is, why didn't you access support if you wanted more? So we also asked, do you wish you could have accessed more support, and why not? And some of the barriers to accessing care, including really the prominently not wanting parents to know. So in conclusion, we really need to ask and think about accessibility. So where young people can access care, but also acceptability of that support to young people. Did they find it helpful? It's not good enough just to be accessible. We really have to maybe co-produce with young people to make sure it's also acceptable. We need to really understand that these informal networks of care are important. They're the mainstay of mental health provision. What are we doing to support that, to facilitate that? And that we need, in services, to understand that adolescents seek multiple sources of mental health support, and that when we're designing them or we're thinking of changing them, we cannot do this in isolation. We need to be thinking, well, those that come to camp, where else are they going to? So if we change this, how might it affect these other networks? And actually, if we're changing this, why don't we work together with the networks? But also, finally, and I suppose the most important thing-- I've said everything is most important. But another one of the many important things, is the importance of deliberate design of services tailored to the most vulnerable. So if we know, and with the OxWell, we're so grateful for students for completing it because we have these large numbers. We're able to see that these certain, more vulnerable groups of young people-- whether it might be those with severe depression, might be those with eating disorders. We can look at their networks and start to tailor our provision in order to meet what is deemed by these groups as most accessible and most acceptable. So if they only want to access support outside of school, then we understand which ones they're more likely to look at, and we can then actually design our services informed by these networks. And that's the strength of the large sample. So this is work that so many people have been involved with. Unbelievable young people who've trusted us by answering the questions. The schools that put so much time into running the survey, and the local authority partners who support it, look at it, work with us really closely. An unbelievable team of people. In the box there is Simon White, who really created these networks in a way that has really made it helpful for us to understand. So thank you very much. [MUSIC PLAYING]