By Lorraine Khan
This week, the long-awaited national survey of children and young people’s mental health was published by NHS Digital. Some 13 years after the last survey was published, this new report gives us the first reliable point-in-time picture of the mental health of children and young people from ages 2 to 19 in England. Its implications for policy and practice are profound.
The headline finding was that one in eight children and young people had a ‘mental disorder’; the equivalent of three children in every class. This represents a modest but significant increase in the number of children presenting with a disorder compared with 2004.
Compared with the previous survey completed in 2004, we are seeing a steady increase in emotional difficulties (a rise that seems to start in primary schools) – largely affecting both sexes up until the age of 16 years. However, during primary school, despite a marginal fall in severe behavioural problems in boys, we are seeing a doubling of their emotional problems compared to 2004. This is concerning. And by the ages of 17 to 19 we also see a steep rise in emotional problems particularly affecting young women, which mirrors troubling rises witnessed in the adult mental health prevalence survey from 2014 (and which included the same age group).
In primary schools, compared with the previous 2004 survey, mental health difficulties have increased by just under a quarter. Emotional difficulties increased by around 70% during primary school years, with a particularly steep rise among boys: girls’ diagnosable emotional conditions had increased by around 44% while for boys, emotional diagnosable conditions had doubled since 2004. The proportion of children with severe and persistent behavioural difficulties remained largely the same, with a slight increase for girls and a marginal decrease for boys.
This rise in emotional problems during primary school reinforces the importance of programmes supporting social and emotional skills in schools for all children. There are good quality programmes available which are proven to be effective and cost effective in giving children the foundational skills to understand feelings, develop effective coping skills, and understand how to seek help appropriately. These interventions also have the advantage of increasing educational performance if well implemented.
Although severe and persistent behavioural problems are stabilising, they are still our most common childhood mental health condition during primary school years, and those that occur at this early age require priority attention. If unsupported, children who develop problems at this early stage face the worst and most costly outcomes as they grow up. Yet there are simple, cost effective and well tested programmes which provide parents with techniques to help children’s behaviour stabilise and promote recovery. An average child with early starting behavioural difficulties not only faces the distress of experiencing poor mental health and reduced life chances but costs society £280,000 over their lifetime. If well implemented, programmes for parents can save society significant costs with benefits starting to be felt by schools and later by the social care and justice system.
Secondary school years
During secondary school years, diagnosable mental health difficulties increased by around a quarter overall compared with the previous 2004 survey. Compared with the 2004 survey, we now see emotional problems emerging as our most common mental health difficulty for this age group; this contrasts with the previous survey in which severe behavioural problems were marginally more common at this age. In 2017, emotional problems increased by just over three-quarters for both girls and boys compared with 2004. With behavioural problems, once again we see a modest reduction during secondary school years for boys and a stabilisation for girls.
17 to 19-year olds
The survey finds that 15% of young people overall had a diagnosable difficulty at this age, with significantly higher rates observed among young women. Emotional problems dominate at this age with 22% of young women and 8% of young men meeting the criteria for a diagnosis with an emotional problem. The complex drivers for this rise in young women’s emotional difficulties need to be better understood, with solutions more effectively co-produced with young women themselves so that we can we can effectively reverse this trend.
Mental health support
Survey figures show that around three quarters of young people with mental health difficulties had sought professional or informal support for them. About a quarter had contact with a mental health specialist: a figure that remains similar to what we saw in 2004. However, when working in local areas, we find a common concern among local stakeholders and young people is a lack of access to mental health support for 17 to 19 year olds due to the common commissioning gap between CAMHS and adult mental health services. This has been a longstanding problem and we need concerted action to ensure that commissioning gaps between adult and child mental health services are systematically addressed. We also hope that green paper developments effectively address the needs of young people in college who tend to remain overlooked.
Multiple mental health difficulties
1 in 20 children and young people had more than one mental health difficulty. When children experience multiple mental health difficulties, symptoms are often more severe and outcomes can be poorer (Woolf & Ollendick, 2010). Furthermore, evidence suggests that multiple difficulties can often be overlooked. Recent analysis of Millennium Cohort longitudinal data completed by the Centre and UCL highlighted that 8% of children experience multiple mental health difficulties which persist from the age of 3 at least until the age of 11 years.
Mental health practitioners should look beyond the primary presenting condition and routinely use tools that screen for more than one problem at a time. Children with multiple difficulties should also be prioritised for early support. This should, for example, be a priority for the new ‘mental health support teams’ being introduced into schools over the next five years and for activity focused on Special Educational Needs.
Self-harm and suicide attempts
5.5% of young people said they had ever self-harmed or attempted suicide. Those with a diagnosable mental health condition were more likely to self-harm than others: young people aged 11 to 16 with a diagnosable difficulty were 8 times more likely to say they had self-harmed or attempted suicide than those with no mental health condition. Nearly half of 17 to 19 year olds with a diagnosable difficulty had ever self-harmed or attempted suicide.
Earlier this week, the Centre published an evaluation of The WISH Centre’s work with young people who self-harm and showed the considerable successes their approach demonstrated. We urgently need more high quality evaluations of interventions designed to support young people who self-harm and to extend access to effective help nationwide.
Children from white communities and of mixed-race heritage were most likely to present with diagnosable difficulties. Children from Black and Asian communities were least likely to present with diagnosable difficulties between the ages of 5 and 19 years.
This raises questions when we consider these findings in the context of other data available. For example, if young black men are less likely to present with mental health disorders as children and adolescents (and therefore also less likely to present with severe and persistent behavioural problems), why is it that these young men are still three times more likely to be excluded from school, and significantly overrepresented in the justice system? Something does not feel right in the system. Similarly, given that adult black men are overrepresented in more restrictive mental health settings and have higher chance of experiencing serious mental health difficulties such as schizophrenia as adults, when do these difficulties begin to emerge, and what is driving both overrepresentation and this higher likelihood of later serious mental health problems? We need to understand young people’s experiences to unpick and solve these anomalies more effectively.
We were pleased to get a greater understanding of important factors associated with poorer mental health in the 2017 survey. One of these is the focus on bullying which has a long-term impact on a child’s ability to achieve and thrive across their life course. 11 to 19 year olds with mental health difficulties were twice as likely as children without to be bullied. However, we also learned that children who bully can often themselves be more likely to experience mental health difficulties. This highlights the importance of supporting schools to implement good quality programmes, such as those advocated by the Early Intervention Foundation, to promote empathy and healthy behaviours among children and reduce the chances of life-damaging bullying behaviours increasing.
Parental mental health difficulties
Finally, the new survey reinforced the important interrelationship between child mental health and parental mental health, which mirrors findings from our study in partnership with UCL’s Institute of Education. Prolonged systemic challenges in our ability to support children and parents/carers as a whole system must be resolved through more integrated and ‘Think Family’ approaches.
We welcome a survey that provides clarity on what is changing and for whom. However, we now need action to effectively address the emerging challenges affecting this generation of children and young people. We need action to address long standing, unresolved gaps in the system which continue to significantly affect children and young people’s ability to thrive and achieve.