Is there a child mental health crisis?

It is now common for media reports to mention a ‘child mental health crisis’ with claims that anxiety and depression in children are rising to catastrophic levels. The evidence behind these claims can be a little hard to track down and when you do find it there seems little evidence for a ‘crisis’ but there are still reasons for us to be concerned.

The commonest claim is something to the effect that ‘current children show a 70% increase in rates of mental illness’ and this is usually sourced to the website of the UK child mental health charity Young Minds which states that “Among teenagers, rates of depression and anxiety have increased by 70% in the past 25 years, particularly since the mid 1980’s”

This is referenced to a pdf report by the Mental Health Foundation which references a “paper presented by Dr Lynne Friedli”, which probably means this pdf report which finally references this 2004 study by epidemiologist Stephan Collishaw.

Does this study show convincing evidence for a 70% increase in teenage mental health problems in the last 25 years? In short, no, for two important reasons.

The first is that the data is quite mixed – with both flatlines and increases at different times and in different groups – and the few statistically significant results may well be false positives because the study doesn’t control for running lots of analyses.

The second reason is because it looked at a 25-year period but only up to 1999 – so it is now 17 years out-of-date.

Lots of studies have been published since then, which we’ll look at in a minute, but these findings prompted the Nuffield Foundation to collect another phase of data in 2008 in exactly the same way as this original study, and they found that “the overall level of teenage mental health problems is no longer on the increase and may even be in decline.”

Putting both these studies together, this is typical of the sort of mixed picture that is common in these studies, making it hard to say whether there genuinely is an increase in child mental health problems or not.

This is reflected in data reported by three recent review papers on the area. Two articles focused on data from rating scales – questionnaires given to parents, teachers and occasionally children, and one paper focused on population studies that use diagnosis.

The first thing to say, is that there is no stand-out clear finding that child mental health problems are increasing in general, because the results are so mixed. It’s also worth saying that even where there is evidence of an increase, the effects are small to moderate. And because there is not a lot of data, the conclusions are quite provisional.

So is there evidence for a ‘child mental health crisis’? Probably not. Are there things to be concerned about – yes, there are.

Here’s perhaps what we can make out in terms of rough trends from the data.

It doesn’t seem there is an increase in child mental health problems for young children, that is, those below about 12. If anything, their mental health has been improving over the since the early 2000s. Here, however, the data is most scarce.

Globally, and lumping all children together, there is no convincing evidence for an increase in child mental health problems. One review of rating scale data suggests there is an increase, the other paper using the more rigorous systematic review approach suggests not – in line with the data from the review of diagnostic studies.

However, there does seem to be a trend for an increase in anxiety and depression in teenage girls. And data from the UK particularly does seem to show a mild-moderate upward trend for mental health problems in adolescents in general, in comparison to other countries where the data is much more mixed. Again, though, the data isn’t as solid as it needs to be.

This leaves open some important questions though. If we’re talking about a crisis – maybe the levels were already too high so even a drop means we’re still at ‘crisis level’. So one of the most important questions is – what would be an acceptable level of mental health problems in children?

The first answer that comes to mind is ‘zero’ and not unreasonably – but considering that some mental health problems arise from largely unavoidable life stresses, bereavements, natural disasters and accidents, it would be unrealistic to expect that no child suffered periods of disabling anxiety or depression.

This also raises the question of where we decide to make the cut-off for ’emotional problems’ or ’emotional disorders’ in comparison to ‘healthy emotions’. We need anxiety, sadness and anger but they can also become disabling. Deciding where we draw the line is key in answering questions about child mental health.

So there is no way of answering the question about ‘acceptable levels of mental health problems’ without raising the question of the appropriateness of how we define problems.

Similarly, a very common finding is huge variation between countries and cultures. Concepts, reporting, and the experience of emotions can vary greatly between different cultural groups, making it difficult to make direct comparisons across the globe.

For example, the broadly Western understanding of anxiety as a distinct psychological and emotional experience which can be understood separately from its bodily effects is not one shared by many cultures.

It’s worth saying that cultural changes occur not only between peoples but also over times. Are children more likely to report emotional distress in 2016 compared to 1974 even if they feel the same? Really, we don’t know.

All of which brings us to the question- why is there so much talk about a ‘mental health crisis’ in young people if there is no strong data that there is one?

Partly this is because the mental health of children is often a way of expressing concerns about societal changes. It’s “won’t someone think of the children” given a clinical sheen. But it is also important to realise that consultations and treatment for child mental health problems have genuinely rocketed, probably because of greater awareness and better treatment.

In the UK at least, it’s also clear that talk of a ‘child mental health crisis’ can refer to two things: concerns about rising levels of mental problems, but also concerns about the ragged state of child mental health services in Britain. There is a crisis in that more children are being referred for treatment and the underfunded services are barely keeping their head above water.

So talk of a ‘crisis in rising levels of child mental health problems’ is, on balance, an exaggeration, but we shouldn’t dismiss the trends that the data do suggest.

One of the strongest is the rise in anxiety and depression in teenage girls. We clearly have a long way to go, but the world has never been safer, more equal and more full of opportunities for our soon-to-be-women. Yet there seems to be a growing minority of girls affected by anxiety and depression.

At the very least, it should make us think about whether the society we are building is appropriately supporting the future 50% of the adult population.