In December 2013, NHS Health Scotland (Scotland’s national health improvement agency) published a landmark report on the mental health of children and young people in Scotland.
This report has been a long time coming. Developing a framework of indicators that could be used to reliably monitor the mental health of children and young people, and relevant risk and protective contextual factors, began back in 2008. The process of agreeing the indicator framework was painstaking and the framework was finally published in 2011. It recommended a complex set of 108 separate indicators: the recently published report now provides the data for the agreed indicators.
The report is not an easy read. It states its intended impact is to ‘easily inform strategic decision making and action for mental health improvement’ but it is unlikely that policy makers and planners will take the time to plough through the complex web of information to draw out clear messages about children’s mental health and how best to protect and promote it. This blog therefore summarises the report’s findings and suggests some key points to support debate and decision making about this critically important aspect of child and adolescent public health.
Of the 108 indicators, a minority (15) relate to mental health outcomes with the remainder (93) relating to contextual risk and protective factors. Taking mental health outcomes first. Thirteen outcome indicators are actually reported on (as no reliable data are available for two). Four of the 13 relate to positive aspects of mental wellbeing and 11 relate to the presence of mental health problems as shown below.
|Indicator||Measurement tool||Data source|
|Overall mental wellbeing||Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS)||Scottish Health Survey (SHeS)
Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS)
|Life satisfaction||‘How satisfied with your life as a whole nowadays’
Health Behaviour in School aged Children Survey (HBSC)
|Happiness||‘Feel very happy with your life at present’||HBSC|
|Pro-social behaviour||Pro-social scale of Strengths and Difficulties Questionnaire (SDQ)||SHeS
|Mental health problems|
|Common mental health problems||General Health Questionnaire (GHQ)||SHeS|
|Emotional and behavioural problems||Total difficulties score on SDQ||SHeS
|Emotional symptoms||Emotional symptoms scale of SDQ||SHeS
|Conduct problems||Conduct problems scale of SDQ||SHeS
|Hyperactivity/inattention||Hyperactivity/inattention scale of SDQ||SHeS
|Sadness||‘Felt sad quite often, very often, or always in the last week’||HBSC|
|Alcohol dependency||CAGE questionnaire||SHeS|
|Drug-related disorders||Patients hospitalised with mental and behavioural disorders due to psychoactive drug use||General and psychiatric hospital discharge records|
|Suicide||Deaths from intentional self harm or events of undetermined intent||Death records|
In general the mental health outcome indicators draw on data collected through established measurement instruments delivered through population based surveys, in particular the Scottish Health Survey (SHeS), the Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS), and the Health Behaviour in School aged Children Survey (HBSC). No information is given in the report on the measurement instruments used or on the size or quality of the surveys as these issues were covered in previous publications reporting on development of the indicator framework, making judgement of the technical quality of the data presented difficult. For example there is no discussion of the (substantial) potential for participation bias in school based surveys. A scan of other sources shows that the SHeS is administered in homes on an ongoing basis and includes around 1,800 children aged 0-15 years per year; SALSUS is administered in schools around every two years and includes at least 5,000 pupils from each of S2 and S4 (children aged 13 and 15) per year; HBSC is administered in schools every four years and includes at least 1,500 pupils from each of P7, S2, and S4 (children aged 11, 13 and 15) per year.
Relatively little use is made in the Health Scotland report of routine administrative data, for example referrals to child and adolescent mental health services or mental health prescriptions for children, presumably due to concerns around the extent to which these may reflect service organisation issues rather than underlying mental health needs.
So what do the mental health outcome data that are presented in the report tell us? Some of the data are fairly intuitive to interpret but some are decidedly not – for example the mean mental wellbeing score for S4 children in 2010 (as measured by WEMWBS) was 49.7. Is that good or bad? WEMWBS scores between 14 and 70, with higher scores indicating better mental wellbeing, and digging around in other sources reveals that the mean score for the general (adult) Scottish population is around 50 so the results for teenagers are probably good-ish. Some stand out results are that 14% of 16-19 year olds in 2011 had GHQ results indicating likely presence of a common mental health problem, and 26% of S4 pupils in 2010 had SDQ scores in the borderline or abnormal range indicating likely mental health difficulties. Hence, whilst the majority of our children and young people have good mental health, substantial numbers clearly don’t.
Perhaps more important than the snapshot absolute numbers/percentages, are trends over time and discrepancies between subgroups of children and young people as these patterns tell us a lot about opportunities for improvement.
Trends are available for 11 of the 13 reported outcome indicators and generally span around 10 years. Eyeballing the available data suggests that four of the 11 have shown probably meaningful improvement across a range of age groups over the time period examined, two each from the mental wellbeing and the mental health problems categories (happiness; pro-social behaviour; emotional and behavioural problems; and conduct problems). Some of the improvements are a bit wobbly and the report subjects some decidedly non-linear trends to regression analyses that rely on assumptions of linear change over time to ‘show’ year on year improvement rates which is unfortunate. One indicator in one age group (emotional symptoms in S4 pupils) showed a statistically significant deterioration over time but as no adjustment for (high levels of) multiple testing has been made this may well be a chance finding. Overall, therefore, there is evidence that over the last 10 years, aspects of the mental health of children and young people have remained stable or improved.
The findings relating to discrepancies between subgroups of children and young people are striking. There are clear differences in mental health outcomes between children of different ages/developmental stages, between boys and girls, and between children living in areas with different levels of deprivation (but not between those living in areas with different urban/rural status).
Although the Health Scotland report aims to cover children and young people from birth to around 17 years of age, in practice there is little information available on the mental health of pre-school children. Amongst school aged children, in general children’s mental health deteriorates with increasing age and in particular as children transition to secondary school and progress through adolescence. Pro-social behaviours, conduct problems, and hyperactivity/inattention show a slightly different pattern of initially improving as children progress through primary school before deteriorating again in adolescence. Overall, boys fare better than girls in terms of overall mental wellbeing, life satisfaction, happiness and the absence of common mental health problems and emotional difficulties whereas girls fare better than boys in terms of pro-social behaviours, conduct problems, drug related disorders, and suicide.
Almost all the mental health indicators showed a clear association with deprivation, with children from increasingly deprived areas showing increasingly poor outcomes. For some outcomes, notably conduct problems, drug misuse, and suicide, the absolute difference in outcomes between children from the most and least deprived areas is particularly great. One exception to the deprivation gradient rule is possible alcohol problems in teenagers which were equally prevalent (around 10%) in all deprivation groups, reflecting the pervasive nature of alcohol in Scotland.
The contextual risk and protective factors are presented in five domains (individual; family; learning environment; community; and structural) and data are available for 60 of the 93 indicators. The volume of information presented risks being overwhelming but stand out results include the following.
- The majority of general health and health related behaviour indicators included in the individual level domain have shown substantial improvement over the past decade, for example there are clear downward trends in the proportion of young people who regularly drink alcohol, smoke or take illegal drugs. We know from other sources however that these generally positive trends may mask increasing inequalities. For example, it is likely that smaller numbers of young people are engaged in increasingly risky substance use with consequent widening of the discrepancy between their experiences and health and those of their peers.
- Within the family domain, the data show the high proportion of children that live in lone parent households (22% of children 17 and under in 2011) and the considerable numbers that experience having a parent in prison for any length of time (7 per 1,000 children 17 and under in the previous year in 2011).
- Within the learning environment domain, the majority of children report feeling generally positive about school and having supportive friendships but there is a clear deterioration in these indicators as children progress through secondary school. Substantial numbers of children also report feeling under pressure with respect to having adequate free time, having control over how they spend their free time, and having a manageable volume of school work.
- Within the structural domain, the welcome reduction in child poverty and income inequality that has been seen in Scotland over the last decade is evident, but the extent to which apparently positive trends may reflect falling incomes across the board, and the extent to which they will be sustained through the age of austerity, is not discussed. The high numbers of children living in workless households (14% of children aged 15 and under in 2011) stands out as a persistent challenge to family wellbeing.
The Health Scotland report focuses very much on the numbers and provides little narrative discussion hence it is useful to assess the extent to which the headline findings are congruent with previous publications. Setting the Scottish data in a more international context is also useful to further explore potential for improvement.
The sustained work tracking the wellbeing of children in the UK by Bradshaw and colleagues provides a useful sense check of the trends and inequalities reported in the Health Scotland report. For example, Bradshaw has reported data from the British Household Panel Survey as showing small but persistent increases in children’s subjective wellbeing over the period observed (1994-2008) (see Bradshaw J, ed. The well-being of children in the UK. 3rd ed. Policy Press, 2011). Conversely, data from the Office for National Statistics surveys on the mental health of children and young people in Britain, conducted in 1999 and 2004, are reported as showing no significant differences in the prevalence of mental health problems in children aged 5 to 16 years between those time points (although comparisons with other surveys suggests that this stable state represents a levelling off of increasing prevalence of childhood mental health problems over previous decades hence is an improvement of sorts). A range of data are reported as showing inequalities congruent with those seen in the Health Scotland report, with mental health outcomes worse for older children, highly patterned by gender, and (particularly for mental health problems rather than wellbeing) worse for children in poverty or deprivation.
Lastly, what do we know about how the mental health of children in Scotland compares to that seen internationally. HBSC data on subjective wellbeing represent the main source of internationally comparable information on children’s mental wellbeing. Internationally comparable data on childhood mental health problems are essentially lacking. Comparative HBSC data on subjective wellbeing have been incorporated into the UNICEF reports (link 1 and link 2) on child wellbeing in high income countries. Data on the life satisfaction of UK children aged 11, 13, and 15 years who participated in the HBSC in 2009/2010 showed that 86% reported high life satisfaction (defined as a score of 6 or above on Cantril’s ladder). This placed the UK 14th out of the 29 high income countries studied (27 from Europe plus the US and Canada - unfortunately data for the constituent nations of the UK were not presented separately). The Netherlands headed the league table with 94% of children reporting high life satisfaction and Romania came bottom with 77%.
So, after all the poring over the Health Scotland and other reports, what do we know about the mental health of Scotland’s children and young people? I suggest the following:
- Most children and young people have good mental health but a substantial minority experience poor mental wellbeing and/or mental health problems. Promoting good mental health for children and young people is a vital part of child public health work.
- All is not doom and gloom: the available evidence suggests small but important improvements have been seen in some aspects of children’s mental health over the past decade, with other aspects remaining unchanged.
- Children’s mental health shows strong associations with age, gender, and deprivation. Mental wellbeing and mental health problems deteriorate markedly as children reach and progress through adolescence. There are marked social inequalities in mental health, particularly for problems such as conduct disorders, drug misuse, and suicide, but no social groups are exempt from mental health issues.
- International comparative data suggest that the UK as a whole is ‘mid-table’ in relation to children’s mental wellbeing. Transforming our performance to match that of league topping countries such as the Netherlands would bring very substantial benefit to children’s lives. International data on the prevalence of child mental health problems are lacking, curtailing our ability to assess room for improvement.
- Improvements have been seen over the past decade in important risk factors for children’s mental health such as substance misuse and child poverty, although there are concerns around trends in inequalities in risk factors and the sustainability of some of the gains made. Other risk factors such as problems sustaining positive relationships in adolescence, perceived pressure, parental imprisonment, and household worklessness continue to pose substantial challenges for children’s mental health. Careful and sustained attention to reducing the range of risk factors and bolstering protective factors will bring important benefits to our children.
Dr Rachael Wood
Consultant in Public Health Medicine, Information Services Division, NHS National Services Scotland