On 1 August 2018, The Spectator published an article on mental health awareness entitled “Mental health awareness may do more harm than good”. Journalism aims to provoke and entertain, and the questions raised – whether teaching mental health awareness in schools may be harmful and whether there is actually an epidemic of poor child mental health – are both valid and important. The dismissive tone of the article, however, is unfortunate and undermines the important point that the author could have made, which is that policy should be evidence-based and evaluated for unexpected consequences. Comments that imply that prescriptions of psychotropics for anxiety in children have only been prescribed because of “anxiety about anxiety”, are both unhelpful and untrue. The presentation of the absolute number of prescriptions issued without consideration of the denominator – the huge number of children who live in this country that they could helpfully be prescribed for is misleading and far more attention grabbing than the relative value, of which more below.
The quote that 1 in 10 children and young people suffer from mental health disorders comes from two large population-based surveys of children and young people in this country. Carried out in 1999 and 2004, the child benefit register (then a universal benefit) was used to generate a representative sample of 10438 (1999) and 7797 (2004) school-aged children. Mental health assessments were based on parent, teacher and young person’s reports gathered using a systematic and validated assessment by a small team of child and adolescent psychiatrists, applying standardised diagnostic criteria. These studies were rigorous and the results were robust. Follow up after three years indicated that half of those initially identified with a mental health condition still met diagnostic criteria. To meet diagnostic criteria requires distress and impairment, not “anxiety about anxiety.”
A 2017 survey will be reported shortly, with more up-to-date figures. The fact that adult mental health has been surveyed at five yearly intervals whilst child mental health has not been surveyed for more than a decade, provides an indication of how we value the welfare of children in this country. It is worth noting that 75% of adult mental health conditions have their origins in childhood, and the costs of poor adult mental health amount to billions. Therefore active, effective and prompt intervention and prevention of child mental health problems should be a policy priority. It is a good thing to see that it currently is, because child mental health services have long been the poor cousins of the Cinderella service that is adult mental health in terms of funding and policy attention for many decades. And as a society, we are all paying for the results.
So significant problems with mental health are impairing a sizeable minority of school age children; 10% equates to two or three children in every classroom. Given that subclinical problems are even more common and also confer difficulties in coping albeit less severe, it is perfectly plausible that four out of five teachers report that they have worked with a child with a significant mental health condition. In fact, it is surprising that it was only four out of five that reported this experience, and yes that might speak volumes of teachers attitudes or “sensibilities” about the mental health of the children that they teach. Until the third national survey is published, we can only speculate whether there has been an increase in the number of children and young who are suffering from mental health conditions in the population at large. What is not in doubt is that both in the health and education sectors, professionals who work with children are seeing many more distressed youngsters seeking help. Presentations at accident and emergency with self-harm, admissions to general paediatric beds as well as psychiatric inpatient units and referrals to child and adolescent mental health services have all massively increased over the last five years or more, leaving services unable to cope. Only about a quarter of those with mental health conditions in the two national surveys quote above were seen by mental health services, and more than a third had no professional support at all over the three year follow up period. Research to date is less clear whether there has been an increase in prevalence but does suggest that parents and young people are more likely to report that they are concerned about mental health problems. If services could manage the work load, more parents and young people coming forward for support for these difficulties would be a good thing.
This article begins with a focus on medication. Outside clinical and administrative datasets, we await the next national child mental health survey to assess whether the increase in prescriptions represents over-prescribing. Based on the data from 2004 survey, it is unlikely to, as only 7% of those with an emotional disorder were taking any kind of psychotropic medication at that time. For this and other disorders, there was no evidence of over prescription and plenty of opportunity for the increase in prescriptions reported to have occurred in the context of more families seeking help and appropriately receiving it. If only 7% of children with cancer were receiving appropriate drug treatment would we see an outcry if prescriptions increased?
These large surveys (and other sources of data) indicate that schools are our default front line service in relation to mental health, with all the costs associated with that. The current policy focus to centre prevention and intervention on schools and colleges therefore makes a great deal of sense in the light of this evidence. Contrary to the view expressed in The Spectator, the aims of new Personal, Social, Health and Economic education (PSHE) curriculum in relation to mental health are yet to be finalised, and are out for consultation. The aim is to teach children and young people how to look after their mental health, in much the same way that PSHE currently encourages them to take care of their physical health. And yes, this may include advice about diet and exercise, and yes exercise certainly has a role in the prevention and intervention for some aspects of poor mental health as well as obesity and particularly depression. But so do – emotional regulation, social and peer relationship skills, and how to stand up against bullying – all of which can and should be taught to children of various ages. If taught well, these are likely to improve mental health. And yes this should all be evaluated.
Public money should not be wasted and public policy should be evidence-based and outcome driven; PSHE is no exception. It is a shame that this argument is lost amidst the polemic, particularly if the flippant tone of this article risks causing further distress to those who may be trying to support a child or relative with significant psychological distress or worse, may deter them from seeking help that could benefit them. What is important is to realise is that parental concerns about their child mental health are indicative of problems in the vast majority of cases, and that we have effective evidence-based interventions. Sometimes, but relatively rarely in the UK, these include medication. We need to do a better job at enabling more families to access them, rather than deriding people for being anxious and leaving them to suffer for longer than necessary.
I fully support and applauded your well written article. I feel there is an aspect that needs to be aired and discussed around how overtime I have perceived a change in – and the power of – language. In this I have observed how some parents and the adults in a child or young person’s network jump too quickly to seek or mis-label depression or anxiety – as lay people with no time or ‘expert’ experience. Thoughts and feelings are a part of life and its ok at times to be sad or worried – these are natural feelings. We all experience these feelings and as parents, adults in trusting positions and/or working with children and young people we should be able to reassure, reassure and reassure again? This takes time and effort and in our fast pace society is easier just to label rather than take the time to understand and offer comfort? I have – only on an odd occasion – seen how labels stick and determine a trajectory (what to live up to). I hope my words and not misunderstood i.e. if a young person is struggling then help should be sought. On balance it is better to seek help then miss an opportunity but words and language in the wrong context are powerful things.
Thank you Professor Ford, a great response.
A very sound case put eloquently. Much of the current despair I am conscious of surrounds the effort, experienced by front-line workers it seems to be taking, to persuade those directing schools and teacher training institutions that MHWB awareness needs to be central to any curriculum – in a climate where counsellors are supporting both youngsters and trainee teachers with crisis-point mental health concerns at increasing volume term on term.