Written evidence submitted by MRC_SCO Social and Public Health Sciences Unit, University of Glasgow (CYP0075)

UK Parliament Health Social Care Committee Consultation

This response is submitted by the MRC/CSO Social and Public Health Sciences Unit (SPHSU), University of Glasgow. SPHSU hosts the Transdisciplinary Research for the Improvement of yoUth Mental Public Health (TRIUMPH) Network (http://triumph.sphsu.gla.ac.uk) one of eight mental health research networks funded by UKRI/ESRC. The Schools Health and Wellbeing Improvement Research Network (SHINE) is also based at SPHSU. Below we have responded to specific points within the inquiry terms of reference drawing on recent research within the field of youth public mental health and information gathered by the TRIUMPH network through engagement with a range of expert stakeholders in young people’s mental health including practitioners, policymakers, researchers and young people themselves.

SUMMARY:

An overall decline in the mental health of young people has occurred in recent years both in the UK and globally. The Covid pandemic has further negatively impacted children and young people’s mental health whilst simultaneously presenting significant challenges to mental health support services. Based on TRIUMPH’s agenda-setting workshops, interventions which target children and young people as early as possible in settings which make them feel comfortable and supported are vital to developing positive mental health and wellbeing. 

Schools and non-clinical settings are a key area where interventions can be better targeted. Whole school approaches involving all members of the school environment – including pupil families – which promote mental wellbeing, belongingness and inclusion are important. Links between schools, mental health services and community support services need to be strengthened to improve signposting. This can also facilitate the collection of data for evaluating and monitoring interventions, which can be an important tool for schools to keep track of pupil mental health as demonstrated in the roll-out of the SHINE mental health survey. Further work is needed to recognise how children and young people can best access resources and support, particularly in the context of digital inequalities that have been highlighted during the Covid pandemic. Loneliness also significantly effects children and young people, further highlighting the need for community and other settings-based mental health and wellbeing support. Underpinning all this is a need to improve capacity as well as mental health awareness & wellbeing training for those working with children and young people.

While individual-level mental health support is important, it is crucial to address the wider social, organisational, environmental, and cultural determinants of mental health ill-health. Marginalised groups are at particular risk of poor mental health and so development of interventions that are delivered in settings and networks in which these young people spend much of their time is required. Based on TRIUMPH’s research priorities, interventions which better support children and young people’s mental health could be:

• implemented within schools and other education settings;
• aimed at helping young people to develop social connections and relationships with their peers, families and professionals that support positive mental health;
• and targeted at specific groups of children at the greatest risk of poor mental health.

Committee Terms of Reference 1: What progress have the Government made on children and young people’s mental health

Despite Government ambitions to improve children and young people’s mental health in the UK, recent evidence indicates an increase in the proportion of children and young people experiencing a probable mental health disorder from one in nine in 2017 to one in six in 2020[1]. There is also evidence of declining trends in subjective wellbeing and life satisfaction and an increase in feelings of anxiety[2]. The COVID-19 pandemic has added increased pressure on the mental health of young people, with government measures in response to the pandemic – particularly the closure of schools and childcare settings – having a disproportionate impact on children and young people[3].

An overall decline in adolescent subjective wellbeing has been shown to be a global phenomenon. A comparison of subjective life satisfaction of 15-year-olds across 46 countries between 2015 and 2018 showed, in 39 of the 46 countries, overall decline in this measure[4]. The UK was among countries with the largest decreases in life satisfaction, with more marked declines among girls.

Between November 2019 and January 2020, the TRIUMPH Network hosted a series of workshops across the four UK regions to bring together expert stakeholders in young people’s mental health from research, policy and practice with young people to identify research priorities within this field. The Government 2017 Green Paper sets out range of important areas to support children and young people’s mental health, and many of these topics came up in our workshop discussions indicating that these are still key areas where further support for young people is required. Discussions among stakeholders at the workshops highlighted that, while there are many examples of good practice in supporting children and young people’s mental health at the local level (e.g. within individual schools and organisations or at the local authority level), further evidence and investment are needed in order to develop these on a larger scale. However, evidence gaps exist and it is not clear at present what the most effective strategies to tackle these issues are. Based on these workshops, we have published a report that identifies priority areas for further research that will support the development of effective interventions to better support young people’s mental health[5].

Where further progress is needed:

Schools

UK research has shown that schools and teachers can play a crucial role in supporting young people with anxiety and depression to seek professional help[6], and that pupils’ feelings of belonging a perception of an inclusive school environment, and positive pupil-teacher relationships are associated with positive pupil mental health[7]. However, recent data from the Health Behaviour in School-aged Children (HBSC)study shows that UK adolescents feel far more pressured by schoolwork than their international counterparts (girls more so than boys), and also report relatively low levels of classmate support[8]. Gender differences are stark, with girls almost always reporting more negative mental wellbeing across a range of indicators (feeling low, feeling irritable, feeling nervous). In a recent UNICEF report the UK also ranks 27th out of 38 countries for overall child wellbeing outcomes, falling to 29th specifically for mental wellbeing[9]. In relation to the provision of mental health support through schools, the work of the TRIUMPH Network has identified a number of areas where further evidence/action is required including:

• relationship education and providing digital literacy training around social media use;
• whole school approaches to support mental health and wellbeing;
• supporting young people during school transitions;
• staff mental health training; and engagement with families around young people’s mental health issues.

While capacity for targeted support for pupils is important, research suggests that identification and treatment of individual students with mental health problems is not enough to improve overall pupil wellbeing across the school. Investment in preventive approaches is needed to stop problems developing in the first place or escalating further following early signs of distress. This requires a focus on wider school environmental factors including school ethos and relationships, as well as patterns of behaviour and wellbeing at the peer group level. Evaluating and modifying these school- and peer-level factors may enhance overall wellbeing as effectively, if not more effectively, than individual pupil support.

Training and knowledge

Capacity issues and training within the mental health workforce was a common theme among stakeholders at the TRIUMPH workshops, indicating that this is also an area where further investment is needed. However, it is important to note that given the focus of the TRIUMPH Network on public health approaches to support mental health, in this context the mental health workforce was recognised to include not only health-care staff, but also those who support young people on a daily basis within schools, youth groups and other community settings. In addition, the importance of providing parents and carers with the skills they need to support young people’s mental health was highlighted. One key training need identified among the wider mental health workforce was in relation to improving understanding of the particular issues faced by specific groups of children and young people at risk of poor mental health, such as LGBTQ+ and care-experienced young people. Areas identified for further training included: how to create inclusive environments and reduce stigma towards these groups; how intersectionality between different protected characteristics can influence mental health; and how best to ensure that these at-risk groups can access the targeted support they may need.

Support in non-clinical settings

Another area in which TRIUMPH stakeholder workshops identified evidence gaps was around how to improve links between different services and settings, and how to improve young people’s awareness, access and experience of services. Particular issues were raised about the best ways to integrate mental health services with schools to provide better signposting and more consistent and appropriate support for young people, and the role of community settings to support mental health and wellbeing. By improving the support offered through these non-clinical settings, there is potential to reduce the pressure on front-line health services, improve understanding of mental health and wellbeing among young people and their families, and reduce stigma that can be associated with mental ill-health. In relation to our work with care-experienced young people, discussions centred on how to establish better interagency working to support this particularly vulnerable group and improve their access to mental health support.

Access to support

More recently, restrictions on face-to-face mental health services during the COVID-19 pandemic have posed particular issues for some young people in accessing mental health support. The TRIUMPH Network contributed to the Independent Children’s Rights Impact Assessment of the response to COVID-19 in Scotland[10], which highlighted issues around access to mental health information and support during the pandemic as a result of the loss of face-to-face mental health services and support from schools and community organisations. While information and services were provided online or via other remote methods, evidence indicates that many children and young people were not confident in knowing where to access information from trusted sources, or were digitally excluded from services due to lack of access to technology/internet or challenges with online communication. Therefore, while we recognise that the accelerated development of digital services as a result of the pandemic has the potential to provide access to mental health support to a broader range of children and young people in the future, there is a need for better understanding of how digital mental health services can be optimised and implemented safely and effectively among young people, and in a way that does not result in the exclusion of groups of children. Recent research has highlighted how co-design of digital mental health technologies with young people and practitioners could support development in this area[11].

Committee Terms of Reference 3: The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing

As a research network focussed on public health approaches to improve mental health, TRIUMPH strongly advocates for prevention and early intervention approaches to children and young people’s mental health. The importance of effective prevention measures cannot be overstated, as these will pay dividends in terms of improving public mental health further down the line. Prevention and intervention policies targeted at early life stages can help avoid individuals requiring crisis support in adulthood. Young people with poor mental health and wellbeing are more likely to have poor educational attainment and employment prospects, social relationship difficulties, physical health and substance misuse problems, and to become involved in offending[12]. Reducing the number of children and young people developing severe mental ill-health will reduce pressure on CAMHS which are struggling to deal with the full extent of youth mental ill-health[13]. The COVID-19 pandemic has highlighted that mental health is extremely vulnerable to social and economic conditions. It demonstrates a need to focus on population-level mental health prevention policies that are targeted in key educational and community settings.

Social factors and key settings

Research has identified that evaluations of individual-level interventions to improve the mental health of adolescents in vulnerable groups is severely lacking, making it difficult to identify what works and what doesn’t[14]. However, many of the risk factors for poor mental health and wellbeing sit outside the individual level[15], therefore it is critical to address the wider social, organisational, environmental, and cultural determinants of mental health ill-health. A socio-ecological systems approach (in which influences on health are modelled across multiple levels: inter-personal relationships, settings, neighbourhoods and communities, and policy[16]) is a useful framework to look at how to change aspects of the system influencing mental health to promote positive change within it rather than only seeking the solution to an individual problem, and will facilitate a prevention focus on the whole population[17]. Mental health and wellbeing is strongly socially patterned[18], strongly gendered, and marginalised young people will often experience the greatest health needs[19]. As such, a focus on the development of interventions that are delivered in the settings and networks in which these young people spend much of their time is required.

These settings can also facilitate effective evaluation and monitoring. The Schools Health and Wellbeing Improvement Research Network (SHINE) works with over 275 Scottish schools to facilitate a data-led, systems-level approach to support health improvement action within the school setting, with a particular focus on mental health. Through the SHINE case studies[20] schools reported that pupil mental health and wellbeing is a major issue and is an area they need further support in responding to. The case studies informed the development of the SHINE mental health survey[21], a flexible resource for SHINE schools to survey pupils from P6 to S6, allowing schools to track and monitor the mental wellbeing of their pupils. More than 50 schools, representing over 6000 pupils have used this resource since its launch in September 2020. The schools are now using the data reports to support action planning and targeted interventions to improve wellbeing.

The closure of schools during the COVID-19 pandemic has further highlighted the importance of these settings in providing mental health support for children and young people[22]. SHINE collaborated with Generation Scotland on the TeenCOVIDLife survey[23] which used questions/measures from both the HBSC survey and the SHINE mental health survey, allowing participating schools and local authorities to monitor changes in wellbeing during this period. Two SHINE schools shared their experiences of using the mental survey as part of an online training course[24] for teachers hosted by Policy Hub Scotland.

Developing systems that encourage and facilitate cross-sector working (e.g., between schools and health care settings and with policymakers) is crucial to successfully identifying and implementing system-level changes. Based on our priority-setting work3, areas of particular relevance from a systems perspective where early intervention would support children and young people’s mental health could include interventions which are:

• implemented within schools and other education settings;
• aimed at helping young people to develop social connections and relationships with their peers, families and professionals that support positive mental health;
• and targeted at specific groups of children at the greatest risk of poor mental health.

Despite being frequently associated with older adults, loneliness is most common among young people[25] and represents an important target for early intervention strategies. Recent research[26] using a socio-ecological systems framework has identified that loneliness among young people is associated with poorer mental well-being. Young people particularly at risk of loneliness include LGBTQ+ youth, young women, and young people from non-minority ethnic backgrounds. Community factors play an important protective role against loneliness. Young people who report higher perceived neighbourhood quality and a greater sense of belonging to their communities also report lower levels of loneliness. Social prescribing – when clinicians refer people to more holistic community services – is known to reduce loneliness among adults[27] , and may represent a useful strategy for increasing community engagement and improving wellbeing among young people if adapted to school and education settings. Loneliness, and key predictors of loneliness such as gender and sexual identity, vary by geographic region suggesting that interventions should be targeted at local level and involve local communities in identifying effective strategies based on local needs and resources.

Committee Terms of Reference 4: How the Government can learn from examples of best practice, including from other countries?

The TRIUMPH network’s involvement in analysis for the Independent Children’s Rights Impact Assessment of response to Covid-19 in Scotland6 highlighted many areas of overlap between rights-based approaches and public health approaches to supporting children and young people’s mental health, with both taking into consideration a wide range of determinants of health and wellbeing[28]. When developing future strategies to support children and young people’s mental health and wellbeing, it will be important to consider how these also meet the rights of the children as set out in the United Nations Convention on the Rights of the Child using tools such as Children’s Rights and Wellbeing Impact Assessments. Given that we know the UK lags behind other countries in relation to young people’s mental health and wellbeing8, learning from other countries is essential with particular reference to educational and social policy. A recent report by UNICEF Innocenti on child wellbeing in rich countries9 provides a useful steer, identifying key elements of children’s activities, relationships, networks and resources that impact on wellbeing within a wider policy and social context.

February 2021