Behind the headlines:
the mental health of children and young people
We often see alarming news stories about the mental health of children and young people, but how helpful – and how accurate – are they? Professor Tamsin Ford summarises a major NHS survey.
‘Mental health of children and young people in England 2017’ was published last November. A major national survey, it suggests that one in eight 5 to19-year old in England has a clinically impairing mental health condition. All teachers should be interested as this equates to three pupils in an average UK class of 26. Additionally, most recent reports about mental health in young people draw on brief questionnaires or data based on their contact with health or social services, while this study rigorously assessed a range of mental health diagnoses and is the long awaited third survey in a series begun in 1999, which therefore allows the study of trends.
Talking to 9,000 children and young people, and their parents
The survey was conducted by the National Centre for Social Research, the Office for National Statistics and youthinmind, and included more than 9,000 children and young people, who were aged between two and 19 years. Children and young people were sampled to be as representative as possible of children and young people from GP registers across England.
All participating children and young people underwent a standardised diagnostic assessment called the Development and Well-being Assessment (DAWBA). The DAWBA covers most common child mental health problems, from several different types of anxiety and depression, through to behavioural disorders, ADHD, autism spectrum conditions and rarer problems such as eating disorders and tics. The assessment involved face to face interviews with the parent and young people aged over the age of 11. Provided the family agreed, a questionnaire was mailed to teachers.
Asking the right questions
The assessment combined highly structured questions that had set responses with open ended questions. A team of mental health practitioners from the University of Exeter and Kings College London reviewed all the information provided by parents, young people and teachers to assign mental health diagnoses according to the World Health Organisation’s International Classification of Diseases (10th edition; ICD 10), an internationally recognised way of classifying all medical diagnoses, symptoms and procedures.
The highly structured questions provide very reliable information but there is no way to detect if the person answering them has understood the questions asked. Open ended questions produce highly varied responses from different people on different occasions so are much less reliable when used alone. However, they can show that the person answering them has misunderstood the question being asked. These descriptive answers also allowed the mental health experts to handle differences in opinion about how a child was coping in the same way as they would in the clinic.
What if the usual diagnoses don’t fit?
There are also a considerable number of children (and adults) who do not fit neatly into ICD 10 diagnosis but have clinically relevant problems that get in the way of their functioning. ICD 10 does allow for this and the open ended questions allowed the clinical raters to assess this and assign children a “not otherwise specified” diagnosis that the very structured questions would not.
The results: changes since 1999
Comparison with earlier surveys had to be confined to the narrowest age range studied. This was five to 15 years from the first survey, which was completed in 1999. In this age group, there has been a slight increase in the proportion of children with any mental health condition from 9.7% in 1999 and 10.1% in 2004 to 11.2% in 2017. This increase was explained by a higher number of young people with clinically impairing anxiety or depression, which increased from 3.9% in 2004 to 5.8% in 2017. The proportion of children with behavioural difficulties, ADHD and other disorders was not different from that found by the earlier surveys.
Extending the survey to 19-year-olds
The survey extended the age range studied compared to earlier surveys up to the age of 19 and among 5 to19-year-olds, one in eight (12.8%) had at least one mental health condition, while one in twenty had two or more. Overall, the proportion of boys and girls with mental health conditions was similar, although the rate of any mental health condition increased with age and was highest (23.9%) among young women aged 17-19 years. Half of the young women in this age group with a mental health condition reported that they had self-harmed at some point in their life. These findings suggest that on average a class may contain at least one child who is struggling with an emotional disorder and those working with older teenagers may face a particular challenge.
What about very young children?
This survey also assessed two to four year- olds for the first time, and found that one in eighteen had at least one mental health condition. In this age group boys were more likely than girls to have a mental health condition, and the commonest types of problem were behavioural (1.9%) and autism spectrum disorder (1.4%). Boys of primary school age were also more likely to have a mental health condition, particularly as behavioural and neurodevelopmental problems were the most common type of difficulty in this age group. There was no difference between the numbers of boys and girls with poor mental health in the secondary school age group, emotional disorders were more common (9%),
and were more common still among older teenagers (15%).
Ethnicity, low income and poor general health
The survey collected a range of other information about children, young people and their families. White British children (15%) and young people and those of mixed/other heritage (12%) were considerably more likely to have a mental health condition than their Black/Black British (5.6%) or Asian/Asian British (5.2%) peers. There were also regional variations in the proportion of children with mental health conditions that might be of interest to local service commissioners and providers. Children with mental health conditions were more likely to have poor general health, live in a low income household, and have less healthy family functioning
or a parent in poor health.
Social media and poor mental health: a complex relationship
Children with a mental health condition reported spending more time on social media than their peers. In addition, they were more likely to perceive negative impacts of their social media use in terms of comparisons with others, anxiety about likes and follows, spending more time than intended or not being able to be honest about themselves. As both the mental health and background information were collected at the same time, these findings do not indicate causality. While poor family function, physical ill health or poor parental mental health may adversely influence the mental health of children, parenting a child in poor mental health may equally have a negative influence on parents’ mental health and on the way the family functions. Similarly, children with poor mental health may be less engaged in other activities so have more time to spend on social media. Equally, their poor mental health might predispose them to think negatively about their experience on social media, rather than social media necessarily explaining their poor mental health. These relationships are likely to be complex, and data gathered from the same children and families over time are essential to help us to understand how they influence each other.
Support for children with mental health difficulties
As in the previous surveys, teachers were the most commonly cited professional source of support among those with mental health conditions (48.5%), while more than a fifth (22.6%) had contacted an educational support service within the last year. The latter achieved the highest level of satisfaction (73.1%)reported for any service. Despite concerns about increases in the prescription of medication for mental health reasons among young people recently, only one in six (16.4%) children with a mental health condition was taking psychotropic medication. Only a quarter of those with a mental health condition had been in contact with a mental health professional, which included counsellors in schools and the third sector, over the preceding 12 months.
A link to special educational needs
The overlap between poor mental
health and difficulty coping with school is emphasised by the high proportion of children with a mental health condition (35.6%) with recognised special educational needs. This reached almost two thirds among those with neurodevelopmental disorders such as ADHD and autism spectrum conditions, although the survey did not establish whether these special educational needs related directly to the mental health condition detected by the DAWBA. Half of the children (49.6%) with recognised special educational needs had an ducation, Health and Care Plan, which emphasises the extent to which they needed support to cope in school. Children who had a mental health condition were approximately ten times more likely to have played truant or to have been excluded from school than their peers without a disorder.
Finding out more
The data from one of the largest surveys of child mental health in which all children had a standardised diagnostic assessment provides invaluable data for policy, service planning and provision, practitioners and families. Few other such surveys have covered such a large age range or provided such a large sample. I would encourage all those interested to visit the NHS Digital website where there are more detailed descriptions about all of the findings described above and how the survey was undertaken. These data were very much worth the wait from 2004.
Professor Tamsin Ford, University of Exeter College of Medicine and Health, on behalf of the survey team.
Mental Health of Children and Young People in England, 2017,
Green, H., McGinnity, A., Meltzer, H., Ford, T., Goodman, R., Mental health of children and young people in
Great Britain, 2004, National Statistics
Newlove-Delgado, T., Moore, D., Ukoumunne, O. C., Stein, K., Ford, T., Mental health related contact with
education professionals in the British Child and Adolescent Mental Health Survey 2004,