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Written evidence submitted by The Education Policy Institute (CYP0078)
About the Education Policy Institute
The Education Policy Institute is an independent, impartial and evidence-based research institute that aims to promote high quality education outcomes, regardless of social background. We have a dedicated mental health team which considers the challenges and opportunities for supporting young people's mental health and wellbeing.
Along with our response, we attach two recent reports on children and young people’s mental health, ‘Access to child and adolescent mental health services in 2019’ and ‘Young people’s mental and emotional health: Trajectories and drivers in childhood and adolescence’. Respectively, these reports cover referrals to CAMHS and waiting times for treatment in 2019 and the determinants of mental and emotional health amongst Gen Z young people.
1.1 A key goal of the CAMHS transformation programme launched in 2015 was for a third of children and young people with a diagnosable condition to be accessing specialist services by 2020/21. While the number of young people accessing treatment has increased, we cannot be sure about the proportion given that government estimates do not take into account recent, and higher, prevalence rates of probable mental illness.
1.2 While waiting times are falling, particularly for eating disorder treatments, time to treatment remains a postcode lottery. As laid out in the Children’s Commissioner’s recent report, many areas remain far from the goal of a four-week waiting time standard laid out in the 2017 Green Paper.
1.3 Poor data obscures our understanding of the state of services and ability to monitor progress. A robust system for reporting data on access to CAMHS, including a clear definition of children who are eligible for treatment, is urgently required. Measures of success should be focused on outcomes, rather than processes. Failure to introduce stronger accountability measures may hinder the government’s plans to improve services.
2.1 Children’s mental health is largely a product of the material, social and economic conditions, in their immediate and wider environment, into which they are born and grow up. By addressing these factors, many problems can be prevented from developing in the first place.
2.2 Cross-government strategy and action is required on the determinants of poor mental health and low wellbeing. Based on the findings of our report and the existing evidence base, we believe this should include, but not be limited to, an explicit strategy to address mental health inequalities in the population as a whole given the strong links between parental and child mental health, action to reduce child poverty, and an evidence-based, national anti-bullying programme in schools with clear details on funding, delivery and accountability.
2.3 Local mental health support teams to address pupil issues in schools are currently being piloted in a minority of local areas, but most children across the country will not benefit from this additional support for several years. It is unclear if schools without designated mental health leads, which the Government has not made mandatory, will benefit from these teams to the same extent as schools with a mental health point person.
2.4 The best evidence on what schools can do to support mental health and wellbeing is a ‘whole-school approach’ which requires school leadership to prioritise mental health alongside attainment. The Government must ensure that local support teams work to embed this approach in all schools, colleges and alternative provision, while considering whether more fundamental reforms to address potential perverse incentives are required.
3.1 Prior to the pandemic, the majority of young people with a mental illness were unable to access specialist support. We do not have data on what, if any, lower-level services existed to support them and their families across the country.
3.2 Recent data suggests that, since the advent of the COVID-19 pandemic, the prevalence of probable mental illness in young people has risen to one in six, up from one in nine in 2017. Referrals to CAMHS have increased, while the number of young people in treatment has remained constant. Findings from the Children’s Society annual ‘Good Childhood Report’ show that close to one in five young people scored low on their measure of wellbeing in 2020 compared to approximately one in ten in previous years. International data consistently shows that young people in England have relatively low wellbeing compared to their counterparts in other countries.
3.3 The Government must continue to regularly collect and closely monitor prevalence data to verify if this is a sustained increase in mental health problems and low wellbeing. Yet, regardless of whether these trends persist, the Government must go beyond current plans to close the gap between demand and available support.
Whitney Crenna-Jennings is a senior researcher in the Social Mobility and Vulnerable Learners team at the Education Policy Institute. Whitney was a co-author of ‘Unexplained pupil exits from schools: Further analysis and data by multi-academy trust and local authority’, ‘Education in England: Annual Report 2019’ and ‘Access to children and young people’s mental health services – 2018’. Prior to joining EPI, she worked as a researcher in the Department of Epidemiology and Public Health at University College London. Whitney graduated with an MSc in Social Epidemiology (with Distinction) from UCL in 2015.
Jo Hutchinson is Director for Social Mobility and Vulnerable Learners at the Education Policy Institute. Jo’s previous publications include ‘School inspection in England: Is there room to improve?’ and ‘Divergent pathways: the disadvantage gap, accountability and the pupil premium’. Jo was a co-author of ‘Closing the gap? Trends in educational attainment and disadvantage’, ‘Grammar schools and social mobility’, ‘Educational Outcomes of Children with English as an Additional Language’ and ‘Access to children and young people’s mental health services – 2018’. Prior to joining EPI, Jo spent ten years as a statistician at the Department for Education.
Acknowledgements
Saimah Khan was a Nuffield summer research intern at the Education Policy Institute. Saimah is completing her A-levels this year in London.
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About the Education Policy Institute
The Education Policy Institute is an independent, impartial, and evidence-based research institute that promotes high quality education outcomes, regardless of social background. We achieve this through data-led analysis, innovative research and high-profile events.
Education can have a transformative effect on the life chances of young people, enabling them to fulfil their potential, have successful careers, and grasp opportunities. As well as having a positive impact on the individual, good quality education and child wellbeing also promotes economic productivity and a cohesive society.
Through our research, we provide insight, commentary, and a constructive critique of education policy in England – shedding light on what is working and where further progress needs to be made. Our research and analysis spans a young person's journey from the early years through to entry to the labour market.
Our core research areas include:
▪ Benchmarking English Education
▪ School Performance, Admissions, and Capacity
▪ Early Years Development
▪ Vulnerable Learners and Social Mobility
▪ Accountability, Assessment, and Inspection
▪ Curriculum and Qualifications
▪ Teacher Supply and Quality
▪ Education Funding
▪ Higher Education, Further Education, and Skills
Our experienced and dedicated team works closely with academics, think tanks, and other research foundations and charities to shape the policy agenda
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Published January 2020 Education Policy Institute.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. For more information, visit: creativecommons.org
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Access to mental health services 7
Provision for groups of vulnerable children 7
Part 1: Access to mental health services 13
Referrals that are rejected or deemed inappropriate 13
Reasons for rejected referrals 16
Median waiting times to assessment and treatment 18
Maximum waiting times to assessment and treatment 20
Part 3: Provision for groups of vulnerable children 22
Children and young people with conduct disorder or difficulties 24
Children and young people in social care 26
Young people transitioning to adult mental health services 27
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The Education Policy Institute is an independent, impartial and evidence-based research institute which aims to promote high quality education outcomes, regardless of social background.
Our research particularly focuses on the long ‘tail’ of low attainment, which is heavily associated with characteristics of student vulnerability – including poverty, special education needs and mental health issues.
There is an increasing understanding of the high prevalence of mental health issues amongst young people, and the links between poor mental health and poor student attainment and progress. However, in the past, the reporting of mental health prevalence, ease of access to services, and speed and effectiveness of treatment has been poor. Without a better understanding of these issues, it is difficult to identify the main problems of service delivery, and it is therefore much more challenging to effectively address these problems through policy change or additional resources.
Our Annual Report on young people’s mental health is designed to improve understanding of the ease of access to mental health services and to identify the main challenges for policy makers. It says much about the continuing unsatisfactory nature of data collection and reporting that it is necessary for us to collect our data through Freedom of Information requests to each provider – this is time consuming, and has raised serious questions about the consistency and reliability of reporting. We hope that in the future the government will take a lead in collecting this data, ensuring its quality, and publishing it regularly.
The data set out in this report show that while in some areas there has been an apparent improvement in speed of access over recent years, there continues to be a serious problem for many young people in accessing services, and doing so in a timely way. And the extent and speed of access differs significantly around the country. Based on the evidence we have collected, it seems that there is much work to do if policy-makers are to realise their stated objective of providing timely access to high quality mental health services to all children who need this.
We welcome comment on the contents of this report.
Rt Hon. David Laws
Executive Chairman
Education Policy Institute
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Each year, the Education Policy Institute collects data through Freedom of Information (FOI) requests sent to child and adolescent mental health providers on indicators of specialist service quality. This year, we again report on the proportion of referrals to child and adolescent mental health services (CAMHS) that are rejected, and waiting times to assessment and treatment for accepted referrals. We also report on mental health provision for certain groups of vulnerable young people: those with conduct disorder or difficulties, in contact with the social care system, and those transitioning from CAMHS to adult mental health services (AMHS).
Access to mental health services
Newly collected data shows that CAMHS continues to be characterised by a large treatment gap, despite significant spending since 2015:
▪ In 2018-19, we found that approximately a quarter of children and young people (CYP) referred to specialist mental health services were not accepted into treatment. This includes young people with an eating disorder, and those who have self-harmed or experienced abuse. Despite the £1.4bn of extra spending over five years announced in 2015, the proportion of rejected referrals has not changed since we started collecting this information four years ago. Our previous research has highlighted that alternative mental health support services for those unable to access CAMHS have been decommissioned in many areas over the past eight years.
▪ We continue to find widespread variation in areas across England. On average, providers in London rejected 17 per cent of referrals, compared to approximately 28 per cent in the South of England and Midlands and East, and 22 per cent in the North.
▪ Referrals were most commonly rejected because providers considered young people’s conditions to be unsuitable for CAMHS, or because they did not meet the eligibility criteria or age specification for the service. These findings echo our previous research and raise concerns that the growing number of CYP with complex needs that do not fit clearly into diagnostic boxes, those with lower-level mental health needs and older adolescents may be unable to access the support they require.
▪ While median waiting times from referral to start of treatment have fallen by 11 days since 2015, children and young people waited an average of two months to begin treatment in 2019, double the length of the government’s proposed four-week standard. Maximum waiting times have also fallen significantly, but several providers reported that the longest waiting times, in some cases of over a year, were experienced by vulnerable children who face barriers to engaging with services.
▪ The longest median waiting times were found in London (65 days) and the shortest in the Midlands and East of England (49 days). This mirrors our 2018 findings and is likely related to the higher number of referrals accepted for treatment in London as compared with the other regions.
Provision for groups of vulnerable children
There are stark geographical differences in the availability of mental health services for some of the most vulnerable groups of children:
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▪ This year, we also sent FOI requests to local health and well-being boards, hosted by the 152 upper tier local authorities, which bring together representatives from local agencies involved in health and social care to ensure that the health needs of the local population are met in an integrated and holistic way. In a handful of cases, we were referred on twice to obtain the requested information or referred back to the LA after they had told us another agency held the information.
▪ We found that while commissioners in most areas engage with an array of groups, including CYP and their families through forums and surveys, to improve understanding of local need and service design, there is notably less engagement with community, and particularly faith, groups. This is concerning as the Care Quality Commission, regulator of health services in England, has found a widespread lack of responsiveness to the mental health needs of minority ethnic communities; meanwhile studies show high levels of mental health stigma prevent care seeking amongst minority ethnic faith groups.
▪ Approximately one in five areas have specific services or pathways for CYP experiencing conduct disorder or difficulties, the most common mental health condition amongst this age group. Several responses from health commissioners indicated a lack of understanding of conduct disorder as a mental illness, or a condition for which health services were responsible.
▪ Specific mental health services for looked after children (LAC), commissioned by either the CCG, LA or both, exist in over half of areas in the country, yet the responses highlighted significant inconsistencies in provision. In some areas, specific services were only available for certain groups of LAC, such as those who had experienced multiple placement moves. All children in contact with social services are able to access general CAMHS if they meet diagnostic thresholds. However, fragmented commissioning across agencies raises concerns that these children will not receive the specific support they need related to adverse childhood experiences, or will fall through the gaps.
▪ Fewer than one in five areas offer a specific service or have a dedicated staff member to support young people transitioning from CAMHS to adult services, despite research showing that the majority of young people face barriers to a smooth transition and many drop out despite ongoing clinical need. Only one area clearly indicated they were following the National Institute for Health and Care Excellence’s guidelines by starting transition planning in year 9.
Conclusion
Our newly collected data reinforces the picture of a system that is failing to meet need across the country, despite significant extra spending on CAMHS since 2015. Waiting times to specialist treatment have fallen but remain twice as long as the government’s proposed four-week standard. It remains unclear what support is available for the one in four children with mental health difficulties referred to, but not accepted into, treatment. Children with complex or less well-understood needs, including those with conduct difficulties, those in care, and those transitioning to adult mental health services, face a postcode lottery of provision.
The variation in figures reported to us by providers each year continues to indicate serious data quality issues. A robust system for reporting data on access to CAMHS, including a clear definition of children who are eligible for treatment, is urgently required. Moreover, the government should
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broaden its focus to prevention of mental ill-health, rather than acute intervention once problems are entrenched. Given the evidence on the importance of a child’s early life experiences and social and physical environment for lifelong mental health, we must ensure that public services holistically address difficulties as soon as they emerge. The 2017 green paper proposals, including establishing mental health support teams serving schools and colleges, may go some way towards improving early intervention; however, they will not be rolled out nationally until 2022-23 and there is likely to be wide geographic variation in how they operate. Given the evidence that mental illness is a key obstacle to social mobility through poor academic attainment, a more ambitious programme to reduce the burden of mental illness is necessary to ensure that all children, regardless of background, have access to opportunity.
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Following many years of underinvestment relative to adult mental health and physical health, a national programme to transform child and adolescent mental health services in England was launched in 2015. The government committed a total of £1.4bn to 2020-21, and all local authority areas developed Local Transformation Plans laying out their multi-agency approach to improving provision and ensuring services were matched to local need.
According to recent national estimates, almost one in eight 5- to 19-year-olds in England – or approximately 1.25 million children and young people – have a diagnosable mental illness. Prevalence is highly dependent on age, gender, socio-economic position and ethnicity: notably, a quarter of girls aged 17 to 19 have a diagnosable condition, with three times as many white British children as those from Asian ethnic backgrounds and twice as many children from low-income as from affluent families.1 There is no national data on the number of children with mental health needs that do not meet diagnostic thresholds.
The government’s focus on improving services and outcomes for children and young people is borne out by the evidence. The large majority of lifelong mental illnesses develop in childhood or adolescence, and the individual and societal costs of untreated adult mental ill health are vast, estimated at £105.2bn each year.2
Yet CAMHS in England continues to be characterised by a significant treatment gap – a disconnect between need and available provision. Currently, only a third of children with a diagnosable condition are accessing treatment. For those who do not meet eligibility criteria for or are unable to access CAMHS, previous research has shown that there may not be other services to fall back on: a quarter of 111 local authorities who responded to FOI requests EPI sent out in 2018 reported de-commissioning services related to the mental health and well-being of children and young people over the previous eight years.3
Each year, EPI queries public CAMHS providers (NHS trusts) using Freedom of Information requests about the number of children referred to their services but not accepted for treatment, and about waiting times to assessment and treatment for those who are accepted – data that is not published by the NHS.
Since we began collecting this data in 2016, we have found that approximately a quarter of referrals are not accepted into specialist treatment. Despite the extra spending since 2015, this has remained relatively steady. We have also found that waiting times for treatment continue to be long, with children and young people across the country waiting a median of 60 days to begin treatment last year – twice the government’s proposed standard of four weeks, currently being piloted in 12 areas.
This year, along with FOI requests sent to CAMHS providers, we have also asked local health and well-being boards about their level of understanding of local need, and provision for certain groups of vulnerable children with complex needs at risk of not being effectively supported. Health and wellbeing boards were established with the 2012 Health and Social Care Act to bring key leaders from the local health and care system together to improve the health and well-being of their local population – according to the King’s Fund, a healthcare think tank, they were originally seen as the primary engine for local integration and partnerships across the NHS, public health and local government.4 The purpose of HWBs is to address health inequalities and to ensure that the health needs of the local population are met in an integrated and holistic way. As such, we expected them
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to have a solid understanding of both local need and existing provision for groups of children and young people with complex needs.
Analysis of the responses to our Freedom of Information requests is presented in the chapters that follow.
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This year, we sent Freedom of Information requests to 64 public child and adolescent mental health services providers across England.
We asked providers for:
▪ condition not serious enough to meet threshold for access to service
▪ duration of condition not long enough (please state if you have a specific time limit)
▪ condition or situation not suitable for CAMHS service intervention (e.g. child does not have a diagnosable mental health condition)
▪ service lacks capacity to support the patient at this time
▪ existence of co-morbidity which excludes support from your service (e.g. substance misuse)
▪ young person over the age of 18
▪ other (please state); and
We received responses from 62 providers by 31 October, a response rate of 97 per cent. Five of these responded that they could not provide the data because another provider had taken over CAMHS in their area (three providers), they had moved to a new reporting system (one provider), or had recently taken over CAMHS in the area and therefore did not have the data available (one provider). The remaining 57 answered at least one of the questions in the request. In each section, we have specified the number of respondents who provided the information.
We also sent a Freedom of Information request to all upper tier local authorities (152) who are statutorily required to have a health and well-being board. We asked four questions about provision for groups of children and young people:
▪ A Healthwatch representative (advocates for service users), who is statutorily required to be a member of the HWB
▪ Children and young people and their families
▪ Community and/or faith groups
▪ Third sector organisations (charities, etc.)
We received 131 responses by 31 October, a response rate of 86 per cent.
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Part 1: Access to mental health services
Referrals that are rejected or deemed inappropriate
Public CAMHS providers were asked to provide the percentage of referrals to their services that had been rejected or deemed inappropriate in the last financial year (2018-19). Sixty providers out of 64 responded to this question.
On average, 26.0 per cent of referrals to CAMHS were rejected or deemed inappropriate. This was consistent with data we have collected since 2015, the year the national transformation was launched (see Figure 1). If we apply this to the number of children and young people accessing NHS-funded community mental health services in 2018-19 reported by NHS England, we estimate that approximately 132,700 children were referred for but not accepted into treatment.5 While NHS England has reported that more children with diagnosable conditions are receiving treatment as a result of the investment since 2015, there are many limitations to their current data, as acknowledged in their data evaluation exercises, meaning that the reported trends may not be fully reliable. In any case, a rise in the number of children being treated does not contradict our finding that the proportion of rejected referrals has remained steady since 2015.
Our previous research has raised concerns that alternative services to support children who cannot access CAMHS are not available in all local areas. The Care Quality Commission has highlighted that in cases where referrals are rejected and alternative services are not available, children are then referred back again for treatment when their mental health has deteriorated even further.6
Figure 1: Proportion of total CAMHS referrals rejected or deemed inappropriate
of rejected referrals |
30.0%
25.0%
20.0% 21.2%
15.0%
National CAMHS
transformation
launched
26.9% | 26.7% | 26.5% |
24.4% |
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26.0%
24.2%
Percentage |
10.0%
5.0%
0.0%
2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19
Financial year
Across providers, the proportion of rejected referrals ranged from 0.38 per cent to 86.0 per cent.
Providers with the highest proportion of rejected referrals in 2018-19 are presented in Figure 2.
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Figure 2: Ten providers with the highest proportion of rejected referrals in 2018-19
Provider | Proportion of |
| In 2017-18 | In 2016-17 |
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| referrals rejected |
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Larkwood Ward, managed by Essex Partnership | 86.0% | 17.9% | - |
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University NHS FT (inpatient) |
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| average) |
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Longview Adolescent Intensive Care Unit, managed | 70.0% |
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by Essex Partnership University NHS FT (inpatient) |
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Hertfordshire Partnership NHS Trust | 66.4% | - | 63.5% |
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Birmingham Women’s and Children’s NHS FT | 63.9% | 0%** | 0%** |
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(inpatient) |
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North Staffordshire Combined Healthcare | 58.0% | - | - |
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Cornwall Partnership* | 47.6% | 51.7% | 54.9% |
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Berkshire Healthcare NHS FT* | 46.0% | 44.9% | 53.4% |
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Norfolk and Suffolk NHS FT | 42.5% | 0% | 64.1% |
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Humber NHS FT | 42.0% | 17.9% | 18.9% |
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Alder Hey Children’s NHS FT* | 41.0% | 43.7% | 30.9% |
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‘-‘ means no reply
*These four providers also had among the ten highest proportion of rejected referrals in 2017-18. **Reported that no referral is deemed inappropriate or rejected; instead they are referred or signposted on to another service.
The variation in reported figures over time highlights the lack of reliability of CAMHS data in general, a major barrier to high quality provision, as highlighted by the CQC and explored further in our 2018 report. 3,6 It is also important to note that the way in which referrals are treated and categorised varies across providers; many who have adopted a ‘single point of access’ (SPA) model – meaning all referrals go through an administrative triage process, and young people who are not admitted for treatment are signposted to another service – state that they no longer reject referrals, and therefore may report a very low proportion of rejected referrals. However, we do not know to what extent an SPA makes a difference to the child who is rejected in practice; this will depend on the model of care that was in place before the SPA was introduced – and could mean the difference between hearing a ‘no’ and being signposted to another service.
As seen in Figure 3, we found greater variation across providers than in previous years: this was partly because some providers provided breakdowns by service or tier for the first time, and reported high numbers of rejected referrals from their inpatient services. Previously a provider-wide average may have masked wide variation in rejected referrals by type or tier of service.
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Figure 3: Distribution of referrals rejected or deemed inappropriate since 2012-13
x=mean
As seen in Figure 4, providers in the South of England reported on average the highest proportion of rejected referrals (with an average of 28.5 per cent of referrals rejected across all providers), followed by those in the Midlands and East (27.9 per cent), the North (21.8 per cent), and finally London (16.6 per cent). These figures were broadly consistent with those from previous years, with average rejected referrals dropping slightly in the South and London (between 2016-17 and 2018-19). Beneath these regional averages, there is significant variation across providers.
Figure 4: Average rejected referrals across regions in England in 2018/19
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Reasons for rejected referrals
We asked providers to report the reasons for referrals not being accepted for treatment, and received responses from 54. We provided six options for providers to choose from, including an ‘other’ option; some wrote in additional reasons (see Figure 5).
Similar to previous years, the most common reasons reported were:
Twenty providers reported that they did not collect or hold the data on reasons for rejected referrals in reportable format, which raises questions about the extent to which they use this data to improve their offer.
Other common reasons provided were:
▪ Referral error (duplicate, incomplete or insufficient information provided); and
▪ Signposted to another service or agency
One provider of community and inpatient services and one inpatient provider reported a referral had not been accepted due to a lack of capacity to serve the patient; these were different providers to the one that reported a lack of capacity as a reason for not accepting referrals in 2017-18.
There were other indications of a gap between available provision and need. One provider reported that referrals were turned away because no appropriate treatment was available. Four reported that referrals were rejected because the duration of the child’s condition was not long enough. Two reported that the service required was not commissioned by their CCG; it is unclear whether the child or young person in these cases would be eligible for treatment from an out-of-area provider.
Furthermore, a significant minority of providers (13) reported that referrals were rejected due to being incomplete, duplicates or not containing sufficient information. Last year, only three providers reported this as a reason.3 It is unclear whether this indicates actual change, indicating lower capacity for follow-up with referrers, or whether providers are simply categorising reasons differently over time. One provider gave not receiving a response to an opt-in letter as a reason for rejecting a referral; this raises questions about the methods used by providers to engage young people and their families, many of whom are vulnerable.
Other providers reported signposting the young person to a different service as a reason for not accepting the referral (13), while three reported they had returned the referral to the referrer, without explaining why.
Several providers stated that good practice dictates that where a referral is deemed inappropriate, the individual and their family are referred or signposted to other forms of relevant support, for example through the voluntary sector or social care. Our research last year highlighted that the majority of providers do this (87 per cent of those that answered the question). However, we also
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found that at least 27 local authorities had decommissioned services for CYP with lower-level mental health needs since 2010 – suggesting that in many places these alternative services are non-existent.3
Figure 5: Reasons for rejected referrals
Condition or situation not suitable for CAMHS intervention (e.g. child does not have diagnosable | 26 |
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MH condition) |
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Do not hold this information | 20 |
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Condition not serious enough to meet threshold for access to service | 19 |
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Aged out of service | 16 |
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Signposted or referred to other agency | 13 |
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Referral error (duplicate or incomplete; insufficient information) | 13 |
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Inappropriate referral | 9 |
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Existence of co-morbidity which excludes support from your service (eg substance misuse) | 9 |
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Cancelled by referrer | 4 |
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Out of area | 4 |
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Patient declined care | 4 |
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Duration of condition not long enough | 4 |
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Returned to referrer | 3 |
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Referral criteria not met | 2 |
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Risk too high; PICU required or to be placed on a section | 2 |
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Service lacks capacity to support patient at this time | 2 |
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Not commissioned by that CCG | 1 |
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No reason stated | 1 |
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Needs met at point of referral | 1 |
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No appropriate treatment available | 1 |
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No response to opt in letter | 1 |
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Offending restrictions | 1 |
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Many children who are accepted into treatment wait weeks to be assessed and to begin treatment. Our research has consistently found that average waiting times to treatment far exceed the government’s goal of a four-week standard laid out in the 2017 green paper.7
This year, we again asked providers to report their maximum and median waiting times from first appointment to start of treatment for the 2018-19 financial year. For many providers, the first appointment is an assessment appointment, and research has shown there can often be a significant wait from assessment to start of treatment.8 However, some providers specified that they considered the first appointment to be the start of treatment.
Median waiting times to assessment and treatment
Forty-eight providers responded to the question about median waiting times to first appointment or assessment and fifty-three to the question about waiting times to treatment. A minority of trusts specified that they considered first appointment to be the start of treatment and only provided one median waiting time figure.
Figure 6 presents the change in the average median waiting times over the last seven years for which we hold data (not all trusts provided data for every year from 2016-17 onward, so these figures are broadly, but not directly, comparable over time). The average median waiting time to treatment in 2017-18 was 56 days, or two months. While there is substantial variation from year to year, there is a general downward trend in median waiting time to treatment over time, and since the CAMHS transformation was launched in 2015.
Figure 6. Average median waiting times for CAMHS (days)
Number of days |
80 | 74 |
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70 |
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60 |
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50 |
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40 | 39 |
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20 |
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National CAMHS
transformation
launched
67
64
56
40 | 39 |
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60
56
34
29
10
0
2012-13 | 2013-14 | 2014-15 | 2015-16 | 2016-17 | 2017-18 | 2018-19 |
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As seen in Figure 7, there is some variation between regions in average median waiting times for treatment, with young people in London waiting the longest for treatment (this is consistent with the data from previous years).3 Regional averages mask wide variation within regions: between providers, median waiting times for treatment varied from 1 to 182 days. The wide variation is largely accounted for by the different types and tiers of service offered by providers; for tier 4 providers there should be significantly shorter waiting times given that these children require immediate intervention, for their own safety or that of others’.
Figure 7. Regional averages for median waiting times for treatment
70.0 65.3
60.0 55.9 55.5
50.0
40.0
30.0
20.0
10.0
0.0
48.8
London South North Midlands and East
Figures 8 and 9 show the ten providers with the shortest and longest median waiting times for treatment this year, with last year’s figures for comparison. In each case, half of all providers have maintained their position in either list between 2017-18 and 2018-19.
Figure 8. Twelve providers with the shortest median waiting times to treatment in 2017-18
| Median wait to | For comparison: |
Provider | treatment (days) | 2017-18 figures |
Hertfordshire Partnership University NHS FT | 27 | - |
Tees, Esk and Wear Valleys NHS FT | 27 | - |
Somerset Partnership NHS FT* | 27 | 26 |
Isle of Wight NHS Trust* | 21 | 28 |
Lincolnshire Partnership NHS FT* | 21 | 28 |
Whittington Health NHS FT | 21 | 43 |
Pennine Care NHS FT | 19 | - |
Humber NHS FT | 17 | 44 |
Norfolk and Suffolk NHS FT* | 15 | 6 |
Midlands Partnership NHS FT* | 14 | 15 |
Rotherham, Doncaster and South Humber NHS FT* | 11 | 23 |
Larkwood Ward, managed by Essex Partnership |
| - |
University NHS FT (inpatient) | 1 |
|
*These six providers also among the ten with the shortest waiting times to treatment in 2017-18.
19
Figure 9. Ten providers with the longest median waiting times to treatment in 2017-18
| Median wait to | For comparison: |
Provider | treatment (days) | 2017-18 figures |
West London Mental Health Trust | 182 | 70 |
South Tyneside and Sunderland | 129 | 92 |
Alder Hey* | 124 | 188 |
Leeds Community Healthcare* | 117 | 111 |
Northumberland, Tyne and Wear* | 116 | 145 |
Birmingham Women’s and Children’s Hospital | 112 | - |
Sussex Partnership* | 100 | 124 |
East London | 90 | - |
Birmingham and Solihull | 87 | 126 |
Cambridgeshire and Peterborough | 82 | - |
*These five providers were also among the ten with the longest waiting times to treatment in 2017-18.
One trust reported targets that were considerably longer than the proposed standard: an 11-week target from referral to first appointment, and an 18-week target from referral to start of treatment. The government aims to roll out the four-week standard across the country by 2022-23.
Maximum waiting times to assessment and treatment
Forty-five providers responded with their maximum waiting times until assessment and forty-eight responded with their maximum wait to treatment.
Figure 10 shows that national average maximum waiting times have fallen substantially over time, yet remain high, at 335 days until assessment (just under a year) and 451 days until treatment (or 1.3 years).
Figure 10. Average maximum waiting times for CAMHS (days)
Number of days |
800 | 761 |
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700 | 682 |
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600
508
500
419
400
300
200
National CAMHS
transformation
launched
608
539
368 | 359 |
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489 |
| 451 |
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| 345 | 335 |
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266 | 267 |
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100
0
2012-13 | 2013-14 | 2014-15 | 2015-16 | 2016-17 | 2017-18 | 2018-19 |
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| Maximum wait to first appointment |
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| Maximum wait to start of treatment |
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Several providers emphasised that maximum waiting times represent one individual, and are often due to extenuating circumstances.
20
In one area, the longest wait of 112 days was for a complex neurodevelopmental assessment. Other providers excluded waiting times for neurodevelopmental assessments, as these generally appear to take considerably longer than other types. One provider indicated that this was due to high demand and limited capacity.
In some cases, during long waits for treatment, the trust specified that the young person was under the care of local universal services and/or being supported by other specialist services locally and regionally.
However, other reasons for very long waiting times illustrate a system that, in many cases, does not work well for vulnerable children and their families. Providers reported being unable to make contact, appointments being repeatedly cancelled due to staff and/or the young person being unwell, and patients not showing up to appointments. One provider reported a family being unable to attend appointments due to difficulty finding transport.
In one case, an appointment cancelled due to staff illness resulted in the young person being seen two months later. In another case, a patient was assessed two months after being referred and offered group work, which the parents declined due to their other child’s special needs; the young person was then put back on the waiting list, and was eventually seen for treatment one year and three months after being referred.
Another provider reported difficulty making first contact after referral, and, subsequently, the family arriving too late for their first appointment and cancelling several others. This was because the young person’s mother had had multiple stays in drug rehabilitation facilities during this period of time, and the family had lost their social worker as soon as the young person was referred to CAMHS; they were not allocated another social worker for one year. The young person waited approximately ten months to be assessed.
Good practice dictates that mental health practitioners delivering interventions should explore alternative ways to engage with ‘hard-to-reach’ children and their families, and give them the choice to receive treatment outside of traditional settings, for example in the home, in schools, or in other public places.9 Yet these responses showcase that inflexibility in the system results in children and young people, for reasons related to their social and economic circumstances and outside of their control, missing out on the care they need. They raise questions about whether providers are adhering to a key tenet of the NHS Constitution, that NHS services must reflect, be coordinated around and tailored to the needs and preferences of patients and their families.10 Furthermore, they illustrate the impact of pressures on wider services supporting children and their families on their capacity to access mental health care, and the lack of, and need for, joined-up working between agencies.
21
Part 3: Provision for groups of vulnerable children
Diagnosable mental health conditions are much more common amongst certain groups of children. These include those with special education needs, those from socioeconomically deprived families, and those who identify as LGBTQ+.1,11
In its 2019 independent review of CAMHS in England, the Care Quality Commission highlighted a widespread lack of understanding of local need amongst providers. Despite individual examples of good practice – which included engaging with service users and joined-up commissioning across agencies – the CQC found that in many areas, services were not responsive to the needs of different groups; these included children with autism spectrum disorder or attention deficit hyperactivity disorder, LGBTQ+ young people, and those from Black and minority ethnic groups, even in areas with well-established ethnically diverse populations.6
This is also likely to be a problem for children and young people with difficulties that are not universally understood as related to mental or emotional health, or which fall under the remit of multiple services.
To investigate this, we contacted local authorities’ health and well-being boards – the aim of which is to ensure the health and well-being needs of the local population are being effectively and holistically met.
We first asked about the extent to which they engaged with CYP and their families, local faith and community groups and charities or other third sector organisations to build their understanding of local need. We also asked about provision for three groups of children and young people identified as being at risk of missing out on mental health support.
We received a range of responses from local authority areas hosting these boards – some from health and well-being boards themselves, or someone else at the council such as the commissioning officer; some reported the information was held by the local CCG(s) and/or NHS trust, who responded; some CCGs, when queried at the direction of councils, reported they did not hold the information and told us to contact the NHS trust covering the area (see Figure 11).
22
FOIs sent to areas statutorily required to have HWBs (152)
Sent information |
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(81) | Sent information |
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| (9) |
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Referred to trust | Referred to CCG |
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(17) | (1) |
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| Sent information |
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| (30) | Final responses: |
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Referred to CCG |
| 131 (86%) |
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(44) | Referred to trust |
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| (2) |
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Referred to | Referred back to |
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published |
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LA (1) |
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mental health |
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offer (14) |
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As local authority areas and clinical commissioning groups do not have the same boundaries, it is difficult to pull together a complete picture of provision for children and young people in one geographical area. Multiple CCGs, for example, can commission different services for different groups of children in one local authority area; meanwhile, providers covering more than one LA area may offer pathways only for certain conditions or groups of children. In some areas, the LA, which is the corporate parent of looked after children, provided a response to us which indicated a lack of comprehensive knowledge about the mental health offer for these children, and referred us on to one or multiple CCGs for the information.
In response to our first question, we found that most local commissioners (LAs and CCGs) engage with a range of groups to improve their understanding of local need and service design (see Figure 12). However, notably fewer engaged with community and especially faith groups; for those who ticked the ‘community and faith groups’ option, a minority (6) did not engage with faith groups specifically. These groups may be more likely to represent the interests and needs of communities that were singled out by the Care Quality Commission as less likely to be well served by local CAMHS. Research has shown that mental health stigma is particularly strong in some minority ethnic faith communities; as such it is particularly important to understand how to engage these children and families.12 One respondent in an urban area did report that they were currently undertaking a BAME needs assessment. Overall, a relatively high level of general engagement with service users and their representatives does not appear to be translating into better provision for marginalised or vulnerable groups.
23
Figure 12: Level of engagement with service users and their representatives to improve understanding of local need (percentage of LA areas)
Note: The dark and light green bars present the upper and lower bounds of the real percentage of all LAs in each category.
Children and young people with conduct disorder or difficulties
One of these groups is children with conduct disorder (CD) or conduct difficulties. Conduct disorder is among the most common mental health conditions in childhood, affecting around 7 per cent of boys and 3 per cent of girls aged 5 to 10 in England according to the 2017 prevalence survey (for comparison, the prevalence of any diagnosable mental health condition in this age group is 12 per cent for boys and 7 per cent for girls).1 However, findings from parental reporting in the Millennium Cohort Study (MCS), a nationally representative cohort of children born in the UK around the year 2000, suggest that the prevalence of severe conduct problems is significantly higher:
Figure 13: Prevalence of severe conduct problems amongst children in the UK
| Boys | Girls |
Age 3 | 22% | 19% |
|
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|
Age 5 | 13% | 8% |
|
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|
Age 7 | 13% | 8% |
|
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|
Age 11 | 14% | 9% |
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|
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Source: Millennium Cohort Study (parental report)
According to the Royal College of Psychiatrists’ definition, CD is a childhood and adolescent condition characterised by repetitive and persistent patterns of disruptive and aggressive behaviour which affect development and the child’s ability to lead a normal life. It is an externalising mental illness, meaning that children who have conduct difficulties experience distress outwards, through aggression, deception, rule-breaking, and/or bullying. In older age groups, it is strongly predictive of involvement in crime: the vast majority of youth in the criminal justice system meet the criteria for a CD diagnosis. However, because of how CD symptoms manifest, children and young people with the
24
disorder may be seen by parents, teachers, and even GPs, as wilfully disobedient – and their need for mental health treatment may not be recognised.
While understanding and recognition of conduct disorder is not yet widespread, it is improving. We know there is a strong link with adverse experiences in early life including low family income, maternal smoking in pregnancy, and maternal depression; CD is clustered in deprived families and children in contact with social services. 13 A posited causal pathway is that exposure to adverse experiences in infancy related to how a child is cared for can negatively affect brain development and lead to a poorly-regulated stress response. This means that children may react in extreme ways to triggers or provocation, and lack the ability to calm themselves down; alternatively, they may adopt a disassociated or “switched off” state whereby they are unable to respond to everyday cues and behave in ways which may seem puzzling or threatening to others.14
Yet CD remains one of the least widely recognised or studied mental health disorders.15 Arguably, this is reflected in the disproportionately high number of official and unofficial school exclusions amongst low-income young people and those in social care, for reasons to do with ‘persistent disruptive behaviour’.16,17
Our previous research has highlighted that children with complex, less well-understood difficulties that do not fit clearly into diagnostic boxes are at risk of not being able to access CAMHS.3,18 For example, some providers reported to us in 2018 that they did not offer treatment to children with family-related issues, and instead instructed the referring party to encourage parents to resolve problems before referring a child for specialist treatment; others stated that the mental health needs of CYP who have a social care related need (including domestic violence or parental substance misuse) would be met by social services.3 Researchers have highlighted that poor awareness among professionals can result in ineffective early identification, misdiagnosis, missed opportunities for strengthening protective factors, and inappropriate or ineffective interventions.12
The individual and societal costs of untreated conduct disorder in early life are significant. The authors of the MCS study state that ‘no other common childhood condition is associated with such far-reaching and pervasive consequences’. These include long-term mental health problems, poor performance in school and the labour market, substance misuse and involvement in crime.19 One study estimates that the overall lifetime cost of conduct disorder is around £280,000 per case.20 As such, identifying children with CD and implementing effective treatment early in development is key for reducing the risk of later, very costly impairments. Given the complex nature of CD and its determinants, it is likely that sustained, multi-agency involvement is necessary if children are to be effectively supported.
We wanted to better understand what support is available across the country for children with conduct disorder and difficulties, and those at risk of developing them. Evidence based programmes as laid out in the National Institute for Health Care and Excellence guidelines (NICE) include parent and carer training programmes, group social and cognitive problem-solving programmes and multimodal interventions like multi-systemic therapy.21
We found that specific services or pathways for children and young people with conduct disorder or difficulties, including parent or carer training, existed in around a fifth of areas (see Figure 14). Two respondents listed systemic therapy approaches, and two others listed parent or carer training.
25
Nine per cent of respondents clearly indicated to us that a multi-agency response was pursued (this does not mean this is not the case in other areas, only that it was not made clear in their response); this could include involvement from youth justice, health and social care, schools and other universal services. A minority reported that children with conduct difficulties could access general LA services and CAMHS and would received additional tailored support. The remainder reported that these children could access general services, including CAMHS, or simply that they did not offer specific provision for this group.
Several respondents described an approach that does not accord with the evidence on CD. One reported that there was no conduct disorder provision across the city they covered, and that CAMHS only supported young people with a conduct disorder when they had ‘a diagnosable mental health condition’ – belying the fact that CD is a recognised mental illness on its own, despite often being co-morbid with other conditions.
Another respondent reported that health services in the area would not diagnose CD in children and young people; however, the LA would offer parenting support in cases where it was deemed necessary. One LA reported that they would want to know which agency had identified the conduct disorder or difficulties and why they themselves were not providing support. Several others reported that CD was viewed as a clinical diagnosis and therefore a single-agency response was deemed sufficient. One respondent reported there was no CAMHS provision for CD in their area, stating that “primarily it does not emerge until older ages and into early adulthood hence the response being more reflective of adult practices”.
Yet, in others areas, recognition of CD is improving: one respondent reported they were in the process of developing a conduct pathway, and a service to be delivered in schools.
Children and young people in social care
Another group at risk of missing out on effective support are children and young people in the social care system. Children in contact with social services, including looked after children, children in need (those who are deemed unlikely to achieve a good level of health and development without the involvement of services) and those under child protection orders, have been exposed to adverse childhood experiences (ACEs), including parental substance misuse, physical or emotional abuse, neglect, parental mental illness or a parent in prison. Close to two thirds of children looked after by the local authority are in care due to abuse or neglect.22 There is a vast body of literature strongly linking exposure to ACEs to severe problems throughout life, including internalising and externalising mental illnesses.23,24
At least half of children in care have a diagnosable mental illness (compared to just 12 per cent of the whole under-19 population); up to 40 per cent have conduct disorder. 25 Around 70 to 80 percent have recognisable difficulties.26 This year, around 78,000 children were in care, a rise of four per cent from last year, 399,000 were ‘in need’ and 52,000 were under child protection orders. 27,28
Furthermore, the age profile of looked after children is becoming older: close to two thirds of LAC are over ten years old, and almost a quarter are 16 or older.29 Older children are likely to have more entrenched, complex needs; in many cases, these may be related to sexual or criminal exploitation.
Our 2018 analysis raised questions around mental health provision for children with (often complex) social care related needs or family issues. Some CAMHS providers reported that they would not
26
accept referrals of children with family issues and that they instructed the referring party to encourage parents to resolve problems before referring the child to specialist treatment. Others reported that the needs of young people who are homeless, or those who have parents with problems including domestic violence, illness, dependency or addiction, will be met by children and young people’s services.3
Based on concerns raised by the data we collected last year, we asked local areas what provision was in place for children in need, children under protection orders and children in care with mental health needs. We found that at least half of local authority areas had specific provision for children in contact with social services, primary looked after children (see Figure 14). This included:
▪ training programmes for foster carers and adopters, for example weekly consultations with a systemic family therapist for social workers and foster carers;
▪ multi-agency and/or multi-disciplinary teams, under LA management, supporting highly vulnerable parents with mental health and/or substance misuse issues, and highly vulnerable children and young people with active safeguarding risks;
▪ mental health and other life support for care leavers aged 18-25 years; and
▪ clinical psychology provision supporting children who are placed within and out of borough care to improve mental health and emotional wellbeing and reducing placement breakdown, for both children currently in care and care leavers.
Several respondents also reported they offered specific services only for certain groups of looked after children, for example those requiring Tier 3 (community specialist) interventions or those who had experienced three or more placement moves.
The remaining respondents reported that children in contact with social care could access general CAMHS. The concern is that this particularly vulnerable group of young people may lose out in a context where services are not effectively joined up or communicating regularly and effectively.
We found that commissioning arrangements varied between areas, with some LAs commissioning mental health services for children in contact with social services; in others, CCGs commissioned these services, or they were jointly commissioned by both agencies. One response highlighted issues of fragmentation and lack of accountability that have been well-documented: a local authority we contacted referred us to the CAMHS commissioners, and when we contacted the CCG, they reported that they ‘do not manage social services’ and referred us back to the local authority.
No respondents highlighted that strategies were in place to ensure that interventions were not disrupted by placement instability, something that particularly affects the most vulnerable children with the most complex needs.28
Young people transitioning to adult mental health services
The transition from child to adult mental health services has been identified as a major problem area nationally. Young people are at significant risk of dropping out of care: between a third and three quarters of individuals are estimated to disengage from adult services on transition from CAMHS, despite ongoing clinical need. 30,31,32 One study estimates that only a small minority – around 4 per cent – experience a smooth transition.31
27
The Office of the Children’s Commissioner has called this a ‘patient safety issue’. 33 It is especially concerning as many mental health issues emerge in late adolescence, especially among girls: the 2017 national prevalence survey found that one in four girls aged 17 to 19 have a diagnosable condition compared to 14 per cent of girls aged 11 to 16. Furthermore, late adolescence and early adulthood can be a difficult transitional time for young people to navigate as it is; this may be particularly acute for vulnerable young people such as those with special educational needs.
Given this, we asked about local arrangements to support young people transitioning to adult services. We found wide variation in what was available across the country.
Firstly, CAMHS in different areas covers different age groups: while age 18 is the norm for transitioning to AMHS, young people might also transition to adult services at age 16 or 25.
Yet there is widespread consensus that a good care model is one in which provision extends to age 25.34 The NHS Mental Health Implementation Plan states that there will be a comprehensive offer for 0- to 25-year-olds by 2023-24.35 However only six respondents reported to us that CAMHS in their area, or at least specific services such as talking therapies, were available for young people up to age 25; another five reported they were moving towards extending CAMHS to age 25. One provider which only offered CAMHS up to age 16 reported planning to extend their offer to age 18. Several others reported that young people were not discharged or transitioned to AMHS according to age, but rather when it is ‘right for the young person’.
Approximately a third of areas reported having a transition protocol or official policy in place (see Figure 14). We also found wide variation in length of transition planning, with one area reporting they started working with young people at age 14 and others reporting they started at age 17.5. One provider only had a transition policy in place for the minority of young people receiving inpatient care. Multiple respondents indicated more informal arrangements, in which CAMHS and AMHS worked together, in some cases for up to six months, to support individuals’ transition, but no specific service, post or protocol was reported. NICE recommendations state that transition planning should begin at the latest by year 9 (age 13 or 14) for groups not covered by health, social care and education legislation.36
A minority (between 15 and 18 per cent) had a dedicated service or staff member to support young people in their transitions (Figure 14). One provider had recently introduced a dedicated transitions lead and reported that their service user satisfaction had significantly improved as a result.
28
Figure 14: Mental health provision for groups of vulnerable children and young people (percentage of local authority areas)
Note: The dark and light green bars present the upper and lower bounds of the real percentage of all LAs in each category.
29
Conclusion
These findings provide an up-to-date picture of key areas of mental health provision for children and young people in England. We continue to find a stark gap between available support and need for the one in eight children with a diagnosable condition. For those referred to specialist services and accepted for treatment, national average waiting times are falling, but are still double the government’s proposed standard four-week standard. Meanwhile, mental health provision for vulnerable groups of children whose needs are likely to fall under the remit of different services is patchy across the country. The difficulties we encountered in tracking down information on provision for these groups suggests a lack of local accountability across local health and care systems for their health and well-being.
According to the Care Quality Commission, a good model of child and adolescent mental health care involves flexibility, the commissioning of lower level or alternative services, information sharing and coordination between agencies. Finally, it is person-centred and based on a solid understanding of local need. In this vein, in recent years, many CAMHS providers have reported that they have introduced new models of care based on the THRIVE framework – now part of the NHS Long Term Plan – which aim to centre the needs of young people and their families. Despite this, our new data shows that the system as a whole continues to fall down in all the domains laid out by the CQC.
Meanwhile the outlook is not positive in terms of extending provision to the children in need of it. The government’s existing plans for rolling out improvements to mental health provision – including a (voluntary) dedicated mental health lead in all schools, local mental health teams supporting schools and colleges, and a four-week waiting time standard – will not reach the majority of children for several years. While new practitioners are being trained to staff the support teams, the number of child and adolescent psychiatrists and mental health nurses is falling.37,38
Moreover, there are multiple flaws in the current system for reporting and disclosing basic data on CAMHS in England, which obscures our understanding of the state of services and ability to monitor progress. The variation in figures reported to us by providers each year indicates serious data quality issues. A robust system for reporting data on access to CAMHS, including a clear definition of
children who are eligible for treatment, is urgently required. Failure to introduce stronger accountability measures may hinder the government’s plans to improve services.
All evidence suggests that the government must broaden its focus to include pre-emptively reducing demand within a system under pressure. We must ensure that all children are born into and grow up in environments conducive to good emotional and physical health, and effectively and holistically address difficulties as soon as they emerge. Adverse experiences in childhood and adolescence, including poverty, are strongly predictive of poor emotional health. By targeting determinants and intervening early when problems arise, we avoid more costly interventions necessary when difficulties become entrenched, and reduce the burden on young people and their families.
Furthermore, it is increasingly clear that mental ill-health is causally predictive of poor academic attainment, meaning that it is an obstacle to social mobility.39 If the government’s aim is a society in which all children, regardless of circumstance, have access to opportunity, a more ambitious and holistic programme to address mental ill-health amongst children and young people is vital.
30
1 NHS Digital, ‘Mental Health of Children and Young People in England, 2017’, November 2018, https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017.
2 Department of Health, ‘No health without mental health: A cross-government mental health outcomes strategy for people of all ages’, February 2011, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/215808/ dh_123993.pdf.
3 EPI Access to CAMHS 2018 Whitney Crenna-Jennings and Jo Hutchinson, ‘Access to children and young people’s mental health services – 2018’ (Education Policy Institute, October 2018).
4 Richard Humphries, ‘Health and wellbeing boards and integrated care systems’, (The King’s Fund, November 2019), https://www.kingsfund.org.uk/publications/articles/health-wellbeing-boards-integrated-care-systems.
5 NHS Digital, ‘Number of children and young people accessing NHS funded community mental health services in England, April 2018 to March 2019, Experimental Statistics’, July 2019, https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-services-monthly-statistics/number-of-children-and-young-people-accessing-nhs-funded-community-mental-health-services-in-england-april-2018-to-march-2019-experimental-statistics.
6 Care Quality Commission, ‘Are we listening? Review of children and young people’s mental health services’,
March 2018, https://www.cqc.org.uk/sites/default/files/20180308b_arewelistening_report.pdf.
7 The government has not specified whether the four-week waiting time standard relates to time to assessment or time to start of treatment.
9 NHS England, ‘Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing’, March 2015, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/ Childrens_Mental_Health.pdf.
10 NHS England, ‘The NHS constitution: The NHS belongs to us all’ July 2015, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/ NHS_Constitution_WEB.pdf
11 Amos, Rebekah, Eric Julian Manalastas, Ross White, Henny Bos, and Praveetha Patalay. ‘Mental health, social adversity, and health-related outcomes in sexual minority adolescents: a contemporary national cohort study.’ The Lancet Child & Adolescent Health 4, no. 1 (2020): 36-45.
12 Mantovani, Nadia, Micol Pizzolati, and Dawn Edge. ‘Exploring the relationship between stigma and help‐ seeking for mental illness in African‐descended faith communities in the UK.’ Health Expectations 20, no. 3 (2017): 373-384.
13 Leslie Morrison Gutman, Heather Joshi, Lorraine Khan & Ingrid Schoon, ‘Children of the millennium: Understanding the course of conduct problems during childhood’ (University College London and Centre for Mental Health, November 2018).
14 Jane Roberts, ‘Understanding Conduct Disorder’ British Journal of Family Medicine, 2 (2) September 2013.
15 Graeme Fairchild, David J. Hawes, Paul J. Frick, William E. Copeland, Candice L. Odgers, Barbara Franke, Christine M. Freitag, Stephane A. De Brito. Conduct disorder. Nature Reviews Disease Primers, 2019; 5 (1)
16 Department for Education, ‘Permanent and fixed period exclusions in England 2017 to 2018’, August 2019, https://www.gov.uk/government/statistics/permanent-and-fixed-period-exclusions-in-england-2017-to-2018
17 Jo Hutchinson and Whitney Crenna-Jennings, ‘Unexplained pupil exits from schools: Further analysis and data by multi-academy trust and local authority, (Education Policy Institute, October 2019).
18 Emily Frith, ‘Access and waiting times in children and young people’s mental health services’ (Education
Policy Institute, September 2017).
19 Holly Erskine, Rosana Norman, Alize Ferrari, Gary Chan, William Copeland, Harvey Whiteford, and James Scott. "Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: a systematic review and meta-analysis." Journal of the American Academy of Child & Adolescent Psychiatry 55, no. 10 (2016): 841-850.
20 Lynne Friedli and Michael Parsonage, ‘Building an economic case for mental health promotion’ Journal of
Public Mental Health, 6(3), 14-23.
31
21 National Institute for Health and Care Excellence, ‘Antisocial behaviour and conduct disorders in children and young people: recognition and management’, April 2017 https://www.nice.org.uk/guidance/cg158/chapter/Key-priorities-for-implementation#child-focused-programmes
22 National Audit Office, ‘Children in Care’, November 2014, https://www.nao.org.uk/wp-content/uploads/2014/11/Children-in-care1.pdf
23 L. van Duin, F. Bevaart, J. Zijlmans et al. “The role of adverse childhood experiences and mental health care use in psychological dysfunction of male multi-problem young adults”. Eur Child Adolesc Psychiatry 28, 1065– 1078 (2019)
24 Hughes, Karen, Mark A. Bellis, Katherine A. Hardcastle, Dinesh Sethi, Alexander Butchart, Christopher Mikton, Lisa Jones, and Michael P. Dunne. "The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis." The Lancet Public Health 2, no. 8 (2017): e356-e366.
25 NHS Digital, ‘Mental Health of Children and Young People in Great Britain, 2004’, August 2005, https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-great-britain/mental-health-of-children-and-young-people-in-great-britain-2004.
26 Joe Sempik, Mental Health of Looked After Children in the UK: Summary, (National Institute for Health and Care Excellence, February 2010) https://www.nice.org.uk/guidance/ph28/evidence/ep22-the-mental-health-of-looked-after-children-under-5-years-joe-sempik-pdf-430133293
27Department for Education, ‘Children looked after in England (including adoption), year ending 31 March 2019’, (December 2019) https://www.gov.uk/government/statistics/children-looked-after-in-england-including-adoption-2018-to-2019
28Department for Education, ‘Characteristics of children in need: 2018 to 2019’ (October 2019) https://www.gov.uk/government/statistics/characteristics-of-children-in-need-2018-to-2019
29 Children’s Commissioner, ‘Stability Index 2019’, August 2019 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/07/cco-stability-index-2019.pdf
30 Care Quality Commission, ‘Brief guide: Transitions out of children and young people’s mental health services
CQUIN’, March 2018, https://www.cqc.org.uk/sites/default/files/20180228_9001400%20_briefguide-transition_CQUIN.pdf.
31 Rebecca Appleton, Catriona Connell, Emma Fairclough, Helena Tuomainen, and Swaran P. Singh. "Outcomes of young people who reach the transition boundary of child and adolescent mental health services: a systematic review." European Child & Adolescent Psychiatry (2019): 1-16.
32 Swaran P. Singh, Paul Moli, Tamsin Ford, Tami Kramer, and Tim Weaver. "Transitions of care from child and adolescent mental health services to adult mental health services (TRACK study): a study of protocols in Greater London." BMC Health Services Research 8, no. 1 (2008): 135.
33 Education Select Committee, ‘The Government’s Green Paper on mental health: failing a generation’ May
2018,
https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/642/64207.htm#_idTextAnchor035.
34 Health Select Committee, ‘Child and adolescent mental health services - oral evidence’, November 2017.
35 NHS, ‘NHS Mental Health Implementation Plan 2019/20-2023/24’, July 2019, https://www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf.
36 National Institute for Health and Care Excellence, ‘Transition from children’s to adults’ for young people using health or social care services,’ February 2016, https://www.nice.org.uk/guidance/ng43/chapter/Recommendations#transition-planning
37 Royal College of Psychiatrists, ‘Children and young people with mental health problems and access to NHS treatments’, January 2019, https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/parliamentary/rcpsych-briefing---children-and-young-people-with-mental-health-problems-and-access-to-nhs-treatments---copy.pdf?sfvrsn=2e924943_2
38 The Guardian, NHS England loses 10,000 mental health nurses in 10 years, May 2019, https://www.theguardian.com/society/2019/may/19/mental-health-nursing-numbers-6000-fall-nhs-england
39 National Centre for Social Research, ‘How does poor mental health in the early years of secondary school impact on GCSE attainment’, (Briefing paper, November 2019).
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Whitney Crenna-Jennings is a Senior Researcher in the Social Mobility and Vulnerable Learners team at the Education Policy Institute. Whitney was a co-author of ‘Unexplained pupil exits from schools: Further analysis and data by multi-academy trust and local authority’, ‘Education in England: Annual Report 2019’ and ‘Access to child and adolescent mental health services in 2019’. Prior to joining EPI, she worked as a research assistant in the Department of Epidemiology and Public Health at University College London. Whitney graduated with an MSc in Social Epidemiology (with Distinction) from UCL in 2015.
Acknowledgements
Grace Breen is the Senior Policy and Public Affairs Manager at The Prince’s Trust, and carried out the focus groups to support this research. As a part of her role Grace leads on education policy for The Prince’s Trust, with the team also covering issues including youth employment and skills. Prior to joining The Prince’s Trust, Grace worked at the Confederation of British Industry covering education and skills policy.
This report is supported by Tesco. The partnership between Tesco and The Prince’s Trust supports young people in schools, as well as helping them to find employment through employability courses and work placements. As a part of the ongoing partnership, this research has enabled the development of new mental health and wellbeing resources for schools across the UK alongside additional mental health training for school support staff on Tesco-funded programmes with The Prince’s Trust. The research will also form the foundation of a new health and wellbeing programme that Tesco is building to support the wellbeing of young people coming to work for them.
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About the Education Policy Institute
The Education Policy Institute is an independent, impartial, and evidence-based research institute that promotes high quality education outcomes, regardless of social background. We achieve this through data-led analysis, innovative research and high-profile events.
Education can have a transformative effect on the life chances of young people, enabling them to fulfil their potential, have successful careers, and grasp opportunities. As well as having a positive impact on the individual, good quality education and child wellbeing also promotes economic productivity and a cohesive society.
Through our research, we provide insight, commentary, and a constructive critique of education policy in England – shedding light on what is working and where further progress needs to be made. Our research and analysis span a young person's journey from the early years through to entry to the labour market.
Our core research areas include:
▪ Benchmarking English Education
▪ School Performance, Admissions, and Capacity
▪ Early Years Development
▪ Vulnerable Learners and Social Mobility
▪ Accountability, Assessment, and Inspection
▪ Curriculum and Qualifications
▪ Teacher Supply and Quality
▪ Education Funding
▪ Higher Education, Further Education, and Skills
Our experienced and dedicated team works closely with academics, think tanks, and other research foundations and charities to shape the policy agenda.
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The Prince’s Trust helps young people all over the UK to build their confidence and skills and supports them into jobs, education and training.
Founded by The Prince of Wales in 1976, the charity supports 11- to 30-year-olds who are unemployed, struggling at school and at risk of exclusion.
Many of the young people helped by The Trust’s youth support workers and mentors are in or leaving care, facing issues such as homelessness, mental health problems, or have been in trouble with the law. The courses offered by The Trust give young people the practical and financial support needed to stabilise their lives, helping develop self-esteem and skills for work.
Three in four young people supported by The Prince’s Trust move into work, education or training. The Trust has helped over a million young people to date.
Further information about The Prince’s Trust is available at princes-trust.org.uk or on 0800 842 842.
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Foreword: Education Policy Institute 6
Foreword: The Prince’s Trust 7
Introduction and background 13
Mental health in childhood and adolescence 13
Drivers of children and young people’s mental and emotional health 15
Gaps in the current policy response 15
Part 1: Mental and emotional health from childhood through adolescence 21
Wellbeing in primary through secondary school 21
Self-esteem in primary through secondary school 26
Levels of psychological distress through secondary school 27
The relationship between wellbeing, self-esteem and psychological distress in childhood and
Part 2: Drivers of mental and emotional health in adolescence 31
Drivers of wellbeing, self-esteem and psychological distress at age 14 31
Drivers of wellbeing, self-esteem and psychological distress at age 17 37
Conclusion and policy recommendations 49
Annex: Factors associated with the change in wellbeing and self-esteem scores through adolescence
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Foreword: Education Policy Institute
Over recent years there has been an improved understanding of the importance of good emotional and mental health, alongside growing concern about the apparently increasing prevalence of mental health problems in society.
Children's mental and emotional health is understood to be a major issue - because of the number of children who experience problems; the potential impacts of this on health, education and longer-term outcomes; and the strong association between mental health problems in childhood and in adulthood.
Mental health and wellbeing among children is therefore a major research priority for EPI, and in this report we seek to use a detailed quantitative survey, supported by qualitative work, to track the prevalence of mental health issues through childhood and to seek to identify the underlying drivers of emotional and mental health problems.
This report shows the scale and importance of this issue, helps identify some of the key causal factors, and sets out a series of policy recommendations.
We are very grateful to the Princes Trust and to Tesco PLC for making this project possible. We welcome feedback on the methodologies and conclusions of this report, which will help inform and shape our future work programme in this area.
Rt. Hon. David Laws
Executive Chairman, Education Policy Institute
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The transition from childhood to adolescence can be a turbulent time, and the findings of this report underline why addressing and supporting young people’s mental health will only become more crucial as the impact of the pandemic unfolds.
Young people continue to be among the hardest hit by the pandemic, so it is more important than ever that they can access support with their mental health during this critical time in their lives.
In particular, the decline in young people’s wellbeing and self-esteem as they go into their mid-late teens, shows the need for early intervention and ongoing support to prevent future harm and potential mental health crises.
Working with partners like Tesco, we are able to use the findings of this research to inform and influence the mental health support we provide young people through schools - ensuring they get the essential support they need.
At The Prince’s Trust we see the damage poor mental health can have on a young person’s life, impacting their education, subsequent employment and overall life chances. It is only by working together, in partnership with government and schools, that we can tackle the issues highlighted by this research and prevent scarring this generation’s future.
We are pleased to have partnered with the Education Policy Institute on this important and timely piece of research and are thankful to Tesco for their ongoing support.
Jonathan Townsend
UK Chief Executive of The Prince’s Trust
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This report investigates how mental and emotional health (MEH) changes as children move into and through adolescence, as well as the individual-, family-, school- and area-level factors that drive positive and poor MEH. To supplement the quantitative analysis, virtual focus groups were conducted with young people aged 14 to 16. These had a mixture of genders, backgrounds and experiences related to mental health.
Given the known rise in prevalence of mental illness from childhood to adolescence, particularly in girls, this analysis aims to dig more deeply into young people’s mental health and wellbeing in this period of life. Poor mental health in adolescence is strongly associated with poor mental health in adulthood, which, in turn, can affect relationships, societal engagement and productivity. Since the arrival of Covid-19, the prevalence of probable mental disorders has risen substantially to one in six young people, from one in nine in 2017. 1 In response, the government has announced a new £500m funding package focused on children and young people’s mental health services, yet this amounts to less than £250 per young person with a diagnosable disorder and is unlikely to make a significant difference.
For the quantitative analysis, we use data on approximately 5,000 young people born around the year 2000 and living in England, surveyed through the Millennium Cohort Study. At ages 11, 14 and 17, young people were asked to rate their wellbeing, or how happy they were in different areas of their lives; their self-esteem, or how much value they placed on themselves; and their levels of psychological distress, or how often they experienced depressive symptoms such as feeling worthless or hopeless. We compare these responses across ages and test the relationship between a range of social factors and these outcomes in early and late adolescence. The focus group discussions were conducted virtually in November 2020.
Part 1: Mental and emotional health from childhood through adolescence
On different measures of mental and emotional health, the transition from childhood to adolescence marks a decline:
▪ Personal wellbeing drops, on average, as children move from primary into secondary school, and continues to drop as children move through secondary school. As children get older, the drop in median wellbeing scores is greater for girls than for boys. While the majority of young people remain at least moderately happy with their families, friends, school, and personal appearance as they move into secondary school, the proportion of girls who are unhappy in each of these areas rises. This is particularly stark in the area of happiness with personal appearance: around one in seven girls report being unhappy with the way they look at the end of primary school, rising to almost one in three by age 14.
▪ Similarly, self-esteem falls on average as children move into adolescence, staying broadly similar for girls as they move into late adolescence and continuing to fall for boys. In focus groups, young people highlighted the transition to secondary school as being particularly hard on their self-esteem due to increased concerns about being judged and not fitting in.
▪ We see a corresponding rise in levels of psychological distress through adolescence, with girls starting off at age 14 with higher psychological distress scores and, on average, seeing a larger rise in levels of psychological distress as they move into late adolescence. Young
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people we spoke with highlighted an increase in levels of worry and pressure as they moved through secondary school.
▪ We find that as children move into adolescence, self-esteem is more strongly correlated with both wellbeing and levels of psychological distress, suggesting that as young people get older, how they see and value themselves becomes more closely tied to how they feel about their lives generally. This is of particular concern for girls, a significant proportion of whom struggle with body image issues and lower self-esteem.
Part 2: Drivers of young people’s mental and emotional health
We examined the impact of a range of characteristics and experiences in childhood on young people’s mental and emotional health through adolescence. The factors below were found to have independent and statistically significant effects on MEH in models controlling for all other factors:
▪ We find a graded relationship between family income and all three outcomes through adolescence: young people’s mental and emotional health scores are worse the lower down their family is on the income scale. We also find that children’s feelings about their family’s socioeconomic circumstances – wishing they could afford more and feeling poorer compared to their peers – are associated in a graded fashion with both lower wellbeing and higher levels of psychological distress, while feeling poorer than peers is also associated with lower self-esteem. These findings highlight the impact of localised inequality and perceptions of inequality, beyond absolute measures of socio-economic circumstances, for young people’s mental health.
▪ Health and activities in childhood, including physical activity and social media habits, are important for all three outcomes. Engaging in physical activity was found to be more important for boys’ mental and emotional health in early adolescence than girls’, with a graded relationship between frequency of exercise and scores on all three outcomes for 14-year-old boys; at age 17, we find a graded relationship with frequency of exercise in both girls and boys. Heavy social media use is associated with worse scores on all outcomes in girls age 14 and 17, but only worse wellbeing for boys at age 14. In a model controlling for pre-existing levels of self-esteem and wellbeing, we find that low levels of physical activity remain associated with low self-esteem and wellbeing scores in girls and boys through adolescence, while heavy social media use contributes to low self-esteem and wellbeing in girls, and wellbeing in boys at age 14. In focus groups, young people highlighted the positive and negative aspects of social media. While girls tended to focus on the negative impact on body image, boys felt that the images they saw on social media platforms could be aspirational. Being overweight in childhood is also found to be associated with worse MEH outcomes for both boys and girls, showing a lasting impact of negative body image and related social interactions throughout adolescence.
▪ The social dimension of life, including quality of relationships with parents and peers, is highly important for young people’s mental and emotional health. Being bullied in childhood has strong and lasting effects on both boys’ and girls’ mental and emotional health through adolescence. Frequent arguing with parents is linked to lower wellbeing at age 17, while at age 14 it is associated with both worse wellbeing and higher psychological distress. Controlling for academic ability, being placed in the bottom stream in primary school is associated with slightly lower self-esteem scores in boys at age 14, but not girls, supporting
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existing evidence of the socially stigmatising effect of being placed in low performance streams. Young people spoke about how relationships can affect mental health in positive and negative way: open and supportive relationships are beneficial, while rocky relationships with family and friends can be damaging.
▪ Family health and wellbeing is also highly important for young people’s MEH. Poor maternal health is predictive of worse scores on all three outcomes in both girls and boys at age 14, and maternal depression in infancy is associated with higher levels of psychological distress in girls at age 17.
▪ Wider community factors were found to play a role as well. Throughout adolescence, girls who feel unsafe in their neighbourhood were found to be at increased risk of worse wellbeing and higher levels of psychological distress.
Policy recommendations
As most lifelong mental health issues are seeded in adolescence and early adulthood, it is clear that any strategy to reduce the burden of mental ill-health for the population as a whole should prioritise interventions in this early period of life.
An effective strategy requires expanding current thinking beyond mental healthcare. Focusing primarily on specialist care is a reactive approach to illness once it has developed, at which point interventions are more costly and less likely to be effective. In the case of mental illness, as with chronic physical health issues, many conditions can only be managed once they are established.
Given our findings and the existing evidence base that the conditions in which children live, go to school and play are highly important for mental and emotional health, policymakers should redirect focus to prevention, through targeting these wider determinants of mental health, and early intervention, to prevent difficulties from turning into chronic illness.
Based on this research, and in light of the risk of the pandemic leading to a further deterioration of young people’s mental health and wellbeing, the Education Policy Institute have developed the following recommendations for the UK government. The Prince’s Trust will endeavour to work in partnership with government and schools to take these recommendations forward, where appropriate. These recommendations are presented broadly in order of more contained action to larger, cross-government policies likely to result in long-term positive change. The government should:
▪ Release a £650m post-pandemic wellbeing funding package to schools to match academic catch-up funding. The number of children with a probable mental illness has risen to one in six since the advent of the pandemic; a substantial number will be struggling with their mental health but fail to meet diagnostic thresholds. Beyond pandemic-related stress, known drivers of poor mental and emotional health, including financial insecurity and limited social support, have been exacerbated by the lockdown and school closures. The current policy focus in schools is on academic catch-up but remedial wellbeing work will be necessary to achieve this catch-up, alongside investment in socio-emotional development interventions. The wellbeing funding should be targeted to schools with disadvantaged intakes and a high proportion of children with special educational needs and disabilities. A £650m package would allow schools, where required, to hire additional staff to deliver
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mental health support to pupils and teaching staff, run interventions to address socio-emotional skills’ gaps, improve links with local CAMHS, and deliver training to teachers.
▪ Build on existing mental health content in the Health Education and Relationships and Sex Education curriculum. This should help young people to understand how different characteristics, identities, and backgrounds, and existing stereotypes around these, can affect their mental and emotional health, including beliefs about themselves. It should cover the impact of conventional beauty standards spread by advertising and on social media platforms on body image, particularly for girls, and address the stigma young people may face for having different body types or gender expressions. Evidence-based techniques to support good mental health and reduce psychological distress, such as mindfulness, should be promoted. Pathways to access different types of support should be clearly laid out. Schools should be advised to engage with parents and carers to ensure they are equipped with the same knowledge. Where relevant, schools should be encouraged to work with external organisations with expertise in this area to enhance delivery. Research into the adolescent brain shows that young people are particularly susceptible to peer influence, and our analysis highlights the importance of the peer environment to good mental health, wellbeing and self-esteem. Maximising mental and emotional health literacy amongst young people will equip them with the tools to support not only their mental and emotional wellbeing, but that of their peers as well.
▪ Improve the capacity of school leaders and teachers to support children with mental and emotional health needs. School leaders should be encouraged to spend time in alternative provision (AP) settings as part of ongoing CPD or prior to entering into a leadership role. The majority of young people in AP struggle with mental or emotional health difficulties. It is crucial for leaders to know how to best support children with additional needs, including how to employ trauma-informed approaches in the classroom, and to be able to cascade this knowledge to teaching staff. Survey findings show that many teachers do not feel equipped
to deal with pupils’ mental and emotional health issues.2 While it is not the job of teachers to provide mental healthcare, given the proportion of children who struggle with their mental health it is inevitable that most teachers will encounter these issues in the classroom. As such, local Mental Health Support Teams, currently being piloted in a number of areas, should be required to deliver training to school staff to ensure that mental health support is embedded across the school community. Schools are the most important, non-stigmatised setting where young people can seek advice and support, and policymakers must ensure leaders and teachers are equipped to offer it.
▪ Develop an evidence-based policy to prevent and tackle bullying with clear plans for funding, delivery and accountability. This could involve more evidence-based guidance from DfE for schools on preventing and tackling bullying – guidance that should be statutory to comply with Equalities legislation when bullying is based on protected characteristics, such as race, gender or (dis)ability – and/or changes to Ofsted’s inspection framework. Evidence shows that interventions which create understanding of and accountability for harm caused by bullying are more effective than punitive action: these include anti-bias training, bystander intervention training, peer support programmes and restorative approaches.3
▪ Publish a plan for rollout of a four-week waiting time for specialist mental healthcare across the country including clear details on funding and staffing requirements. Increasing
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access to timely care must continue to be a priority for those children who need it, and the government should make clear when and how all children in the country will be able to quickly access the treatment they need.
▪ Ensure that all young people have access to options for engaging in physical activity, including non-competitive activities, in their local area and commission research, working with diverse young people, to identify scalable interventions to increase activity among children and adolescents. This research should include a critical assessment of how physical education is currently delivered in schools and address the areas that require improvement.
▪ Increase funding to local mental health providers to allow them to better identify and work together to support children with needs which do not meet diagnostic thresholds. Current thresholds for access to specialist mental health treatment are high meaning that many children have to reach a crisis point before they are able to access care. A system focused on identifying difficulties early and providing sustained support to prevent them from worsening would reduce the suffering of young people and their families as well as the high costs of more complex interventions.
▪ Develop a cross-government and cross-sector strategy to reduce family poverty and ensure young people feel safe in their communities. Given the social gradient in mental and emotional health, this would reduce the burden of mental illness and poor wellbeing in the population as a whole. Poverty, which has risen amongst families with children in the last decade, leads to worse health generally and increases the need for more costly, late
interventions putting pressure on squeezed health services.4 Given the high and rising number of families in in-work poverty, this action must go beyond getting people into work.5
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In the last five years, there has been growing government recognition of the need to radically improve mental health services, particularly ease of access to support for children and young people (CYP). In 2015, the NHS committed £1.6bn to 2020/21 to ‘transform’ child and adolescent mental health services (CAMHS). Yet progress against targets remains difficult to gauge as published data is insufficient to paint a clear picture of the state of CAMHS and how it is changing.
What is clear is that need continues to surpass available support. While the number of young people able to access mental healthcare is growing, it remains around a third of all CYP in the country with a diagnosable mental illness. Between a quarter and third of young people referred to CAMHS do not meet criteria for access to treatment.6,7 It is unclear whether alternative services for these young people, as well as those struggling with poor mental health or wellbeing who are never referred for specialist care, are available across the country. EPI research has found that many local authorities have cut child and family wellbeing support services over the last decade.8
In 2017, the first prevalence data in more than a decade was released confirming anectodal reports and showing a rise in the prevalence of diagnosable mental illness from approximately one in ten young people (aged five to sixteen-years old) in 1999 to one in nine in 2017.9 Potential drivers of this increase often cited include the rise of digital technologies such as social media and increased academic pressure. Since the arrival of Covid-19, the prevalence of probable mental disorders has risen substantially to one in six young people.1 In response, the government announced a new £500m package focused on children and young people’s mental health services, yet this amounts to less than £250 per young person with a diagnosable disorder and is unlikely to make a sustainable difference.
Alongside their focus on improving the availability and quality of specialist care, policymakers have acknowledged that early intervention and prevention are necessary parts of any effective strategy to reduce the burden of mental ill-health in young people.10 But these have received much less focus and fewer resources in practice than specialist care. Since 2018, the Government has been piloting new mental health support teams working with groups of schools and colleges to support young people’s mental health but it remains unclear when they will be rolled out across the country.
Mental health in childhood and adolescence
Most lifelong mental health issues develop early in life: estimates vary, but at least 50 per cent by age 14 and 75 per cent by age 24.11
Prior to the pandemic, national prevalence data shows that from childhood to adolescence, the proportion of young people with a probable disorder increases, and in later adolescence, continues to increase for girls while dropping slightly for boys. As seen in Figure 1, at primary school age (five-to ten-years old), this stands at seven per cent of girls and 12 per cent of boys, at secondary school age (11- to 16-year olds), at 14 per cent for both girls and boys, and in later adolescence (17- to 19-years old) at 24 per cent for girls and 10 per cent for boys.9
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Figure 1. Prevalence of probable mental illness in young people in England
Source: Mental Health of Children and Young People in England, 2017, NHS Digital
While the policy response has been primarily focused on diagnosable mental disorders, mental health is more than the absence of illness. According to the World Health Organisation (WHO), mental health is ‘a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.’
Some have pointed out gaps in the WHO definition, including that it does not account for the dynamic nature of mental health through different stages of life. For example, many adolescents go through a period of emotional turbulence, or of being shy or socially uncomfortable, and have yet to master a skill or subject area.12 Furthermore, it ignores that ‘poor’ mental health is a rational reaction to certain social, economic and political contexts, such as being an asylum seeker fleeing political violence or being incarcerated, a point which highlights the importance of living conditions for mental health.
Regardless of any gaps, there appears to be growing recognition by policymakers that outcomes beyond mental illness should be tracked. In 2018, DfE began publishing an annual ‘State of the Nation’ report which brings together the evidence on children and young people’s wellbeing.13 The latest report shows that young people in England, while less happy than those in other countries, continue to be mostly satisfied with their lives in 2020. It is less clear from existing evidence how wellbeing changes as children move from childhood through adolescence, a period during which mental illness becomes more common.
There is considerably less focus, by both policymakers and researchers, on the other components of mental health listed in the WHO definition. Despite this, evidence shows a clear link between low self-esteem, or placing low value on oneself, and psychological distress in young people, and that high self-esteem is protective against the development of poor psychological health.14 Existing research into self-esteem across the lifespan in earlier generations shows a dip in adolescence particularly for girls.15
In this report we adopt a broad view of mental health in young people. We look at levels of personal wellbeing, self-esteem and psychological distress. For clarity, we use the term ‘mental and emotional
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health’ to refer to all three outcomes. We rely on young people’s reports about their own mental and emotional health at all ages rather than parent reports as existing research shows discrepancies between the two.16,17 We look at these outcomes at the end of primary school (childhood), at Key Stage 3 (early adolescence) and after GCSEs (late adolescence). We do not examine all aspects mentioned in the WHO definition but still aim to paint a more complete picture of mental health through this period.
Drivers of children and young people’s mental and emotional health
Mental health is determined by both biological, psychological and social factors, often working in tandem. However the specific causes of most mental disorders are not well understood. What we do know is that the environment into which children are born and grow up is crucial for their psychological and emotional development.
Most research on social drivers is focused on psychological distress or mental illness as the outcome, with a smaller body of evidence on wellbeing, and little existing research into determinants of self-esteem. Research is conclusive that worse socio-economic circumstances (SEC) predict mental illness in young people, with some evidence in adults suggesting low SEC is linked to poor self-esteem.18,19 Existing research using data from the Millennium Cohort Study on children throughout the UK has found that, in addition to relatively low family income, unhappiness with family socio-economic position and being bullied are significant predictors of higher depressive symptoms scores and lower wellbeing scores in early adolescence.17 Both quantitative and qualitative studies consistently identify relationships with family and friends as key for wellbeing.20 Maternal mental health is strongly associated with child mental health, while maternal mental health problems in very early life are linked with poor child development outcomes, which can have a lasting impact on psychological and emotional functioning.21, 22 Wider factors, including school and neighbourhood conditions, also play a role, with some evidence linking positive teacher-pupil relationships to better mental health outcomes, ability streaming to the stigmatisation of children in bottom streams, and experiencing an exclusion and feeling unsafe in the community to worse outcomes.18, 23-25 There is also some evidence suggesting that the same social factors may be differentially related to wellbeing and mental ill-health for girls and boys, as well as at different ages.26
Gaps in the current policy response
Experts agree that good health and wellbeing in adolescence is key for the development of emotional and cognitive skills, the completion of education and transition to employment, civic engagement and the formation of lifelong relationships.27 In addition, the foundations that determine health throughout life, and that of future generations, are laid down in this period: adolescents are the next generation to parent, and their health and wellbeing reserves can determine the healthy start to life they provide for their children.
Mental ill-health is highly costly to individuals and society as a whole: it predicts worse physical health, lower productivity and lifelong earnings, and shorter life expectancy, along with higher healthcare and social services costs. 28-30 Research shows that mental and emotional health are also strongly related to educational attainment and suggests that low self-esteem may play an important role in the disadvantage achievement gap.31
Yet, this evidence is not reflected in the current policy response. Past governments have been overwhelmingly focused on specialist care, specifically increasing access to treatment and reducing
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waiting times. Even so, while at least half of adult mental health conditions are established by adolescence, only 8.75 per cent of NHS mental health funding goes to children and young people.32 On early intervention, it remains unclear when local Mental Health Support Teams, currently being piloted in a handful of areas, will be rolled out to all schools and colleges and to what extent they will improve their capacity to identify difficulties and support children across the country.
As the number of children requiring treatment continues to exceed available provision, and is likely to rise as a result of the pandemic, improving access to support for those with difficulties should continue to be a priority for the government.
However, as mental and emotional health is strongly influenced by the social and economic environment in which children and young people live, many problems could be prevented from developing at all. A more cost-effective, long-term strategy would redirect focus and resources to prevention. 33 This requires policies which comprehensively target the upstream determinants of poor mental health and low wellbeing amongst young people. Research identifying these determinants opens up opportunities for universal interventions of this kind.
As well as tracking changes to mental and emotional health through adolescence, this report investigates the factors – from individual characteristics and habits, to family health and wellbeing, to experiences in primary school, to wider community factors – which drive poor and positive mental and emotional health in young people.
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Quantitative data
We use data from the Millennium Cohort Study (MCS), a nationally representative longitudinal cohort study of children born between 1 September 2000 and 31 August 2001 in England and Wales, and between 24 November 2000 and 11 January 2002 in Scotland and Northern Ireland. The MCS came out of a renewed interest in child wellbeing in the late 1990s and was developed as a multidisciplinary survey which could capture the influence of early family context on child development and outcomes throughout childhood, into adolescence and subsequently through adulthood.
The MCS is clustered by electoral wards and is disproportionately stratified to over-represent areas with a high percentage of ethnic minority and socio-economically disadvantaged children. This analysis uses data on children living in England at ages 11, 14 and 17, as well as some data from earlier waves (age 9 months, age 7) on some variables in the regression models.
The MCS received ethical approval from the South West and London Multi-Centre Research Ethics Committees, UK. All carers gave their informed consent. The anonymised data was accessed through the UK Data Service where it is publicly available.
Outcomes
We look at three components of mental and emotional health at ages 11, 14 and age 17: wellbeing, self-esteem and psychological distress.
At age 11, wellbeing is measured with a set of questions about happiness in six areas of life and self-esteem using a subset of questions from the Shortened Rosenberg Self-Esteem Scale on positive feelings about self and self in relation to others. Children did not report on their levels of psychological distress at age 11. At age 14, wellbeing and self-esteem are measured using the same scales as at age 11 and psychological distress using the Short Mood and Feelings Questionnaire. At age 17, psychological distress is measured using the Kessler-6 scale, wellbeing with the Short Warwick Emotional Mental Wellbeing Scale and self-esteem with the same measure as at earlier ages. More information on these measures is available in the text boxes below.
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Wellbeing
At ages 11 and 14, children were asked how happy they were with their appearance, family, friends, school, schoolwork and life. Responses were scored on a seven-point Likert scale ranging from ‘completely happy’ to ‘not at all happy’. At age 17, young people were asked about general feelings of wellbeing – e.g. their level of optimism, feeling close to others, feeling relaxed in their lives
– using the validated Short Warwick Emotional Mental Wellbeing Scale. Responses were scored on a five-point Likert Scale.
Self-esteem
At all three ages, children were asked about their feelings about themselves and themselves in relation to their peers using the validated Shortened Rosenberg Self-Esteem Scale, scored on a four-point Likert scale with responses ranging from ‘strongly agree’ to ‘strongly disagree’.
Psychological distress
At age 14, young people were asked about their recent feelings and actions using the Short Mood and Feelings Questionnaire. Thirteen questions were answered on a three -item Likert scale: ‘not true’, ‘sometimes true’ and ‘true’. At age 17, young people were asked about recent depressive symptoms using the Kessler-6 scale and responses were scored on a five-point Likert scale. Both scales are validated for use in this age group.
Overall scores for the three outcome were aggregated from responses to each item. For the box charts in part 1, we standardised and rescaled aggregate outcome scores to a zero-to-20-point scale to compare change over time. In part 2, we used standardised aggregate scores for each outcome to allow for comparison of regression coefficients across outcomes.
Drivers
Model 1 (base model): gender + ethnicity + family income (demographic information)
We run three models to examine the effect of drivers on each of our three outcomes at ages 14 and 17 separately.
Model 1 is our base model and controls for the effect of gender, ethnicity and family income.
A limitation of our analysis is that our ethnicity variable is simplified into broad categories (White, Pakistani or Bangladeshi, Black or Black British, Indian, mixed, ‘other’) due to small sizes of some ethnic groups in our study sample, meaning findings may not be applicable to all sub-groups.
We use family income quintiles as our measure of socio-economic circumstances (SEC).
Model 2: demographic information + individual and family characteristics
We then added in the following factors to the model. This information was recorded at age 11, unless otherwise specified:
▪ weight status (according to World Health Organisation cut-offs for body mass index)
▪ chronic illness in childhood
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▪ frequency of physical activity at age 11 for models looking at outcomes at age 14, and at age 14 for models looking at outcomes at age 17
▪ time spent on social media at age 11 for models looking at outcomes at age 14, and at age 14 for models looking at outcomes at age 17
▪ perceived socio-economic position (SEP). Children were asked if their family was richer, poorer or about the same as their friends’. They were also asked how strongly they agreed with the statement ‘I wish my family could afford more’.
▪ living in a single-parent home
▪ maternal depression in infancy
▪ maternal general health
▪ quality of the young person’s relationship with their parents: parents reported on how frequently they ‘battled’ with their child
▪ cognitive ability: to generate a cognitive index score, we combined young people’s scores on measures of reading, pattern construction and maths at age 7. We used principal components analysis to generate an overall indicator of cognitive ability.
▪ number of siblings
Model 3 (full model): demographic information + individual and family characteristics + peer and community factors
We then added in wider factors and experiences to the models. Given evidence showing a link between the quality of teacher-pupil relationships and wellbeing, we tested whether teacher characteristics that might plausibly affect relationships were significantly predictive of worse mental health outcomes. We only tested the relationship with experiences in primary school and outcomes at age 14, due to the high proportion of missing data which could impact the results of our analysis (see ‘Analysis’ section for more information):
▪ teacher qualifications
▪ teacher years of experience
▪ whether the young person experienced a fixed term exclusion in primary school
▪ whether the young person was streamed in primary and, if so, the stream in which were they placed
▪ how often they argued with friends
▪ how often they were bullied in primary school
▪ how safe the young person felt in their neighbourhood
▪ whether they had access to green space in their neighbourhood
Analysis
In our sample of 5,002 young people in England with complete data on the wellbeing, self-esteem and psychological distress scores at ages 11, 14 and 17, we had complete data on demographics (gender and ethnicity) and socio-economic circumstances (family income). We did not find statistically significant differences in mean wellbeing, self-esteem or psychological distress scores of participants with complete outcome data at all three ages and those missing this data. We therefore excluded cases missing outcome data at ages 14 and 17 from the analysis. We were missing less than 5 per cent of data on other predictors, and approximately 30 per cent of responses on school data; this data was provided by teachers who completed mail-in surveys rather than participating in in-
19
person interviews which contributed to the relatively low response rate. In order to include cases in the analysis missing data on the drivers, we imputed missing values. Forty imputed data sets were created for the analysis.
A limitation of this approach is that we do not know the characteristics of the schools and teachers for whom we are missing data. If these schools and their teaching workforces differ significantly along the characteristics we examine as drivers, for example, they have a disproportionately high number of teachers with few years of experience, this could affect the results of our analysis. Findings on the impact of school factors should therefore be interpreted with caution.
All analyses account for the design of the MCS and include weights. In Part 1, we present aggregate outcome scores for wellbeing, self-esteem and psychological distress at ages 11, 14 and 17, for the sample as a whole and separately by gender. We also present the strength of the correlation between different areas of wellbeing and self-esteem at age 11, areas of wellbeing, self-esteem and psychological distress at age 14, and wellbeing, self-esteem and psychological distress at age 17. In Part 2, we present results from weighted regression analyses separately for each outcome at ages 14 and 17. We also present results from separate models for girls and for boys, based on results showing an improvement in model fit when including interactions with gender. Finally, we present results from analyses of wellbeing and self-esteem at ages 14 and 17, controlling for pre-existing wellbeing and self-esteem scores to test if drivers account for any change in these outcomes through adolescence.
Focus groups
To supplement the quantitative analysis, we conducted focus group discussions with young people in secondary schools. Due to the Covid-19 pandemic and school closures, we were only able to run these groups virtually in two secondary schools, one in Cheshire and one in Greater Manchester. The groups had a mixture of genders, backgrounds, and experiences with their mental health and the mental healthcare system, and ranged in age from 14- to 16-years old. The overall aim of the focus groups was to better understand young peoples’ perspectives on mental and emotional health, their views on the current support systems in place and their ideas for change. The sessions lasted between two and three hours.
Findings from the focus groups are organised thematically and presented throughout the report in green text boxes.
20
Part 1: Mental and emotional health from childhood through adolescence
In part 1, we look at changes in mental and emotional health as children get older and the relationship between the different components of MEH.
In focus groups, young people spoke about mental health being more than psychological distress and about not feeling equipped to discuss mental health issues.
‘I feel like when people hear the words mental health they just think about depression and anxiety, but there’s so much more to it’
‘You don’t know how you feel because you’ve not been taught a way to explain it’
‘You feel like you’re letting your friends down because you don’t know how to help them’
‘As a kid you’re just trying to figure out what’s going on in your head’
Wellbeing in primary through secondary school
Figure 1.1. shows the spread of wellbeing scores at ages 11, 14 and 17. A high score indicates a high level of wellbeing and a low score indicates low wellbeing. The middle line represents the median score at each age, while the top and bottom of the boxes represents the 25th and 75th percentiles of scores respectively.
As seen in Figure 1.1, wellbeing falls on average as children age. At the end of primary school, the majority of children have high levels of wellbeing. Average wellbeing scores drop by secondary school, and by post-GCSE age, most young people have satisfactory wellbeing scores, the lowest, on average, of the three ages.
21
Figure 1.1 Change in wellbeing scores from childhood through adolescence
As seen in Figure 1.2, the drop in wellbeing differs by gender and is larger for girls. Girls start with a slightly higher median wellbeing score at age 11 and have a lower median score at ages 14 and 17 compared to boys. Scores remain concentrated toward the higher end of the scale throughout, showing that the majority of young people continue to have at least satisfactory wellbeing scores.
Figure 1.2 Change in wellbeing scores from childhood through adolescence by gender
22
The young people did not speak explicitly about experiences of the gender divide in mental and emotional health that emerges at the beginning of adolescence. They discussed how girls and boys tend to approach the subject of mental health differently, with stigma around sharing one’s mental health struggles and fear of being judged by male peers more of a barrier for boys.
‘Girls are more open and more prone to talk about how they feel – but boys are more bottled up’
‘[Boys] begin to open up as they get older. As a kid they’re like “oh I need to be [masculine]”, but as they get older they realise that bottling it up is no good.’
Change in areas of wellbeing between primary and secondary school
This section looks at changes in different areas of wellbeing as children transition from primary to secondary school.
As seen in Figure 1.3, the large majority of children finish primary school happy in all areas of their lives, in particular with their families, friends, and school. Fewer, but still at least three quarters, are happy with their schoolwork and appearance.
Figure 1.3 Wellbeing at the end of primary school in different areas of life
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Note: percentages may exceed 100% due to rounding
23
As children move into secondary school, there is a drop in the proportion who are completely happy, but the majority remain mostly or quite happy in all areas of life (Figure 1.4). Meanwhile the proportion who are ambivalent or unhappy increases in all areas of life, particularly in areas of schoolwork and personal appearance. This corresponds to the drop seen in self-esteem in this period; the transition to adolescence is accompanied by growing self-consciousness and worse feelings about the self.
In focus groups, young people spoke about the transition from childhood to adolescence as a time when their experiences with mental and emotional health changed: they felt there was more to worry about as they got older and that challenges, including academic and exam pressure, grew as they moved through secondary school. Others spoke about developing more understanding of their own emotions at older ages and being more open about their mental health as a result.
‘In primary school everything is black and white in your head’
‘In primary and year 7 and 8, you have no care in the world and then after that it gets worse’
‘If you asked everyone in year 9, 10 and 11 if they’re happy themselves, barely anyone would say ‘yes’ and be confident about it’
‘Sometimes you set yourself goals that you know you can’t achieve – pushing yourself over the limit, and that has a massive impact on your mind because you’re always thinking I could be doing better’
Figure 1.4 Wellbeing in secondary school in different areas of life
Completely happy 
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Quite unhappy 
Mostly unhappy 
Completely unhappy
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| 6 |
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| 18 |
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Note: percentages may exceed 100% due to rounding
While we see a drop in average wellbeing in all areas of life for both boys and girls, the size of this drop varies by area and gender as seen in Figure 1.5. Generally, the increase in proportion who are
24
unhappy in different areas of life is greater for girls and is most pronounced in the areas of schoolwork and appearance. The proportion of girls unhappy with their schoolwork doubles from 7 per cent to 14 percent from primary to secondary school, while remaining static at 9 per cent for boys. Similar proportions of boys and girls are unhappy with their looks (11 per cent and 15 per cent respectively), but this stays constant for boys as they move into adolescence and rises to 29 per cent for girls.
Figure 1.5 Changes to areas of wellbeing from primary to secondary school by gender
80%
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20%
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| Boys | Girls | Boys |
| Girls | Boys | Girls |
| Boys | Girls |
| Boys | Girls |
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| Friends |
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| Appearance |
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| Completely happy at age 11 |
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| Unhappy at age 14 |
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Young people were not asked to rate their happiness in different areas of life at age 17 so we are unable to look at changes through secondary school.
In focus groups, young people expressed different beliefs about generational differences in how the subject of mental health is approached.
‘Adults can be more open-minded than children’
‘People our age are more open to talking about it. A lot of adults grew up in a time where you just had to “get over it”.’
‘You’re more willing to talk about it as you get older, as more experience means you know what’s going on’
25
Self-esteem in primary through secondary school
We see a similar, but less pronounced, drop in self-esteem as children move into and through adolescence (Figure 1.6). Most of the fall in self-esteem happens between childhood and adolescence, although scores are generally more concentrated towards the low end of the scale at age 17 compared to age 14.
Figure 1.6 Self-esteem scores from childhood through adolescence
Figure 1.7 shows the change in self-esteem for boys and girls separately as they move from primary through secondary school. We find a more precipitous drop in self-esteem for girls than for boys from ages 11 to 14. Between ages 14 and 17, boys’ scores continue to fall, on average, while girls’ self-esteem appears to remain broadly stable.
26
Figure 1.7 Change in self-esteem scores from childhood through adolescence by gender
Young people highlighted challenges with self-esteem as they moved from primary to secondary school, including ‘caring more about what other people think of you’, as well as the difficulty of navigating relationships with peers. They talked about a ‘standard’ they felt they had to fit and concerns about being laughed at and called names, including for caring about their schoolwork and grades.
‘As soon as you get to high school there’s people making comments about you’
‘It’s very easy to [judge] other people, especially if you’re insecure about yourself’
‘If you care about your work, it’s seen as embarrassing’
Levels of psychological distress through secondary school
We see a corresponding rise in levels of psychological distress as young people move through adolescence (Figure 1.8). This rise is larger for girls, who start off with higher levels of distress at age 14, on average (Figure 1.9).
27
Figure 1.8 Change in psychological distress scores through adolescence
Figure 1.9 Change in psychological distress scores in adolescence by gender
28
The relationship between wellbeing, self-esteem and psychological distress in childhood and adolescence
Figures 1.10 and 1.11 show the strength of the relationship (correlation) between areas of wellbeing, self-esteem and psychological distress at ages 11 and 14. The bubbles show correlation coefficients between 0 and 1 or -1, and the closer the value to 1 or -1, the closer to a perfect correlation between the factors in question. A perfect correlation means that an increase or decrease in variable A always predicts the same directional change for variable B. Darker colours indicate stronger correlations.
The young people spoke about the importance of mental health in this period:
‘It can affect everything in your whole life -- your relationships with family and friends, and your schoolwork and how you apply yourself’
‘[Mental health is] one of the main things that can impact your life if it’s not looked after properly’
Figure 1.10 The relationship between areas of
Figure 1.11 The relationship between
wellbeing and self-esteem at age 11
areas of wellbeing, self-esteem and psychological
distress at age 14
We find that areas of happiness and self-esteem are weakly related at age 11, as shown by the light-coloured bubbles along the bottom of the chart. How children feel about themselves is not strongly related to how they feel about different areas of their life. Happiness with one’s appearance is the only area of wellbeing which shows a modest correlation with self-esteem. Areas of wellbeing are generally weakly correlated with one another, except for a moderately strong correlation between happiness with friends and happiness with family and a moderate correlation between friends and school, indicating that school is an important social space for children.
29
At age 14, happiness in all areas is more strongly, yet still moderately, correlated with both self-esteem and levels of psychological distress, compared to age 11 (Figure 1.11). The exception to this is how happy a young person is with their appearance which is strongly related to self-esteem, and moderately (negatively) correlated with psychological distress. Self-esteem and psychological distress are also moderately strongly, negatively correlated, meaning that a high self-esteem score is linked to lower levels of psychological distress. These findings suggest that as children get older, how they see and value themselves, and how they feel about themselves in relation to others, becomes more closely tied to how they feel about their lives generally.
Figure 1.12 The relationship between wellbeing,
self-esteem and psychological distress at age 17
Wellbeing and psychological distress are more strongly correlated at age 17 (Figure 1.12), but this is likely related to the different measures used at this age. Self-esteem has a similar moderate negative correlation with psychological distress at ages 14 and 17, despite a different measure of the latter being used. Regardless of measures, there are moderate associations between the different components of mental health, but not complete overlap; the same is true for other ages. This means while scores on these outcomes are related, they do not fully predict one another.
Young people shared different attitudes and experiences around accessing support for mental health issues, with some feeling more wary of accessing support if they felt they didn’t have a reason to feel poorly. Young people felt it was not ideal that they were unable to access support without their parents’ help or knowledge.
‘The thing with CAMHS is waiting lists and feeling as if your problems aren’t good enough almost, like you’ve not got it as bad as others’
‘There’s lots of support open for younger people’
‘If you are looking for that professional support it is very hard to get it as a young person… you have to go with family, it’s not like you can reach [it] by yourself.’
‘The only way you can get help with your mental health is through your parents’
‘There doesn’t need to be a reason for people to feel sad. You don’t need a reason for it to be valid’
30
Part 2: Drivers of mental and emotional health in adolescence
We examine the relationship between aspects of children and young people’s lives and their mental and emotional health in early and late adolescence. We start with simple models adjusting for gender, ethnicity and family income (base model). We then add in individual and family factors (model 2), followed by school and community factors (full model). All models apart from base models also control for cognitive ability and number of siblings, but these are not included in the charts. We run models for each of the three outcomes at ages 14 and 17. We then split these models by gender to examine the differential impact of factors on girls’ versus boys’ mental and emotional health. Finally, we run models controlling for pre-existing self-esteem and wellbeing for these outcomes at ages 14 and 17, to isolate the impact of drivers on changes to self-esteem and wellbeing through adolescence (Annex).
Drivers of wellbeing, self-esteem and psychological distress at age 14
Figure 2.1 presents a model adjusting for gender, ethnicity and socio-economic circumstances (SEC), as represented by family income, for each outcome at age 14. The black dots represent the effect size of each factor, or how much the mean of each outcome score changes given a change in the factor in question, while holding other variables in the model constant. A negative effect means that the factor in question is associated with a lower score, a positive effect that the factor is associated with a higher score. Factors with dots along the middle line are the comparison groups, e.g. when looking at the impact of gender, we are comparing girls to boys. The bars show 95% confidence intervals (an effect is statistically significant if the bar does not cross the middle line).
In a simple model controlling for only gender, ethnicity and socio-economic circumstances (SEC), female gender is strongly predictive of lower wellbeing, lower self-esteem and higher levels of psychological distress, as seen in Part 1. Young people of Indian, Pakistani or Bangladeshi heritage are found to be at lower risk of poor mental and emotional health, with Black and Black British ethnicity also associated with higher self-esteem and lower psychological distress scores. This corresponds with national mental illness prevalence data which shows a lower rate of probable disorders amongst minority ethnic young people.9
We see a graded relationship between family income and all three outcomes: lower family income is associated with worse wellbeing and self-esteem and higher levels of psychological distress.
31
Figure 2.1 Demographic and socio-economic drivers of mental and emotional health at age 14 (base model)
Figure 2.2 presents findings from model 2 which includes individual and family factors. We see that the relationships between our three outcomes and gender and ethnicity hold after the addition of these factors, but the effect of family income is partially attenuated – meaning it works partially through these other factors.
We find that how a child feels about their family’s socioeconomic circumstances – wishing they could afford more and feeling poorer compared to their peers – is associated in a graded fashion with lower wellbeing and higher levels of psychological distress, while feeling poorer than peers is also associated with lower self-esteem, showing the importance of relative social standing beyond absolute measures of socioeconomic position.
Physical health status in childhood is significantly associated with mental and emotional health. Having a chronic illness is associated with a lower wellbeing score in this early adolescent period but does not appear to have an effect on self-esteem or psychological distress. Being overweight is associated with worse scores on all three outcomes.
Habits and activities are also important: frequent social media use in childhood is associated with worse wellbeing and psychological distress scores, but not self-esteem scores. Very infrequent social
32
media use was also associated with lower wellbeing, indicating that social media engagement in childhood may be a proxy for general social engagement which we know to be important for wellbeing. Physical activity is very clearly associated with all three outcomes, in a graded fashion: the less physical activity a child engaged in, the worse their wellbeing, self-esteem and levels of psychological distress at age 14.
We do not find a significant effect of living in a home with a single parent, when adjusting for family income and other factors. We do find that maternal mental and physical health are related to a young person’s mental and emotional health: worse maternal health is linked to poorer scores in all three areas. We also looked at the impact of maternal depression in very early years of life and did not find a significant effect at age 14. Arguing frequently with parents is associated with lower wellbeing and higher levels of psychological distress, with no significant effect on self-esteem.
Figure 2.3 presents findings from the final model with includes teacher, peer and community factors. The impact of individual and family factors remains largely unchanged. Additionally, we find that being in the bottom stream in primary school is associated with worse self-esteem scores at age 14. We did not find a statistically significant association between the other factors in primary school we looked at and our outcomes at age 14. As discussed in the methodology section, one limitation of this analysis is the substantial number of cases missing school and teacher data which could affect results. Additionally, the very small number of children who experience a fixed term exclusion in primary school could be a reason why we did not detect an effect.
We find that being bullied in childhood is associated in a graded way with all the outcomes, meaning that the more frequently a child is bullied, the worse their outcomes at age 14. This is particularly clear for wellbeing; the more often a child was bullied in childhood, the more likely they have low wellbeing at age 14. We find a less clear association with the quality of friendships and our outcomes; it appears that arguing with friends is predictive of lower wellbeing and self-esteem and higher psychological distress, but the association is not significant at every level. Finally we find that feeling unsafe in one’s neighbourhood is associated with worse wellbeing and higher psychological distress, but not self-esteem.
Young people spoke about factors they considered important for their mental health. They highlighted the importance of balancing different aspects of their life.
‘Growing up, people might not have had enough money and might have struggled – and that might have affected their mental health.’
‘Families can be on both sides [have negative and positive impacts for mental health]’
‘Everything can go either way – if you have a good relationship with your siblings and parents and you’re open with each other, that can make you happier – but if it’s the other way around that can affect you badly’
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Figure 2.2 Demographic, socio-economic, individual- and family-level drivers of mental and emotional health at age 14 (model 2)
Figure 2.3 Demographic, socio-economic, individual-, family-, school- and community-level drivers of mental and emotional health at age 14 (full model; continued on next page)
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The young people spoke extensively about social media, highlighting both the negative and positive aspects for mental and emotional health. While this discussion was dominated by the female participants, the boys also agreed with the statements including those around body image. They did however suggest that some of the pressure being created could be aspirational – underlining the difference in experience. The young people also acknowledged the importance of controlling how you use social media to limit negative impacts.
‘Social media can have quite a drastic impact on mental health’
‘Beauty standards and what other people think, and [what] other people look like, can make you think that’s how you’re meant to look’
‘You can meet people online – I have loads of online friends. Sometimes it’s easier to talk to people online rather than in real life’
‘People younger than us on social media don’t know what’s real and what’s not’
‘Comments on social media can be vile – people are vile to each other. It’s the same in school – people do make comments on people’s bodies’
‘There’s so much going on – and if you don’t have social media you can’t see what’s actually happened’
‘On social media it’s easy to sort of like build a life – like a fake life and make it seem like everything’s perfect’
‘There’s people in our year that I compare myself to’
‘Rumours on social media can lead to bullying’
‘At the same time, it’s how you use it and what you choose to see’
Drivers of wellbeing, self-esteem and psychological distress at age 17
We ran the same models for our outcomes at age 17, except we looked at the impact of social media use and physical activity at age 14 rather than in childhood. In addition, to simplify the model, we removed the school-level variables from the model, given the relatively weak or lack of associations at age 14.
Figure 2.4 presents a simple model adjusting for gender, ethnicity and family income. We find a similar relationship between these factors and wellbeing, self-esteem and psychological distress at age 17 as at age 14.
The young people spoke about the links between mental and physical health.
‘If a person is struggling mentally it can [affect] their body physically too – like with their daily routine’
‘When your mental health is low, you can lack motivation to exercise’
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Figure 2.4 Demographic and socio-economic drivers of mental and emotional health at age 17 (base model)
Broadly, the same factors are important for mental and emotional health at age 17 as at age 14 (Figures 2.5 and 2.6).
Perception of socio-economic circumstances in childhood continues to have an impact on wellbeing and psychological distress at age 17, although not self-esteem. Having a chronic illness in childhood is linked to lower self-esteem and higher psychological distress at age 17, while being overweight is linked to lower self-esteem. We find a significant relationship between heavy social media use at age 14 and worse self-esteem and higher psychological distress at age 17. We do not find a similar relationship between heavy social media use and wellbeing, contrary to findings at age 14. We also find a graded relationship with physical activity, similar to age 14. Worse maternal health is predictive of higher psychological distress at age 17; while not statistically significant at all levels, we also find an association with worse wellbeing and self-esteem scores. Contrary to the findings for young people age 14, we find an association with maternal depression in infancy and higher psychological distress at age 17. Frequent arguing with parents is linked to lower wellbeing at age 17, while at age 14 it is associated with both worse wellbeing and higher psychological distress. Peer factors continue to have an effect in later adolescence, with experiences of bullying particularly strongly associated with psychological distress. Feeling unsafe in the neighbourhood also has a negative impact on wellbeing and psychological distress, while lacking access to green space in childhood is associated with worse wellbeing at age 17.
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Figure 2.5 Demographic, socio-economic, individual- and family-level drivers of mental and emotional health at age 17 (model 2)
Figure 2.6 Demographic, socio-economic, individual-, family- and community-level drivers of mental and emotional health at age 17 (full model)
Given the gender differences in mental and emotional health in adolescence, and the significance of gender interaction terms in the model, we generated results separately by gender (Figures 2.7 to 2.10). We find substantial differences in the effect of factors on girls’ and boys’ mental and emotional health.
We find that the graded relationship with income is apparent primarily in girls at both ages, although we see a social gradient, albeit not a statistically significant one, in boys’ psychological distress scores at age 14 and wellbeing scores at age 17. Perceptions of socio-economic position are also more important for girls’ mental and emotional health at age 14.
Being overweight is associated with poorer scores on all three outcomes for girls at age 14, and poorer self-esteem and higher psychological distress for boys.
Daily social media use is associated with worse score on all outcomes in girls age 14, but only worse wellbeing for boys at age 14. Physical activity appears to be more important for boys’ mental and emotional health in early adolescence, with a graded relationship between frequency of exercise and scores on all three outcomes at age 14; at age 17, we see a graded relationship in both girls and boys.
Poor maternal health is predictive of worse scores on all three outcomes in both girls and boys in early adolescence, and maternal depression in infancy is associated with girls’ psychological distress level at age 17. Frequent arguments with parents are associated with lower wellbeing in boys age 14 and lower wellbeing in girls age 17.
Placement in a low stream in primary school appears to be particularly significant for boys’ self-esteem, while experiences of bullying in childhood are important throughout adolescence for both boys and girls.
At both ages 14 and 17, feeling unsafe in one’s neighbourhood is significantly predictive of worse wellbeing and higher psychological distress for girls only.
We also ran models looking at self-esteem and wellbeing at ages 14 and 17, separately by gender, controlling for pre-existing levels of self-esteem and wellbeing to identify factors associated with the change in these outcomes in adolescence (Annex 1). We were unable to do the same for psychological distress as children were not asked to report on their psychological state at age 11. Broadly speaking, the same factors remain associated with worse self-esteem and wellbeing scores. Notably, we find that heavy social media use remains associated with low wellbeing in both boys and girls at age 14, girls at age 17, as well as low self-esteem in girls at both ages. We also find that low levels of physical activity remain predictive of low wellbeing and self-esteem for both boys and girls through adolescence. This suggests that regardless of a young person’s pre-existing emotional health status, heavy social media use and low levels of physical activity are linked to worse wellbeing and self-esteem as young people get older.
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Conclusion and policy recommendations
The transition from childhood to adolescence is a turning point for mental and emotional health, especially for girls. As most lifelong mental health issues are seeded in adolescence and early adulthood, it is clear that any strategy to reduce the burden of mental ill-health for the population as a whole should prioritise interventions in this early period of life.
An effective strategy requires expanding current thinking beyond mental healthcare. Focusing primarily on specialist care means a reactive approach to illness once it has developed, at which point interventions are more costly and less likely to be effective. In the case of mental illness, as with chronic physical health issues, many conditions can only be managed once they are established.
Policymakers should refocus on prevention and early intervention, and expand current thinking around these approaches. While mental health support teams will possibly be a step in the right direction, the risk is that these are seen as ticking this box, when it is unclear exactly what role they will play or when all children across the country will benefit from them.
Prevention is about creating the conditions that are conducive to healthy psychological development and functioning for children and young people. This means policies that go beyond the mental health sector to include economic and social factors, the upstream determinants of mental health – also known as a mental health in all policies approach.
The findings of our analysis add to the existing body of evidence showing that targeting socio-economic factors would have an impact on young people’s mental health. We find that socio-economic circumstances, according to both objective measures and children’s perceptions of their family’s position on the socio-economic ladder, are strongly predictive of both mental and emotional health.
Our findings also confirm the importance of the social dimension of life – including young people’s relationships with their parents and peers – and show the lasting impact of social experiences in childhood, particularly bullying, on adolescent mental health. The quality of family relationships has been shown to be affected by financial stress, suggesting that policies targeting socio-economic factors could also have an impact on these important drivers of young people’s mental health and wellbeing.34,35 We know from existing research into adolescent brain development that peer influence is particularly strong in this period of life, and further research on policy action to harness this to support young people’s wellbeing is necessary.
Our findings also confirm the importance of habits including physical activity and social media use. As social media has become a fully integrated part of young people’s lives, we must ensure that young people are equipped with the tools to engage with it in ways that do not adversely affect their mental health.
Investing in the prevention of mental health issues, through targeting upstream determinants, is likely to have a knock-on effect in other areas. Existing research shows that mental health is strongly, and possibly causally, related to educational attainment.36 This means that young people’s mental health is a mechanism through which intergenerational social inequity can be transmitted. The gender divide in mental and emotional health as young people enter working age, particularly in areas of self-esteem, raises questions about the extent to which this contributes to the gender pay gap. The Lancet Commission on Adolescent Mental Health and Wellbeing calls the promotion of
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education and health ‘synergistic goals’: health and wellbeing interventions boost educational attainment while educational attainment, and the opportunities it provides, boosts health and wellbeing.31
The young people we spoke with showed a clear desire for change to the current approach.
Several indicated that more attention should be paid to mental health starting in primary school.
‘Schools should be more aware of these things and have more training’
‘If school helped us out about and gave us suggestions of different things we could do to take action for ourselves that would be good.’
‘[Government] should spend money on more space[s] for young people’
‘They should discuss it more in school. It would be helpful to have a separate subject on mental health. It should be taught from primary school’
[In primary school,] there was anti-bullying stuff, but there was never a big emphasis on how your actions can make others feel. Talking about it would [normalise it] because you do it from a young age.’
‘[We should be] educating teachers, parents, kids, everyone’
‘Kids should know who to talk to and that they’re allowed to – and if they’re not taught that it gets worse’
‘I think it is important that schools talk about [mental health] and give you support, because that’s where young people spend most of their time’
Based on this research, and in light of the risk of the pandemic leading to a deterioration of young people’s mental health and wellbeing, the Education Policy Institute have developed the following recommendations for the UK government. The Prince’s Trust will endeavour to work in partnership with government and schools to take these recommendations forward, where appropriate.
Recommendations are presented in order of more contained action to larger, cross-government policies likely to result in long-term positive change. The government should:
Release a £650m wellbeing funding package to schools to match academic catch-up funding. The number of children with a probable mental illness has risen to one in six since the advent of the pandemic; a substantial number will be struggling with their mental health but fail to meet diagnostic thresholds. Beyond pandemic-related stress, known drivers of poor mental and emotional health, including financial insecurity and limited social support, have been exacerbated by the lockdown, its economic fallout and school closures. The current policy focus in schools is on academic catch-up but remedial wellbeing work will be necessary to achieve this catch-up, alongside investment in socio-emotional development interventions. The wellbeing funding should be targeted to schools with disadvantaged intakes and a high proportion of children with special educational needs and disabilities. A £650m package would allow schools, where required, to hire additional staff to deliver mental health support to pupils and teaching staff, run interventions to address socio-emotional skills’ gaps, improve links with local CAMHS, and deliver training to teachers.
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Publish a plan for rollout of a four-week waiting time for specialist mental healthcare across the country including clear details about funding and staffing requirements. Increasing access to timely care must continue to be a priority for those children who need it, and the government should make clear when and how all children in the country will be able to quickly access the treatment they need.
Build on existing mental health content in the Health Education and Relationships and Sex Education curriculum. This should help young people to understand how different characteristics, identities, and backgrounds, and existing stereotypes about these, can affect mental and emotional health. It should cover the impact of conventional beauty standards spread by advertising and on social media platforms on body image, particularly for girls, and address the stigma young people may face for having different body types or gender expression. Evidence-based techniques to support good mental health and reduce psychological distress, such as mindfulness, should be promoted. Pathways to access different types of support should be clearly laid out. Schools should be advised to engage with parents and carers to ensure they are equipped with the same knowledge. Where relevant, schools should be encouraged to work with external organisations with expertise in this area to enhance delivery. Given the importance of peer influence in this period, maximising mental and emotional health literacy amongst young people will equip them with the tools to support not only their mental and emotional wellbeing, but that of their peers as well.
Improve the capacity of school leaders and teachers to support children with mental and emotional health needs. School leaders should be encouraged to spend time in alternative provision (AP) settings as part of ongoing CPD or prior to entering into a leadership role. The majority of young people in AP struggle with mental or emotional health difficulties. It is crucial for leaders to know how to best support children with additional needs including how to employ trauma-informed approaches in the classroom, and to be able to cascade this knowledge to teaching staff. Survey findings show that many teachers do not feel equipped to deal with pupils’ mental and emotional health issues.2 While it is not the job of teachers to provide mental healthcare, given the proportion of children who struggle with their mental health it is inevitable that most will encounter these issues in the classroom. As such, local Mental Health Support Teams should deliver training in all areas to school staff to ensure that mental health support is embedded across the school community. Schools are the most important, non-stigmatised setting where young people can seek advice and support, and policymakers must ensure leaders and teachers are equipped to offer it.
Develop an evidence-informed policy to tackle bullying including clear plans for funding, delivery and accountability. This could involve more evidence-based guidance from DfE for schools on preventing and tackling bullying – guidance that should be statutory to comply with Equalities legislation when bullying is based on protected characteristics, such as race, gender or (dis)ability – and/or changes to Ofsted’s inspection framework. Evidence shows that interventions which create understanding of and accountability for harm caused by bullying are more effective than punitive action: these include anti-bias training, bystander intervention training, peer support programmes and restorative approaches.3
Ensure that all young people have access to options for engaging in physical activity, including non-competitive activities, in their local area. Commission research, working with diverse young people, to identify scalable interventions to increase activity among children and adolescents. This
research should include a critical assessment of how physical education is currently delivered in schools and address the areas that require improvement.
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Increase funding to local mental health providers to allow them to better identify and work together to support children with needs which do not meet diagnostic thresholds. Current thresholds for access to specialist mental health treatment are high meaning that many children have to reach a crisis point before they are able to access care. A system focused on identifying difficulties early and providing sustained support to prevent them from worsening would reduce the suffering of young people and their families as well as the high costs of more complex interventions.
Develop a cross-government and cross-sector strategy to reduce family poverty and ensure young people feel safe in their communities. Given the social gradient in mental and emotional health for young people as well as adults, the strong links between poor mental health in adolescence and adult mental health problems, and the interconnectedness of parental and child mental health, this would reduce the burden of mental illness and poor wellbeing in the population as a whole. Poverty, which has risen amongst families with children in the last decade, leads to worse population health generally and increases the need for more costly, late intervention putting pressure on squeezed health services.4 Given the high and rising number of families living in in-work poverty, this strategy must go beyond getting people into work.5
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Figure A1. Drivers of wellbeing and self-esteem in girls age 14, controlling for childhood wellbeing and self-esteem (continued on next page)
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Figure A2. Drivers of wellbeing and self-esteem in boys age 14, controlling for childhood wellbeing and self-esteem (continued on next page)
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Figure A3. Drivers of wellbeing and self-esteem in girls age 17, controlling for childhood wellbeing and self-esteem
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Figure A4. Drivers of wellbeing and self-esteem in boys age 17, controlling for childhood wellbeing and self-esteem
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