What is mental health?

There are two aspects to mental health: mental illness or ill-health, and mental or psychological well-being.

Mental ill-health measures consider whether a person has a higher likelihood of a clinically diagnosable illness, from anxiety or depression to problems such as bipolar disorder or schizophrenia. Mental ill-health in children can manifest in different ways to adults, often resulting in behavioural and conduct problems, such as Attention Deficit Hyperactivity Disorder (ADHD) or Oppositional Defiant Disorder (ODD), as well as emotional problems such as depression or anxiety. These conditions can also be symptoms of underlying problems, which may be environmental (for example, parental conflict) or developmental (for example, Autistic Spectrum Disorders).

In this course, we discuss the prevalence of mental ill-health, as shown by the total difficulties score from the Strengths and Difficulties Questionnaire (SDQ).

Mental well-being is concerned with how people feel about their lives and whether their lives are worthwhile. It is not just the absence of mental health problems and can be described as “a dynamic state, in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community”. The 31 measures of children’s well-being capture many aspects of mental well-being using measures such as quarreling with parents, talking to parents about things that matter, happiness with family and friends, satisfaction with time use, desire to go on to further education, and considering the things that one does are worthwhile. Furthermore, subjective measures of both life satisfaction and happiness are included.

Why is mental ill-health important?

The World Happiness Report cites research that found over half of children who have a mental health problem will suffer from mental ill-health as adults. Furthermore, it explains that mental health problems such as depression can be more disabling than physical problems such as arthritis or asthma.

The Mental health of children and young people in Great Britain, 2004 study found that 1 in 10 children aged 5 to 16 years had a clinically diagnosable mental disorder. Boys were more likely to have a problem than girls and prevalence increased with age. Girls were more likely to have emotional problems whereas boys were more likely to report conduct or hyperactivity problems. The study also found that children with mental disorders were more likely than children without mental disorders to have time off school, especially unauthorised absences, and were less likely to have a network of family and friends with whom they felt close.

More recently, Mental Health Difficulties in Early Adolescence compared mental ill-health prevalence from two different cross-sectional samples of children aged 11 to 13 years in 2009 and 2014 and found that there were similar levels of mental ill-health in both cohorts (19.7% compared with 19.0%). However, the study did identify a significant increase in emotional problems amongst girls and a decrease in the proportion of boys reporting “at-risk” levels of total difficulties scores. The authors suggest that an increased focus on interventions to tackle disruptive behaviour has helped boys, but there have been no similar interventions to tackle emotional problems, which are more likely to affect girls.

In March 2015 the government pledged £1.25 billion to improve children and young people’s mental health services over the next 5 years. In tandem with this announcement the Department of Health and NHS England published ‘Future in mind’, detailing the work of the children and young people’s mental health and well-being taskforce, which was set up to identify ways of improving mental health services and access to these services for children and young people.

Proposals include:

• a hard-hitting anti-stigma campaign which raises awareness and promotes improved attitudes to children and young people affected by mental health difficulties
• a five-year programme to develop a comprehensive set of access and waiting for times standards that bring the same rigour to mental health as is seen in physical health
• commissioning a new national prevalence survey of child and adolescent mental health
• encouraging schools to continue to develop whole school approaches to promoting mental health and wellbeing

More recently, local transformation plan guidance has been published to help local areas implement changes and ensure the momentum of improvement is maintained.

How is mental ill-health measured?

The national measures of well-being include the proportion of adults aged 16 and over reporting symptoms of mental ill-health using the General Health Questionnaire (GHQ). However, this has not been validated for use in children; it is focused on symptoms experienced by adults and would not be appropriate or informative if used for children. To measure children’s mental ill-health, a more “child-centric” measure had to be identified. The Strengths and Difficulties Questionnaire (SDQ) was designed by Professor Robert Goodman as a behavioural screening questionnaire for use with children aged 2 to 171. It consists of questionnaires administered to the child, a parent and a teacher. As its name suggests, it measures a child’s strengths and difficulties in a number of areas:

1. Emotional symptoms
2. Conduct problems
3. Hyperactivity or inattention
4. Peer relationship problems
5. Pro-social behaviour

The first four of these areas can be combined together to provide a “total difficulties” score, which can then be used as a predictor of mental ill-health. The SDQ has been extensively validated and was used as the screening tool for the Mental health of children and young people in Great Britain, 2004 report. It must be noted that only the child self-reported questionnaire is being used to provide the total difficulties score for use as a measure of mental ill-health in the children’s well-being framework. The sensitivity of predicting clinical diagnosis is much higher using a multi-informant SDQ, and so the total difficulties score presented here should only be considered an indication of the prevalence of mental ill-health.

The self-completion SDQ is included in every other wave of the Understanding Society Youth module3, providing regular and reliable estimates for a headline measure of children’s mental ill-health. Furthermore, the longitudinal design of the Understanding Society survey will allow for further exploration of changes in total difficulties scores as the survey progresses.

The total difficulties score can be reported as an average (mean) score, or categorised into 4 groups:

1. Close to average or normal (score 0 to 14 out of 40)
2. Slightly raised (score 15 to 17 out of 40)
3. High (score 18 to 19 out of 40)
4. Very high (score 20 or more out of 40)

For the purposes of children’s well-being, the headline measure for the prevalence of mental ill-health is the proportion of children reporting a high or very high total difficulties score, although the mean score will also be provided for completeness.

What do the data tell us?

The latest data from Understanding Society (2011 to 2012) shows that around 12% of children aged 10 to 15 reported high or very high total difficulties scores. The proportion was the same for both boys and girls (12%) and did not significantly differ from the proportions reported in the 2009 to 2010 wave of Understanding Society. Similarly, the average score was 10.6 out of 40 in 2011 to 2012, broadly similar to the 2009 to 2010 average score of 11.0. There are, however, some interesting differences in the associations between the average total difficulties scores and other factors.

Of the 31 children’s measures of well-being (including the total difficulties score), 12 are sourced from the Understanding Society survey. Measures other than total difficulties score are:

• happiness with the appearance
• quarrel with mother/father
• talk to mother/father about things that are important
• bullied at school (physically, in other ways or both)
• time spent on social websites
• feel safe walking in your neighbourhood after dark
• like your neighbourhood
• happiness with school
• want to go on to full-time education

In the 2011 to 2012 wave of the survey, all 12 measures were included so a more detailed analysis of the associations between the total difficulties scores and these other measures was possible. All of the variables shown in Table 1, including age and gender, were included in a regression analysis, which allows us to look at the relative importance of these different factors for children’s mental health. It must be noted that these measures are not a definitive list of factors affecting children’s mental health. Other factors may be as or more important but have not been included as they are either not a measure of children’s well-being, or not available in the Understanding Society dataset.