Is our children’s mental health worse than ours? If so – why?
Raj Persaud and Professor Sir Simon Wessely
Under a headline: ‘Children as young as five suffering from depression’, The Daily Telegraph Newspaper recently declared that the National Institute of Health and Clinical Excellence (NICE) reported 80,000 children in the UK with severe depression, including 8,000 below the age of 10. Children as young as five can suffer from the psychiatric disorder; NICE affirms more identification of these children is needed.
A few days later The Daily Telegraph’s new headline was: ”Toxic childhoods’ blamed for 22,000 self-harm cases’ – beneath was a byline: ‘More than 22,000 children and teenagers were treated in hospital for self-harming in 2012, according to official figures which experts said showed the “toxic” effects of social media and a society obsessed with body image’.
The article went on to report that in the past year, NHS hospitals treated 18,037 girls and 4,623 boys aged between 10 and 19 after they had deliberately harmed themselves — a rise of ’11 per cent’. During the same period, cases involving children between 10 and 14 rose from 4,008 to 5,192 — ‘an increase of 30 per cent’. Later in the same article ChildLine said it had carried out 47,000 counselling sessions in the past year for children who self-harmed, a 40 per cent rise on the previous year.
But do these figures reflect real increases, or are children more forthcoming, and youth mental health problems better recognised?
In a now classic study, ‘Is there an epidemic of child or adolescent depression?’ Jane Costello, Alaattin Erkanli and Adrian Angold from Duke University in the USA, analysed twenty-six studies generating close to 60,000 observations, on children born between 1965 and 1996. Pooling all this data revealed no evidence for a genuine increased prevalence of child or adolescent depression, over the past 30 years. The authors suggested public perception of an ‘epidemic’ may arise from heightened awareness of difficulties long under-diagnosed by clinicians.
But what about studies focusing just on Great Britain?
After all, the UK currently has one of the highest divorce rates in Europe, with at least one in three children experiencing parental separation before the age of 16 years, plus between a third and a half of all children have a non-resident parent, usually the father, during some part of their childhood.
A study entitled ‘Trends in adolescent emotional problems in England: a comparison of two national cohorts twenty years apart’, compared large samples of youth 20 years apart, using identical symptom screening in each survey. Twice as many young people reported frequent feelings of depression or anxiety in 2006 as in 1986. Some symptoms showed marked increases in prevalence over time (e.g., worry, irritability, fatigue), whereas others showed no change (e.g., loss of enjoyment, worthlessness).
Increased openness in reporting mental health problems would be expected to have a general effect across all symptoms.
But in this large investigation, involving thousands of children and parents, there was considerable specificity: only some symptoms increased over time. The greatest rise were for symptoms of worry, irritability, fatigue, sleep disturbance, panic and feeling worn out/under strain.
Stephan Collishaw, Barbara Maughan, Lucy Natarajan, and Andrew Pickles from Cardiff University and the Institute of Psychiatry, London concluded was there has has indeed been a real and substantial increase in adolescent emotional problems in England over recent decades, especially among girls. The proportion of girls with five or more psychological symptoms doubled.
Published in the ‘Journal of Child Psychology and Psychiatry’, the study found that whether or not they were raised in an intact or socially advantaged family was associated with girls’ mental health, but not boys’.
Iryna Culpin from the School of Social and Community Medicine, University of Bristol led a team which conducted a major study entitled, ‘Father absence and depressive symptoms in adolescence: Findings from a UK cohort’, whose results are just about to be published.
This team of researchers, including J. Heron, R. Araya, R. Melotti and C. Joinson, followed up 5631 UK children, and found an association between father absence during the ﬁrst 5 years of life and increased depressive symptoms at 14 years. But father absence experienced during middle childhood (5–10 years) was not associated with increased depressive symptoms at 14 years.
The authors of the study – to be published in the medical journal ‘Psychological Medicine’, found that their findings echo previous research on the effects of marital dissolution, where psychological distress is more severe for those children whose parents separate during preschool years (0–6 years) than for those who experience parental separation later in childhood (6–10 and 11–16 years).
The association between father absence during the ﬁrst 5 years of life and depressive symptoms at 14 years was stronger in girls than boys.
But exactly why girls are more sensitive to father absence during early childhood remains a mystery. The authors of the current study point to previous work which found father absence during the ﬁrst 5 years is associated in daughters with earlier timing of first period, increased rate of sexual activity and teenage pregnancy, which are, in turn, associated with increased levels of depressive symptoms in girls.
Dr Benjamin Baig, Clinical Lecturer, Department of Child and Adolescent Psychiatry at the Institute of Psychiatry, London, points out that the age of first period has become younger by one year over the last 80 years. He suggests that modern childhood appears to mean becoming biologically older at a younger age, and displaying adult type psychiatric symptoms, chronologically earlier.
The same team who reported the convincing evidence for a recent true rise in adolescent mental health problems, Stephan Collishaw and his colleagues, found that parenting differences in England between affluent and disadvantaged families had narrowed, as opposed to widened, between 1986 and 2006. The study entitled ‘Do Historical Changes in Parent–Child Relationships Explain Increases in Youth Conduct Problems?’ found little evidence of a decline in quality of parenting for the population as a whole, or for disadvantaged subgroups.
Instead, the study published in the ‘Journal of Abnormal Child Psychology’, found increases over time in parental monitoring, youth disclosure about out-of-home activities, and parental expectations about good behaviour. Adolescents rated their parents as just as interested in them in 2006 as in 1986. There was a reduction in joint family meals, but young people reported spending more quality time with their parents.
This study, which compared two national samples of English adolescents aged 16–17 years in 1986 and 2006, found little evidence of a decline in many aspects of parenting and parent–child relationships known to be most strongly linked with youth anti-social behaviour.
In fact, the results tended to suggest that in some respects the quality of parenting had improved (notably increases in parental expectations, monitoring and parent–child quality time).
The authors explain this by pressures due to increases in parental work time and changes in family type, being offset by decreasing family size, and beginning a family at an older age following longer periods of post-school education. Parents might now also spend less time in adult leisure activities, personal care and sleep, thus compensating for an increase in maternal time in employment.
Parents may also now be expected to be more actively involved in child care activities, reading and playing with younger children.
According to this study the main trend that was not in a positive direction was that child-father relationships became more fractured for those in single or step-parent families.
The authors suggest that whilst quality of parenting behaviour has improved, parent mental health has significantly worsened over time and it’s this which has most probably contributed in a major way to increases in youth emotional problems.
Karen Schepman, Stephan Collishaw, Frances Gardner, Barbara Maughan, Jacqueline Scott and Andrew Pickles in another study, posed the specific question, ‘Do changes in parent mental health explain trends in youth emotional problems?’” The concluded that they might. English adolescents in 2006 were considerably more likely to be exposed to maternal emotional problems than their counterparts in 1986. The study published in ‘Social Science and Medicine’ found maternal emotional problems increased across all socio-demographic groups between 1986 and 2006, mirroring increases in adolescent emotional problems over this period.
If it’s not so much bad parenting – but poor maternal mental health – which could be a major culprit, should another favourite media whipping boy – new technology – also still be in the frame for rising childhood mental health problems?
A study just published entitled ‘Older Versus Newer Media and the Well-being of United States Youth: Results From a National Longitudinal Panel’, followed 719 nationally representative young people, ages 14-24 years in the USA, and found use of older media was more related to school grades. Television was negatively, and book reading, positively related to academic performance.
But as long as you kept reading books, and if using other media didn’t detract from reading, then school performance was not affected. So books seemed to protect you against the more negative effects of television viewing on its own. Likewise, heavy use of the Internet and games was not found harmful to academic performance, particularly if the users kept up their book reading.
The authors of the study, Daniel Romer, Zhanna Bagdasarov, and Eian More from the University of Pennsylvania, conclude that despite concerns that excessive use of new media is harmful to adolescent development, it’s actually television which most detracts from academic performance and book reading which most supports it.
Heavy use of the Internet and video gaming may in fact be more a symptom of mental health problems than a cause. The authors of the study, published in the ‘Journal of Adolescent Health’ point out that withdrawal from social activity, which is a symptom of depression, leads many young people to turn to media use as a replacement for hanging out with friends.
Even if causes for childhood depression remain unclear, writing in ‘The Lancet’, Anita Thapar and her colleagues from the University of Cardiff, draw attention to the fact eﬀective treatments are available. Their review, entitled ‘Depression in adolescence’, also links depression in adolescents and clinical low mood in adults, strengthening the case for early intervention if possible
Yet Child and Adolescent Psychiatrists at the country’s largest mental health trusts point out they face 30% cuts over the next two years.
Jane Costello, Professor of Psychiatry at Duke University in the USA, comments on the predicament: ‘The bottom line is that services are so scarce that it hardly matters how many kids need them—the gap between need and availability is so huge.’
Cycles of unhappiness repeat themselves. Parental depression is associated with child and adolescent emotional problems, via a variety of pathways, and certainly not just genetic.
Given that parental mental health problems are amongst the strongest predictors of child and adolescent emotional disorders, this raises the prospect of a ‘vicious cycle’ of inter-generational transmission of anxiety and depression.
More support for Child and Adolescent Mental Health Services, CAMHS in the jargon, is an investment not just for the present, but for the future.
49th Maudsley Debate: ‘Sick Children or Sick Society?’
“What should we make of the seemingly inexorable rise in psychiatric diagnoses in children?” Tuesday 15th October 2013, 6pm to 8pm (refreshments served from 5.30pm) Wolfson Lecture Theatre, Institute of Psychiatry Main Building, De Crespigny Park, London SE5 8AF. All Welcome.
Stephan Collishaw, Barbara Maughan, Lucy Natarajan and Andrew Pickles. Trends in adolescent emotional problems in England: a comparison of two national cohorts twenty years apart. Journal of Child Psychology and Psychiatry 51:8 (2010), pp 885–894.
Stephan Collishaw, Frances Gardner, Barbara Maughan, Jacqueline Scott and Andrew Pickles. Do Historical Changes in Parent–Child Relationships Explain Increases in Youth Conduct Problems? Journal of Abnorm Child Psychology (2012) 40:119–132.
Jane Costello, Alaattin Erkanli, and Adrian Angold. Is there an epidemic of child or adolescent depression? Journal of Child Psychology and Psychiatry 47:12 (2006), pp 1263–1271.
Daniel Romer, Zhanna Bagdasarov and Eian More. Older Versus Newer Media and the Well-being of United States Youth: Results From a National Longitudinal Panel. Journal of Adolescent Health 52 (2013) 613-619.
Karen Schepmana, Stephan Collishaw, Frances Gardner, Barbara Maughan, Jacqueline Scott and Andrew Pickles. Do changes in parent mental health explain trends in youth emotional problems? Social Social Science & Medicine 73 (2011) 293-300.
Anita Thapar, Stephan Collishaw, Daniel Pine and Ajay Thapar. Depression in adolescence. Lancet 2012; 379: 1056–67.