Written evidence submitted by Health Action Campaign (CYP0011)
Health Action Campaign is a public health charity. We have a particular interest in the underlying causes of health problems, as tackling the causes is key to prevention.
We are submitting this evidence because preventing mental health problems in children and young people is important in its own right. However, it also has important longer-term implications for the nation’s mental health.
In this submission we draw on our research into both the importance of the early years for mental health and, more recently, student mental health. This has included extensively reviewing published research; undertaking our own research; and interviews with staff working with students in schools and universities.
Our focus in the submission is on:
The importance of clarifying what mental health means
The threshold for diagnosing mental health conditions has been lowered significantly in recent years. For example, ‘mental disorder’ has evolved from being a pre-requisite for sectioning under the Mental Health Act 1983 to a term which a 2020 report described as probably affecting one in six children in the UK. It is unlikely that one in six children in the UK are now at risk of being sectioned, more likely that the term is now being used much more loosely than originally envisaged.
We therefore recommend that the inquiry considers and clarifies the terms mental health, mental health problem, mental distress, mental health condition, mental illness and mental disorder - and who is therefore at serious risk and should be a priority for specialist support.
The importance of the early years for long term mental health
To reduce diagnosed mental illness, action during the formative early years is important, as the brain undergoes particularly significant growth and development in its first two years.
The main risk factors here are well known. They include stress and trauma in early childhood (for example as a result of parental abuse, abandonment or neglect), or (for anorexia) parents who are low on care, high on control; the chances of parent-child bonding being reduced by post-natal depression or by substance abuse; and a lack of external support.
Given the significant influence of parenting on children’s mental health, in particular in the formative early years, we recommend targeted programmes to support ‘at risk’ mothers and mothers-to-be and provide examples of successful early years initiatives from the UK, Australia and the USA, for consideration.
Reduced resilience increases vulnerability to mental distress
Resilience is protective of mental health. However, children and young people in the twenty first century appear to exhibit less resilience and more ‘mental health problems’ than their counterparts during the upheavals of the Second World War.
Resilience is a combination of innate ability, a supportive environment and opportunities to experience and learn from challenge and failure. Social changes in recent decades have significantly reduced that third element for many young people – the opportunities to experience challenge and failure – which may help explain why levels of resilience now appear lower.
We recommend the inquiry considers what factors are reducing the resilience of children and young people and how these can be addressed; and what factors are encouraging their resilience and how these can be encouraged.
The unintended consequences of safeguarding for mental health
In recent decades there has been an increasing, well-intentioned desire to protect children and young people from harm, safeguarding them from risk. Unfortunately, as the children’s charity Barnardo’s reported as early as 2002, the more children have been protected from risk, the less resilient and prone to psychosocial disorders they have become.
While enhanced support and protection is an appropriate response where young people have experienced abuse and neglect in childhood, or have grown up in dysfunctional families, providing ever more support for children from caring, supportive families is proving counterproductive, reducing their resilience and increasing the risk of mental distress.
This safeguarding culture also leads to social pressure on parents to seek to protect their children from all possible risks, for fear of being branded a ‘bad parent’ if they don’t.
In contrast, a recent study found no evidence of an increase in student mental health problems over the last ten years in the Netherland. In the Dutch style of parenting the main concern is to raise children to be independent and to learn from their own experiences. Whereas, in the UK, one Head Teacher we spoke with commented, ‘I’ve really noticed a change in parenting in recent years…They can be unwilling to let their children grow up.’
We recommend that the inquiry distinguish between the need to safeguard ‘at risk’ children and the need to encourage resilience among the majority of children and young people who are not ‘at risk.’
Four factors reducing resilience and predisposing to mental distress
Our research has identified four overlapping and mutually reinforcing factors:
We therefore recommend that:
Factors increasing resilience and reducing mental distress
Opportunities to experience life away from over protective schools and parents (and social media) and opportunities to experience ‘productive failure’ appear to increase resilience and coping skills and reduce reported mental health problems. Evidence here includes:
We recommend that the inquiry explores how young people can be provided with more opportunities to experience life and challenges away from over-protective schools and parents, to develop their resilience and reduce their vulnerability to mental distress.
Evidence provided for the children and young people's mental health inquiry
1. The importance of clarifying what mental health means
We recommend that the inquiry considers and sets out clearly what it understands ‘mental health’ to mean, what it understands other terms such as ‘mental health problems’ to mean, and which aspects of mental health it considers a priority for action.
This is because definitions of what constitutes a mental health problem have expanded in recent years. It will be important to identify where there have been genuine increases in mental health problems as opposed to apparent increases due to changes in the way mental health problems have been defined, to ensure accurate like for like comparison. This is particularly important given current pressures on mental health services, to ensure that support can be provided for those who need it most.
Three examples illustrate the way definitions have changed in recent years:
1.1 Generalized Anxiety Disorder
DSM has been described as ‘The Psychiatrists’ Bible.’ It is the standard diagnostic guide used by mental health professionals around the world. In 2013, the American Psychiatric Association published the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM – 5).1
The 2013 edition made significant and controversial changes, so controversial that the Nursing Times described it as provoking, ‘a storm of controversy and bitter criticism.’ 2
For example, DSM-5 changed the diagnostic threshold for Generalized Anxiety Disorder (the most common anxiety disorder). Before 2013, to be diagnosed with GAD any three of six symptoms needed to be demonstrated for at least three months. From 2013 the threshold was lowered to just one of four symptoms for one month – leading critics to argue this could lead to everyday worries being misdiagnosed and needlessly treated.
Similarly, as an article in the British Medical Journal (BMJ) that year noted, DSM-5 allowed the diagnosis of major depressive disorder just two weeks after bereavement, in a situation where depression was already more likely to be over-diagnosed than underdiagnosed in primary care.3
1.2 A probable mental disorder
In 2020 NHS Digital published Mental Health of Children and Young People in England, 2020. This reported that rates of probable mental disorder had increased since 2017, with one in six children aged 5-16 now identified as having a ‘probable mental disorder.’4
To put this in context, a diagnosis of a ‘mental disorder’ is a pre-requisite for sectioning under the Mental Health Act.5 Historically it has included diagnoses such as anorexia, bipolar disorder, clinical depression, personality disorder, psychosis and schizophrenia. Does the 2020 report therefore mean that one in six UK children are now at risk of being sectioned under the Mental Health Act? Closer reading of the report reveals that the diagnosis of ‘probable mental disorder’ related to ‘difficulties with their emotions, behaviour, relationships, hyperactivity or concentration’ – quite some distance from the more serious mental illnesses originally envisaged by the term ‘mental disorder.’
1.3 Mental distress
In its 2017 report Not by degrees the Institute for Public Policy Research explains that in its report, ‘mental distress is understood as where individuals self-report mental health problems, which have not been subjected to clinical screening measures.’6
However, as Professor Frank Furedi had already commented in the Times Educational Supplement (TES) in 2016, 'Children have become socialised into interpreting their experience through the language of mental health deficits. That is why, unlike children who went to school 30 to 40 years ago, today's pupils readily communicate their problems through a psychological vocabulary and use words like "stress", "trauma" or "depression" to describe their feelings. Through medicalising children’s normal emotional upheavals, young people are trained to regard the challenges integral to growing up as a source of psychological distress.’7
The examples reported above, in relation to generalised anxiety disorder, depression, probable mental disorder and mental distress suggest there has been an increasing medicalisation of normal human feelings, emotions and behaviour. In turn this medicalisation has been taken up by the media and has passed into everyday use, not least among young people, their parents and their schools and universities, who are now increasingly interpreting the negative feelings and emotions many children and young people have historically encountered from time to time while charting their journey through adolescence into early adulthood as symptoms of mental health problems requiring professional support.
1.4 Emotional contagion
The increase in young people interpreting and self-reporting normal negative feelings and emotions as symptoms of mental distress is potentially significant because emotions (unlike most serious mental illnesses) are communicable. Panic is a good example. This may explain why, for example, a University tutor with pastoral responsibility for a student Hall of Residence reported to us that (in the years immediately before Covid-19 became an issue) the number of panic attacks reported by students in her Hall of Residence had increased from 5 to 15 to 60 in just three years. It is difficult to imagine what objective changes would have generated a 12-fold increase in panic attacks in three years. It is perhaps easier to understand if we see this as an example of how easily feelings and emotions can be socially communicated or ‘go viral’ within a specific community, making emotional problems (increasingly now interpreted as ‘mental health problems’) a ‘communicable disease’ spread by ‘social contagion.’
We therefore recommend that the inquiry considers and clarifies the terms mental health, mental health problem, mental distress, mental health condition, mental illness and mental disorder – and who is therefore at serious risk and should be a priority for specialist support specialist support.
2. The importance of the early years for long term mental health
What we can do to reduce the risk of physical illness, for example by not smoking, is usually well-known, thanks to decades of research and public health messaging. In contrast, what can be done to reduce the risk of mental illness appears less well known, perhaps in part because the causes of mental illness have been less widely agreed and communicated and what constitutes a ‘mental health problem’ is still being debated.
However, existing research suggests that factors increasing the risk of diagnosed mental illness include: stress and trauma in early childhood,8 for example as a result of parental abuse, abandonment, neglect9, or (for anorexia) parents who are low on care, high on control;10 the chances of parent-child bonding reduced by post-natal depression11 or by substance abuse,12 with insecure attachment increasing the risk of substance abuse;13 and a lack of external support.14,15
Factors reducing the risk of diagnosed mental illness include parent-child bonding (assisted by breast-feeding);16 early cognitive stimulation -including play;17 initiatives to reduce or treat post-natal depression (including successfully piloted arts and music programmes);18 targeted support where parents have mental illness (e.g. Australia’s national COPMI initiative)19 or are at risk for other reasons (e.g. Mom Power in the USA);20,21 home-based interventions14 and neighbourhood social cohesion.15
Taken together these illustrate the importance of the early years for long term mental health. This isn’t surprising. Research into neurodevelopment reveals that the brain undergoes particularly significant growth and development in the first two years of life. This means that in mental health as in physical health, environmental conditions during the early days of life appear to have particularly long-term health implications. This is also the time of life when there is greatest dependence on parents, and mothers in particular, meaning their influence is arguably at its peak. The early years are therefore a period where time and resource committed to reducing risk appears likely to prove especially productive and when the means of achieving this is also particularly clear i.e. through mothers and mothers to be in particular.
This is a point recognised by the World Health Organisation (WHO) which advises, ‘Ample evidence exists that early intervention programmes are a powerful prevention strategy. The most successful programmes addressing risk and protective factors early in life are targeted at child populations at risk, especially from families with low income and education levels. They include home-based interventions during pregnancy and infancy, parent management training and preschool programmes.’
Timely intervention with new parents is therefore an effective starting point for primary prevention, if we wish to reduce levels of mental illness among children and young people. We can start by identifying who is most at risk, such as the children of parents with a family history of mental illness or at risk of post-natal depression and single teenage mothers, each of whom may face potential difficulties with parent-child bonding. Interventions yielding positive results include:
COPMI (The Children of Parents with a Mental Illness) was a national initiative funded by the Australian Government. It recognised that parenting and the parent-child relationship; communication, understanding and problem solving; active involvement in the community; a supportive network of relationships (within and outside of the family); help-seeking; and hope were all important protective factors.
Mom Power was a US project, which provided a 13-session parenting and self-care skills group program for high-risk mothers and their young children who had been referred by community health providers. It focused on enhancing mothers’ mental health, parenting competence, and engagement in treatment. Women who attended at least 70 % of the programme improved both their parenting and mental health outcomes.
Examples of arts and music programmes for young mothers which reduced mental health risks are provided in the All-Party Parliamentary Group on Arts, Health and Wellbeing’s 2017 report. They included an early arts-on-prescription activity in Stockport that helped to both prevent and overcome postnatal depression; Creative Families programmes in Southwark, where mothers experienced a 77% reduction in anxiety and depression and an 86% reduction in stress, as well as improving mother-child attachment and stimulating children’s emotional, social and cognitive development; and Dreamtime Arts in one of the most deprived areas in Bristol, which reduced anxiety by 57% and also facilitated access to mental health services where needed.
These examples may have wider mental health application. In just a few generations the UK has moved from geographically close extended families to widely dispersed nuclear families and single mothers. In earlier extended families, expectant mothers usually already had ‘hands-on’ experience of babies, role models and nearby help from other family members. Modern parents often lack such experience and support, which may have knock on effects on breast-feeding (particularly low in the UK), parent-child bonding and risks to longer term mental health. Given this changed social context, greater support for new mothers, especially those identified as being at risk, may help reduce the risk of mental illness, with interventions that have been demonstrated to help ranging from social prescribing to home-based interventions. The voluntary sector also has useful resources here, including Barnardo’s five ‘building blocks for a healthy brain’.
Given the significant influence of parenting on children’s mental health, in particular in the formative early years, we recommend targeted programmes to support ‘at risk’ mothers and mothers-to-be and have provided examples of successful early years initiatives from the UK, Australia and the USA, for consideration.
3. Reduced resilience increases vulnerability to mental distress
3.1 Children’s resilience in a historical context
We move now from clinically diagnosed mental illness to self-reported mental distress, which currently represents the vast majority of ‘mental health problems’ among children and young people in the UK.
Resilience is recognised as being protective of mental health.22,23,24 So it is useful to consider how the resilience and consequent mental health of today’s children and young people compares with that of their predecessors in previous generations.
We can, for example, compare the mental health of children and young people during the Second World War with their mental health during the 21st century (both prior to and then during Covid-19).
From 1939 to 1945 children and young people in the UK faced a range of challenges. As the Imperial War Museum reports, ‘The Second World War was a time of major upheaval for children in Britain. Over a million were evacuated from towns and cities and had to adjust to separation from family and friends. Many of those who stayed endured bombing raids and were injured or made homeless. All had to deal with the threat of gas attack, air raid precautions, rationing, changes at school and in their daily life’.25 Changes at school, incidentally, included some 2,000 schools being requisitioned for war use, one in five schools being damaged by bombing, and air raids frequently interrupting lessons for hours.
It is true that there is evidence of greater mental health problems in adult life for those children evacuated while they were very young or who received poor foster care.26. However, we have found little evidence of increased mental health problems for children and young people overall during the Second World War. This may, in part, be due to issues of under-reporting in a period with less sophisticated diagnostic methods. It is probably, though, also due to higher levels of resilience among children at that time.
In comparison with the Second World War the challenges faced by children and young people today, even during Covid-19, are real but overall of a lower order of magnitude than were experienced in six years of world war. This suggests that today’s children should, overall, be less vulnerable to mental health problems than their wartime equivalents. However, the reverse seems to be the case, with report after report describing rising levels of mental health problems.
3.2 Why might children’s levels of resilience have reduced?
Young people who have experienced abuse and neglect in childhood, or have grown up in dysfunctional families, are likely to benefit from enhanced support and protection. However, as we explain in more detail below, providing ever more support for children from caring, supportive families may prove counterproductive, reducing their resilience and increasing the risk of mental distress. We see this not only in schools and universities but also in the world of work, where the 2020 report on Mental health and employers by Deloitte reported that young professionals (i.e. recent graduates) were twice as likely to suffer from depression as the average employee.27
This is particularly important in a changing and sometimes unpredictable world – with Covid-19, the gig economy and the Fourth Industrial Revolution just some of the factors disrupting our expectations of what life will be like. Students with varied experience of meeting and learning from change and challenge are likely to find it easier to adapt in a changing world – whereas those constantly protected from change and challenge are likely to fare less well and be more predisposed to mental distress.
Resilience can probably best be explained as a combination of innate ability, a supportive environment and opportunities to experience and learn from challenge and failure. However, social changes in recent decades have significantly reduced that third element for many young people – the opportunities to experience challenge and failure. This contrasts with their twentieth century predecessors, who were more likely to be the product of ‘free range parenting’ and for whom their time at school was relatively free of safeguarding and spoon-feeding. It also perhaps explains why fear of failure is now at record levels among UK students and why staff at universities like Harvard have been talking for some time about students arriving at university ‘failure deprived’ 28,29
Traditionally research has suggested that a key to resilience in children and young people is at least one stable and committed relationship with a supportive parent, caregiver, or other adult.30 This fits with our earlier assessment that initiatives to support parenting in the early years is important in reducing the risk of diagnosed mental illness. However, as the education system, parenting, information technology and perceptions of mental health have changed and evolved in recent decades in the UK, this appears to have impacted on opportunities for children and young people to develop resilience and increased their vulnerability to mental distress.
Mental health is a complex issue, potentially influenced by many factors. However, our assessment is that the following four factors are all implicated in making today’s children and young people less resilient, less able to cope with the challenges of adolescence and emerging adulthood and more predisposed to report mental distress:-
These factors may also help explain why the vast majority of students reporting mental distress at university first experienced symptoms while still at school.61,62
Conversely, opportunities to experience life away from over protective schools and parents (and social media) and opportunities to experience ‘productive failure’ appear to increase resilience and coping skills and reduce reported mental health problems.,63,64,65,66,67,68
In this context we were particularly struck by research into the long-term effects on mental health of being a Guide or Scout, which concluded, ‘Participation in Guides or Scouts was associated with better mental health and narrower mental health inequalities, at age 50. This suggests that youth programmes that support resilience and social mobility through developing the potential for continued progressive self-education, ‘soft’ non-cognitive skills, self-reliance, collaboration and activities in natural environments may be protective of mental health in adulthood’.
We also note research published by Leeds Becket University in 2019, which found that a single one-week Outdoor Adventure programme resulted in significant positive gains in the resilience of those participating, as well as heightening sub-domains of resilience, such as the capacity to make friends, solve problems and take control.
Meanwhile, back in the classroom we note that in its 2016 assessment of innovative pedagogy, the Open University rated the ‘productive failure’ approach as having high potential impact. This is a method of teaching that gives students complex problems to solve and attempt to form their own solutions before receiving direct instruction. Students may lack confidence at first but the experience can help them become more creative and resilient.
We also note that, from Ivy League Universities in the USA to independent schools in the UK and Australia, the importance of encouraging students to consciously experience and learn from failure, in order to boost resilience, is now being recognised. Professor Stephen Dinham, Associate Dean of the University of Melbourne's Graduate School of Education observes, ‘When you give kids a lot of positive reinforcement and no negative feedback ... it tends to confuse them and gives them a false sense of how they are going. It sets up a situation where they get into the big world and suddenly they are not as good as they think they are’. Conversely, as the Head of Counselling at an independent school comments, "We want our students to recognise that failure, and making mistakes, is a really crucial part of learning."
To develop children and young people’s resilience and reduce their vulnerability to mental distress, we recommend that opportunities are provided to experience life and challenges away from over-protective schools and parents.
Research provides a number of examples of how this can be achieved, including:
3.3 The unintended consequences of safeguarding for mental health
In recent decades there has been an increasing and well-intentioned desire to protect children and young people from harm, safeguarding them from risk. Unfortunately, as the children’s charity Barnardo’s reported as early as 2002, the more western countries have sought to protect children from risk, the less resilient and prone to psychosocial disorders they have become.69
This is a point recognised by Ofsted’s Chief Inspector. In 2017 she warned against, ‘good intentions creating an unnecessarily risk-averse culture which does nothing for children’s development and learning’ and went on to say, ‘over the years an over-cautious culture has developed in our schools, one that too often tries to wrap children in cotton wool….It is, I am sad to say, a culture that deprives children of rewarding experiences, of the opportunity to develop resilience and grit, and which makes it hard for them to learn to cope with normal everyday risk’.70.
Students in the UK are probably less likely to fail than ever before. For instance, the proportion of first class honours awarded has tripled since 1994.72 Yet fear of academic failure has risen, particularly among girls here, who now rank fifth in the world for fear of failure.72
Rachel Simmons, a leadership development specialist explains that those who are "failure deprived" (a term coined by staff at Stanford and Harvard) have poorer coping skills and are much more likely to experience depression and anxiety. Smith College, for instance, offers a "Failing Well" initiative.73 The program also encourages resilience, offers workshops on impostor syndrome and perfectionism and aims to destigmatise failure by making it known that it is OK and common to "fail".
We recommend that the inquiry distinguishes between the need to safeguard ‘at risk’ children and the need to encourage resilience among the majority of children and young people who are not ‘at risk.’
We also recommend that the inquiry takes note of and encourages active implementation of the revised (2019) Ofsted inspection framework, in particular as it relates to the extent to which, ‘the curriculum and the provider’s wider work support learners to develop their character – including their resilience, confidence and independence.’
3.4 Over-protective parenting
Some parents may also share responsibility here. We know that poor parenting (neglecting or abusing children) increases the risk of diagnosed mental health conditions. However, excessive parenting, hovering over your children to protect them from any possible challenge (what American researchers have dubbed ‘helicopter parenting’) appears to increase the risk of mental distress. Most research suggests that helicopter parenting has harmful psychological effects. These include increased emotional problems; increased levels of anxiety, stress, depression and life satisfaction; neuroticism; dependency; sense of entitlement (the extent to which young adults believe others should solve their problems); and poorer coping skills.
Meanwhile, here in the UK, one Head Teacher we spoke with commented, ‘I’ve really noticed a change in parenting in recent years…They can be unwilling to let their children grow up.’ While a Healthy University Project Coordinator in Scotland noted, ‘reliance on parents until they leave home, for even the most basic things.’
Examples of helicopter parenting reported by schools include:
That this might increase the risk of mental distress is logical. Resilience and coping skills are developed by experiencing and overcoming challenges. So, if those challenges are removed by parents and schools then coping skills are also reduced. Similarly, if children have never been allowed to experience and learn from failure, they may find the prospect of failure particularly stressful, which helps explain the increasing fear of failure among young people at a time when, paradoxically, academic success is at record levels. The growth of a safeguarding culture in the UK, while well intentioned, may be exacerbating the problem. Anecdotal evidence suggests it may also be leading to social pressure on parents to seek to protect their children from all possible risks, for fear of being branded a ‘bad parent’ if they don’t. For example, one parent who allowed her two primary age children to walk together to the local corner shop (something that would have been seen as normal only a generation or so ago) was described as ‘feckless’ by some of her friends.
One interesting international comparison is with the Netherlands, where a recent study found no evidence of an increase in student mental health problems over the last ten years.74 This probably isn’t surprising as, since the World Happiness report started in 2012, the Netherlands has never finished outside the top seven, whereas the UK has never come higher than 15th.75 One important difference is the Dutch style of parenting, where the main concern is reported to be to raise their children to be independent and to learn from their own experiences. Parents there are not afraid to openly discuss issues such as drugs and alcohol, but they do not ‘lecture’ their children. Perhaps a more collaborative parent-child approach to parenting that recognises the realities of growing up could foster more autonomy and self-confidence among young people in the UK, better preparing them for the challenges of life and reducing the risk of mental distress.76,77
Parenting isn’t easy and we shouldn’t make parents feel even guiltier. However, the more parents can see that helicoptering may help in the short term but could be storing up problems for their children longer term, then hopefully the more they will be open to scaling back their interventions.
We therefore recommend that the inquiry considers how autonomy supporting parenting can be encouraged, to limit the unintended harm potentially caused by over protective and over indulgent parenting. This includes consciously avoiding doing everything for your children (including their homework) – helping them to work out how to do things for themselves, including encouraging them to come up with creative solutions. It also includes letting your children take responsibility for their actions, where appropriate, so they can learn from their experience.
3.5 The influence of social media – another potential factor
A further factor is the impact of social media, a relatively recent phenomenon, widely used by young people in particular and seen as beneficial by many. However, there can be potentially negative effects on mental health. This can be due to the malicious use of social media, for instance to bully, troll or harass, as well as to insufficient monitoring of content that encourages eating disorders and self-harm. In addition, there are more subtle but potentially harmful effects for mental health:
A 2019 study in the USA concluded, ‘there has been an increase in smartphone use, which has been found to be associated with lower grades, alcohol use disorders, anxiety and depression.’
This perhaps explains why the American researcher, Jean Twenge, who has been researching intergenerational differences for over 20 years, concludes, ‘There is compelling evidence that the devices we’re placing in young people’s hands are having profound effects on their lives – and making them seriously unhappy.’ She also observes that, in part because young people are spending more time on screen at home rather than out with friends, across a range of behaviours - drinking, dating, spending time unsupervised - 18-year-olds now act more like 15-year-olds used to. Because of social media, are today’s young people less independent and equipped with coping skills than their predecessors? If so, this might also help explain the significant reported increase in mental distress (stress, anxiety, panic, worry, loneliness, feeling unsupported and overwhelmed).
The negative effects of social media on young people’s mental health can be reduced by:
• Reclassifying social media platforms as publishers, to ensure they take more responsibility for their content (including content relating to eating disorders and self-harm)
3.6 A significant shift in how negative feelings and emotions are being interpreted
For centuries negative feelings and emotions have been a natural response to the challenges and adversities we all experience at some stages in our lives. Indeed, they have been a staple of literature and popular music. Loneliness, for instance, was an issue for fictional characters from Jane Eyre (‘The trouble is not that I am single and likely to stay single but that I am lonely and likely to stay lonely.’) to Huckleberry Finn ('I felt so lonesome I most wished I was dead.’) It has been a recurring theme in popular music, for instance in Heartbreak Hotel, Elvis Presley’s first million selling record (‘Where I get so lonely, baby. Well, I'm so lonely, I get so lonely, I could die.)
It is only relatively recently that these negative feelings and emotions (and their dramatized expression by adolescents) have been interpreted and reported as ‘mental distress.’
Unfortunately, media coverage has often exacerbated the problem. Stories of young people’s mental health crises may boost sales among worried parents but are sadly not always evidence-based. For example, some newspapers have given the impression that university students are at particular risk of committing suicide, whereas the Office for National Statistics (ONS) has confirmed that university students are less likely to commit suicide than their non-university counterparts and that, although there has been an increase in suicides among females aged 10 – 24 in recent years, overall young people are less likely to commit suicide than adults.79,80
Our brains are still developing until we’re in our mid-twenties. As we go through adolescence and seek to develop our own individual identities, we face a range of challenges (biological, social and psychological) in making a successful transition to adulthood. This usually involves a fair amount of trial and error along the way. This is a normal developmental process for us as human beings. However, a combination of the pressure this places on adolescents and the increasing tendency to medicalise normal feelings and emotions may lead this normal developmental process to be interpreted as mental distress. S
A further point is raised by Dominique Thompson, a former university GP who has heard from thousands of students about mental difficulties. She says it is crucial for students to stop viewing everything in life as a competition. According to her, comparing ourselves to others all the time only leads to a toxic form of perfectionism which leads to being terrified of failing at anything at all.81 This tendency to compare though is far less prevalent in Dutch culture. One of the key reasons Dutch teens are reported to be happier than their UK counterparts, according to a report in The Times, is the tendency to not constantly compare oneself to others academically or socially.82
We recommend that the inquiry considers how parents and schools can help children and young people recognise that their lives will not always be perfect, that they will encounter challenges and setbacks, and that as a result they may sometimes feel anxious, stressed and upset – but that this is normal, not a sign that they are experiencing mental health problems.
It would also be very helpful if the media could ensure responsible coverage of children and young people’s mental health, in particular ensuring that stories are evidence based and use medical terminology only where this is appropriate.
Appendix A How we use mental health terms in this submission
We use mental health to refer to a positive state of mind, in line with the World Health Organisation’s 2014 definition i.e. ‘a state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively or fruitfully and is able to make contribution to his or her own community’
Examples here include: Life satisfaction, feelings that things done in life are worthwhile, happiness and low levels of anxiety.
We use mental distress in the sense described by the Institute for Public Policy Research (IPPR) in its 2017 report Not by degrees i.e. ‘where individuals self-report mental health problems, which have not been subjected to clinical screening measures.’ In practice, this typically refers to self-reported negative feelings and emotional distress.
Examples here include: Stress, anxiety, panic, worry, loneliness/social isolation, feeling unsupported, problems sleeping, fear of failure and fear of being judged.
We use mental illness in the sense described by the IPPR in their 2017 report i.e. ‘where an individual experiences the symptoms of one or more clinically diagnosable mental health conditions’.
A key point here is that there has been clinical diagnosis, although we do have concerns regarding the extent to which the bar for diagnosis has been lowered in recent years, as this may result in less specialist help available for those in more serious need.
Mental illness includes but also extends beyond mental disorders (see below) to conditions that would not normally be grounds for sectioning, for example to more common conditions such as depression and anxiety.
An example of a less severe and enduring mental illness is reactive depression (as opposed to major depressive disorder), typically linked to definable life events and milder symptoms (sadness, loss of interest, feelings of guilt and unworthiness, difficulty sleeping).
We use mental disorder in the more concise sense described in the fourth edition of the American Psychiatric Associations’ Diagnostic and Statistical Manual of Mental Disorders (DSM – 4) i.e. ‘A clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or important loss of freedom.’
A ‘mental disorder’ in this sense is a pre-condition for sectioning under the Mental Health Act
Examples here include clinically diagnosed: Anorexia, bipolar disorder, clinical depression, personality disorder, psychosis and schizophrenia.
Web links are provided for ease of access by Inquiry members, where available.
53. Demedicalising Misery: Psychiatry, Psychology and the Human Condition Rapley M and Moncrieff J (co-editors) Palgrave Macmillan 2011