Secular trends in adolescent mental health

Secular trends in adolescent mental health

Is childrens mental health really getting worse? Barbara Maughan MRC SGDP Centre Institute of Psychiatry Kings College London Questions what do we mean by emotional/behavioural problems in childhood? how common are they? how does the UK compare with other countries? do they matter in the longer term? have rates changed over time? Child psychiatric disorders Emotional disorders Depression Conduct disorders

Oppositional defiant disorder Anxiety disorders Separation Anxiety Social phobia Conduct disorder Hyperkinetic disorder (ADHD) Agoraphobia Post Traumatic Stress Disorder (PTSD) Specific phobia Less common disorders Panic Pervasive developmental disorder Obsessive-Compulsive Disorder (OCD)

Psychotic disorder Generalised Anxiety Disorder (GAD) Eating disorders Diagnosis requires distress or substantial interference with functioning 1999 ONS/DoH National Survey 5-15 year-olds England, Scotland & Wales n=10,438 2004 Prevalence of psychiatric disorders: girls

14 Age 5-10 12 Age 11-16 10% 10 % 8 5% 6 4 2

0 Anxiety disorders Depression Conduct Hyperkinetic disorders disorder Less Any disorder common disorders Mean score 2004

Prevalence of psychiatric disorders: boys 13% 27 26 25 24 23 22 21 20 19 18 17 10% Problems Competencies

1976 1989 1999 Associated difficulties impact on other family members many parents depressed / feel stigmatized family relationships & parents social activities affected strong overlap with physical health strong overlap with educational needs emotional problems: > 1 in 3 Special Ed Needs conduct disorders: > 1 in 2 SEN hyperkinetic disorders: > 70% SEN

strong overlap with smoking drinking cannabis use offending Questions what do we mean by emotional/behavioural problems in childhood? how common are they? how does the UK compare with other countries? do they matter in the longer term? have rates changed over time?

UNICEF: An overview of child well-being in rich countries, 2007 11, 13 and 15 year-olds: peers kind and helpful 30 40 50 60 70 80 90 Risk behaviours smoking, drugs/alcohol, hazardous sex, early pregnancy

11, 13 and 15 year-olds: above median life satisfaction 40 50 60 70 80 90 European School Survey Project on Alcohol and Other Drugs Trends in drug use among 15-16 year olds in the UK and other European countries: 1995-2003 1995

45 1999 United Kingdom 2003 All particpant countries 40 % that have used 35 30 25 20 15 10 5

0 Lifetime: any drug Lifetime: cannabis Lifetime: Past month: other drugs cannabis Lifetime: cannabis Lifetime: other drugs Questions what do we mean by emotional/behavioural

problems in childhood? how common are they? how does the UK compare with other countries? do they matter in the longer term? have rates changed over time? Persistence of psychiatric disorders: 1999 sample 3 year follow up 46% 50 40% 40 30 % 20 10 0

Anxiety / Depression Conduct disorders Hyperkinetic disorder Boys Girls Less common disorders Any disorder Psychiatric disorder age 26:

age at first diagnosis 1.5 m eanem otional score 1.25 Boys 1 Girls 0.75 0.5 1974 Kim-Cohen et al., 2003

1986 1999 Aspects of functioning affected continuities in disorder but also effects on educational attainments social functioning family formation & parenting health and disability exposure to stress social exclusion costs to society Questions what do we mean by emotional/behavioural problems in childhood? how common are they? how does the UK compare with other countries?

do they matter in the longer term? have rates changed over time? Rutter & Smith 1995 Psychosocial Disorders in Young People Evidence for ..substantial increases in psychosocial disorders of youth since World War II sudden increases, not continuation of earlier trends juvenile crime, depression, alcohol & drug use specifics varied by time and country but

major methodological difficulties older people may forget past problems general increase in psychologically-mindedness ideally need repeated surveys using the same methods Data sources - and their difficulties Official statistics (suicide, crime) coverage changes in reporting / processing / recording Referrals / service contacts proportions accessing services public / clinician awareness Suicide and undetermined deaths England and Wales 1968-2000 25

Rate per 100,000 20 15 10 5 0 Office for National Statistics, 2003 Males 20-24 Males 15-19 Females 20-24 Females 15-19 Deliberate self-harm: 12-18 year-olds Episodes referred to one general hospital 1990-2000 250

Episodes 200 150 100 50 0 . 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Females Hawton al, 2003 Males Referral data Autism real increase in prevalence?

changing diagnostic criteria? improved awareness? Prescribing for ADHD public / clinician awareness? More common emotional / behavioural problems best approach repeated studies similar samples same assessments mainly questionnaire-based studies US: Parent CBCLs 7-16 year-olds 1976, 1989 & 1999 Achenbach, Dumenci & Rescorla, 2003 Scotland: Psychological distress (GHQ)

15 year-olds, 1987 & 1999 35 % GHQ caseness 30 25 20 1987 1999 15 10 5 0 West & Sweeting, 2002 Boys

Girls Time trends in adolescent mental health Stephan Collishaw, Barbara Maughan Robert Goodman, Andrew Pickles Funded by the Nuffield Foundation Trends in psychosocial problems among young people in the UK opportunistic comparison of long-term trends in emotional/behavioural problems over three decades 1970s 1980s

1990s Samples C o h o rt 1 C o h o rt 2 C o h o rt 3 S tu d y N a tio n a l C h ild D e v e lo p m e n t S tu d y (N C D S ) 1 9 7 0 B r itis h C o h o r t S tu d y (B C S 7 0 ) O N S C h ild

M e n ta l H e a lth S u rv e y D e s ig n L o n g itu d in a l: B ir th -a g e 3 3 L o n g itu d in a l: B ir th -a g e 2 9 C r o s s -s e c tio n a l P a re n t r a tin g s R u tte r A R u tte r A

G oodm an SDQ N 1 0 ,4 9 9 7 ,2 9 3 868 Age 16 A ge 16 1974 1986 1999 Measures of adolescent mental health

Adolescent hyperactivity fidgeting inattention restlessness Adolescent emotional problems misery worries fearful of new situations Adolescent conduct problems fighting bullying stealing lying disobedience Time trends in adolescent hyperactive problems mean hyperactive score

1.5 1.25 1 Boys Girls 0.75 0.5 0.25 1974 1986 1999 Time trends in adolescent emotional problems mean emotional score

1.5 1.25 Boys Girls 1 0.75 0.5 1974 1986 1999 Time trends in adolescent conduct problems mean conduct score 1.75

1.5 1.25 Boys 1 Girls 0.75 0.5 0.25 1974 1986 1999 Trends in conduct problems: by family type mean conduct score

1.75 1.5 1.25 Two natural 1 Single/step 0.75 0.5 0.25 1974 1986 1999 Trends in conduct problems:

by social class mean conduct score 1.75 1.5 1.25 NM M 1 0.75 0.5 0.25 1974 1986 1999 mean conduct score

Time trends in adolescent conduct problems white only 1.5 1.25 1 0.75 0.5 0.25 1974 1986 1999 Trends in aggressive and non-aggressive problems 1 non-aggressive

mean score 0.8 0.6 0.4 aggressive 0.2 0 1974 1986 1999 Conduct problems: high scores % high scores

18 16 14 12 10 Boys Girls 8 6 4 2 0 1974 1986

Total OR = 1.56 per cohort 1999 Conclusions so far Over a 25-year period (mid 70s to late 90s) Adolescents no clear trend in hyperactivity recent increase in emotional problems steady rise in conduct problems (mainly non-aggressive) probably not a reporting artefact (NB: no further change 1999 2004) What contributes? Risk factors for conduct problems established risk factors more common? more risky?

new risks introduced to later cohorts Divorce rate per 1,000 married population 1961-1999 (England & Wales) 16 14 12 10 8 6 4 2 0 1961 1966 1971

ONS Population Trends 102, 2000 & Social Trends 20, 1990 1976 1981 1986 1991 1993 1996 1999 Divorce rate per 1,000 married population 1961-1999 (England & Wales) 16

Cohort 3 14 Cohort 2 12 10 8 Cohort 1 6 4 2 0 1961 1966

1971 ONS Population Trends 102, 2000 & Social Trends 20, 1990 1976 1981 1986 1991 1993 1996 1999

Changing family structures 100 80 Family type Step family Single parent Intact % 60 40 20 0 1974 1986 1999

Adolescent conduct problems and family type % conduct problems OR = 1.7 20 18 16 14 12 10 8 6 4 2 0 OR = 2.3

OR = 2.2 Family type Traditional Single parent Step family 1974 1986 1999 What contributes to time trends in conduct problems? Odds ratio 2 1.8

1.6 1.4 1.2 1 Base model Allowing for family type and low income What contributes to time trends in conduct problems? Odds ratio 2 1.8 1.6 1.4 1.2 1

Base model Family type and low income All predictors Where do we look next? family life and parenting? early childhood adolescence effects of peers? social multiplier effects effects of wider social factors?

changing social attitudes / expectations changing meaning of adolescence changing moral beliefs exposure to media violence, targeted advertising Primary Review (2007) Community Soundings: University of Cambridge Faculty of Education Respondents consistently commented children are under intense and perhaps excessive pressure from policy-driven demands of schools commercially-driven values of the wider society

family life and community breaking down pervasive loss of respect and empathy within and between generations life outside the school gates increasingly insecure and dangerous and the task facing teachers and other professionals who work with children is much more difficult now than it was a generation ago Is childrens mental health really getting worse? Barbara Maughan MRC SGDP Centre Institute of Psychiatry Kings College London

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