Introductory Chapter: Selected Topics in Child and Adolescent Mental Health

1. Child and adolescent mental health: context, causes and solutions

Improving people’s mental health has been identified as one of the most critical public health priorities [1, 2]. Child and adolescent mental health is a global concern, and although each nation faces its own unique challenges, there are common concerns, challenges and solutions to this problem. Statistics suggest that mental ill health in children and young people is increasing. Research suggests that half of all psychological disorders begin before the age of 14 years [3]. However, the increase in diagnoses may also be attributed to the de-stigmatisation of mental ill health in recent years, increasing awareness of mental health among professionals and government investment in mental health research. It is important to remember that stigmatising and deficit discourses associated with mental ill health over the last century resulted in its concealment and internalised shame.

2. Whole school approach

Recent efforts by nations to eradicate the stigma associated with mental health have resulted in increased awareness of mental health among children, young people, professionals and parents. In some countries (e.g. the United Kingdom), it is statutory to provide children and adolescents with a mental health curriculum. Research demonstrates that educating young people about mental health not only increases their mental health literacy, it has a positive effect on their attitudes towards mental health and increases help-seeking behaviours [4]. However, providing young people with a mental health curriculum is only one part of a whole school or college approach to mental health. Educational institutions which have positive cultures promote a sense of belonging which is critical for positive mental health. In addition, schools and colleges need to consider approaches for working in partnership with young people, parents and health and social care professionals to ensure that young people’s holistic needs are met. Approaches to identification of mental ill health need to be proactive rather than reactive. Often, mental ill health is identified through observing changes in a child’s mood, behaviour or physical appearance. The problem with this type of reactive approach is that it fails to identify those young people who do not demonstrate these obvious signs. A proactive approach which incorporates universal screening ensures that children who do not demonstrate visible signs of mental ill health, but actually experience it, can be identified.

3. A clinical model

Within some countries, in recent years there has been a focus on providing in-school interventions to support children and young people’s mental health. These vary from universal interventions which are available to all children (e.g. a mental health curriculum), to group and highly personalised individual interventions. In the United Kingdom, there has been government investment into training a new group of professionals—education and mental health practitioners. These professionals are deployed to work in schools alongside teachers. Their role is to provide low-level clinical interventions, including counselling, cognitive behaviour therapy and other therapies, so that young people can receive mental health support within their school contexts. Although it might be argued that this is a positive step in the right direction, it also reflects a clinical model which fails to address the root causes of mental ill health.

4. Finding solutions by addressing the causes

The solutions of mental ill health in childhood need to be found by identifying the causes of it. If the root causes are not addressed, then societies risk only addressing mental ill health at a surface level. The causes of mental ill health in childhood and adolescence are complex and multifaceted. The biopsychosocial model of health [5] demonstrates how mental health is a product of overlapping biological, social and psychological factors. In some cases, poor mental health is rooted in the individual. Those with disabilities are more likely to experience mental ill health. Young people with autistic spectrum conditions are likely to experience stress due to sensory sensitivities which are linked with their autism. However, often the causes of poor mental health are rooted in social circumstances. Young people living in social deprived communities are more likely to experience poor mental health. According to the Mental Health Foundation [6]:

A growing body of evidence, mainly from high-income countries, has shown that there is a strong socioeconomic gradient in mental health, with people of lower socioeconomic status having a higher likelihood of developing and experiencing mental health problems. In other words, social inequalities in society are strongly linked to mental health inequalities.

Children who experience parental conflict, neglect, abuse and poor parental mental health are at a heightened risk of developing mental ill health [7]. Children who form weak attachments with their primary caregiver are also at increased risk of developing mental ill health. We also know that school-related factors play a role in mental ill health. Limited curriculum choice and examination stress are also factors which result in poor mental health [8]. In addition, exposure to bullying in school can result in young people not feeling safe and therefore not experiencing a sense of belonging.

Meyer’s model of minority stress [9] is a useful conceptual framework which demonstrates that individuals with a minority status are more likely to experience poor mental health. The model identifies three stressors which include general stressors and distal and proximal stressors. According to the model, general stressors may include financial-, employment-, relationship- or housing-related stressors which most people experience. However, individuals with a minority status may experience additional stressors which result in poor mental health. Distal stressors relate to exposure to bullying, prejudice and discrimination as a result of their minority status, whilst proximal stress is the internalised stress that results from the anticipation that individuals with a minority status will encounter distal stressors. The model demonstrates how race, sexuality, gender and disability can result in poor mental health as a result of exposure or anticipation of exposure to prejudice, discrimination and bullying.

5. Responding at a systemic level

As we have demonstrated above, the causes of mental ill health in childhood and adolescence are often rooted in social circumstances. Therefore, it could be argued that intervention at the level of the individual is insufficient. A clinical model which focuses on therapeutic intervention will address the symptoms of mental ill health, but it will not address the factors which have caused it to occur in the first place. Children and adolescents who receive therapy still have to continue to live their lives in homes, communities and schools which are often the cause of poor mental health. Governments therefore need to adopt a response which addresses the systemic factors which cause poor mental health. These factors include poverty, adverse childhood experiences, societal prejudice and discrimination (including racism, sexism, ageism, homophobia, biphobia and transphobia and disablism) and the structures which underpin the education system.

Adolescents who are not in education, employment or training also risk developing poor mental health. Therefore, investment in this area is vital to secure positive outcomes for young people. Providing young people with a relevant curriculum which meets their needs and prepares them for employment will ensure that they have the knowledge, skills, motivation and qualifications to secure employment. Providing curriculum breadth and balance and broadening out what constitutes academic achievement will support young people to stay motivated and engaged in their learning as well as supporting aspiration. This needs to be matched by government investment in education, employment and training to ensure that opportunities are available to all young people, irrespective of their social backgrounds.

Although a clinical model can promote resilience, resilience is not just rooted within individuals. Resilience is dynamic and changes in different contexts. Although individual factors play a role in supporting resilience (e.g. sense of hope, sense of purpose, self-worth and self-efficacy), resilience is supported through access to social networks and relationships [10]. Positive relationships with peers, family members and teachers help to support resilience. Resilience is influenced by family, community and school contexts, the nature of the challenges that individuals are exposed to and the broader policy and legislative framework which influences the lives of individuals [10]. Resilience interventions in education locate resilience within the individual rather than acknowledging that the individual is not solely responsible for their own resilience.

The relationship between technology and mental ill health has been identified in several studies [11, 12]. Schools play an important role in developing young people’s digital literacy and awareness of digital citizenship so that they can be responsible users of technology. Schools also play a crucial role in supporting young people to critically engage with digital content so that they can evaluate it. However, despite the risks associated with technology and social media specifically, the benefits outweigh the limitations. Technology enables young people to network, access support and advice and to function as global, connected citizens, all of which are vital for good mental health.

It is clear that improving people’s mental health is a priority [1, 2]. Destigmatising mental ill health is crucial in order to support effective diagnoses, and it is essential that action is taken to continue raising awareness of mental health among professionals but also at a governmental level. Education will continue to play a vital role in relation to mental health literacy and attitudes towards mental health [4], and the whole school or college approach is essential to promote a sense of belonging. However, educational institutions must also be proactive in establishing and developing partnerships with stakeholders to ensure that young people’s needs are met holistically. These approaches and mechanisms for promoting positive mental health must acknowledge the heightened risk of poor mental health for those with experiences of conflict, neglect and abuse as well as those with a minority status [9].

Likewise, adolescents who are not in education, employment or training are also at a heightened risk of developing poor mental health. For these young people, government investment plays a critical role in providing opportunities to all, irrespective of social background. Young people must be equipped with the knowledge, skills, motivation and qualifications required to secure employment, and educational institutions cannot meet these needs unless they are prioritised at a governmental level. Social networks, relationships and the educational curriculum are essential to positive mental health, and these must be supported holistically by broader policy and legislative frameworks within and throughout society [10].