Guidance

Improving the mental health of babies, children and young people: a framework of modifiable factors

Published 8 January 2024

Applies to England

Introduction

The mental health of babies, children and young people (BCYP) influences their future mental health, as well as their current and future physical health, affecting their wider life chances and outcomes. The early part of the life course, from birth to young adulthood (0 to 25 years), provides important opportunities for promoting and protecting mental health.

The audience for this document includes organisations that lead and develop strategy, policy and guidance that influences BCYP mental health, and those who plan, manage and provide promotion and prevention approaches. It will be particularly relevant to public health professionals and others whose role involves leading and co-ordinating partnership-working to improve BCYP mental health - for example, commissioners and providers working in the NHS, local authorities and other parts of the public sector, as well as the voluntary and community sector, and wider stakeholders.

The purpose of this document is to:

• highlight the wide range of modifiable factors that interact to influence the mental health of BCYP
• summarise these in a framework (figure 1)
• convey opportunities across the BCYP life course for promotion and prevention (figure 2)

This information can be used as a prompt for stakeholders who work across different parts of a local system to review what work is underway to improve BCYP mental health, and identify where there might be gaps and opportunities for taking further action.

Definitions of terms used in this document are set out in the glossary below.

The methodology of and findings from the literature search that informed the content of the framework are described in the accompanying document, Improving the mental health of babies, children and young people: methodology, literature and stakeholder feedback that informed the framework. The methodology document also includes data and evidence about targeted populations and can be used as a source of reference for stakeholders who want to consider the supporting evidence more closely.

A third related document, Improving the mental health of babies, children and young people: examples of government-led contributions, provides examples of policies and programmes being delivered by central government that contribute in a positive way to addressing the factors that are identified in this framework.

How this information can be used in practice

The information in this document can be referred to for the following purposes:

• informing the scope and content of a local BCYP mental health strategy and action plan
• identifying and addressing gaps in local provision for BCYP mental health and leveraging action to address these
• considering which BCYP population groups should be the focus of targeted support
• prompting the consideration of relevant sources of local evidence - for example, the views of children, young people and families, and insights from wider system stakeholders
• considering which metrics can help to monitor and measure impact
• enabling conversations between system partners to identify the contribution their work can make to help keep BCYP mentally well
• creating more systemic solutions to positively influence factors that underpin the mental health of BCYP

Factors that influence the mental health of babies, children and young people

Mental health is influenced by multiple risk and protective factors. Risk exposures that occur during developmentally sensitive periods, especially during early childhood, are particularly detrimental and can affect mental health or predispose towards mental health conditions later on in life. Conversely, protective factors experienced across the life course - such as secure attachment, supportive, sensitive and responsive parenting, living in safe and cohesive communities, and health-promoting education and workplace settings - can serve to strengthen mental health (see the UNICEF report The State of the World’s Children 2021).

Some factors are shaped at an individual level; others are influenced by family and social relationships, and in particular contexts such as education, work and community settings. Other factors operate at a wider societal or environmental level. These different levels are described in Dahlgren and Whitehead’s socio-ecological model of the determinants of health.^{[footnote 1]}

Risk and protective factors not only occur across different levels, they also have a temporal dimension. At different points across the life course, these determinants will exert a greater or lesser influence on individual and population mental health. The adverse effects of risk factors accumulate through life so the earlier in the life course that action can be taken to protect the BCYP population, the greater the benefits.

While single risk or protective factors do not predict an individual’s state of mental health, the interacting determinants across the circumstances and experiences of BCYP’s lives can enhance or undermine mental health. These factors are often interconnected - for example, material circumstances, family relationships, school experience and neighbourhood environments.

The accumulation of risk factors in babies, children and young people’s lives can be particularly problematic for a range of outcomes including mental health. It is therefore the interplay of actions led by multiple stakeholders across a child or young person’s life course that has the potential to address the risk and protective factors, and improve mental health outcomes.^{[footnote 2]}

Framework of modifiable factors to guide promotion and prevention

The conceptual framework outlined below (figure 1) is informed by the socio-ecological model of the determinants of health and builds on a conceptual framework for public mental health that was published by the National Institute of Health Research School for Public Health Research in 2021 (the focus of this was the adult population). It is also helpfully complemented by Understanding and supporting mental health in infancy and early childhood - a toolkit to support local action in the UK published in 2023 by UNICEF UK and the University of Cambridge Centre for Research on Play in Education, Development and Learning.

The BCYP mental health conceptual framework focuses on modifiable factors where there is scope to intervene to create the conditions that help to keep BCYP mentally well. The factors were identified through reviewing the outputs from a literature search alongside input from thematic experts and stakeholder consultation. Further details of the methodology and findings are set out in ‘Improving the mental health of babies, children and young people: methodology, literature and stakeholder feedback that informed the framework’.

Figure 1: babies, children and young people’s mental health: a framework of modifiable factors to guide promotion and prevention

Figure 1 contains 4 headings, each representing a different domain. These are, from left to right: 

• individual level
• interpersonal relationship level
• local community level
• wider environment and society level

Underneath each heading is a list of modifiable factors that influence BCYP health and fall within the relevant domain. 

The lists are contained within rectangles embedded within each other and increasing in size from left to right - conveying the widening scope of each domain. Individual-level factors are less broad than interpersonal relationship-level factors, which are in turn less broad than local community-level factors, which are in turn less broad than wider environment and society level factors. Factors within each domain may influence one another as well as factors across broader and/or narrower domains, represented by the embedding of the rectangles.

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Domain: individual BCYP level

Modifiable factors that influence this domain include:

• premature birth
• exposure to adversity or traumatic events
• attachment
• speech, language and communication abilities
• physical health and health behaviours
• substance misuse
• gambling
• resilience
• body image
• social media and screen time
• hobbies and leisure time including arts, culture and play

Domain: interpersonal relationship level

Modifiable factors that influence this domain include:

• quality of relationships with parent or caregiver
• quality of relationships between parents or caregivers
• relationships with peers and adults outside of the home
• abuse and neglect
• physical and mental health of parent or caregiver
• parental substance misuse
• poor experience of being in care
• bullying, including cyber bullying

Domain: local community level

Modifiable factors that influence this domain include:

• educational attainment and attendance
• safe, calm, supportive and inclusive learning environment
• mental health literacy, and social and emotional learning
• transitions between stages of education or into employment
• quality, security and nature of employment
• community networks, engagement and inclusivity
• safety, crime and violence
• access to health, care and support services
• loneliness and isolation

Domain: wider environment and society level

Modifiable factors that influence this domain include:

• poverty
• quality of housing and the built environment
• access to quality green and blue space, and engagement with nature
• quality and accessibility of transport
• access to digital resources
• experience of discrimination, stigma and prejudice
• exposure to online, media and advertising harms
• conflict, natural disasters and humanitarian crises
• climate change

The allocation of factors to one of the 4 domains in figure 1 was informed by a judgement about the level at which the action to modify the factors is most likely to be taken (see methodology publication). However, the content across the domains should be read as an integrated whole. Some factors experienced at an individual level are mediated by family circumstances. Some factors identified at a wider environment and society level can be influenced at both a local authority level and at the level of national government. Some factors are cross-cutting in nature and could arguably sit in every domain. Although the factors are listed vertically in the domains this does not reflect a hierarchy of priorities.

The content of figure 1 should also be read in conjunction with the section below, ‘Targeting the babies, children and young people most at risk’. This section highlights demographic and wider population characteristics associated with disproportionately poorer mental health and/or higher prevalence of mental health conditions.

Targeting the babies, children and young people most at risk

Data and evidence highlight a range of characteristics that are associated with disproportionately poorer mental health outcomes and/or higher prevalence of mental health conditions. The list below provides some (non-exhaustive) examples of these:

• being of adolescent age
• being lesbian, gay, bisexual or transgender
• being in contact with social care
• having a parent with psychosis
• experiencing brain damage
• having a special educational need or disability (SEND)
• having diverse cognitive functioning
• experience of poverty or deprivation
• experience of youth and criminal justice system
• experience of displacement (being an immigrant, asylum seeker or refugee)
• not being in education, employment or training
• being a carer
• living in a rural area
• experience of homelessness

Data also shows that there are disparities in mental health outcomes between BCYP according to ethnicity and gender. However, these are variable according to other characteristics, such as age. Readers are advised to consult the sources under the ‘ethnicity’ and ‘gender’ headings listed in the methodology document that supports this framework.

It is important for policy and practice to be designed in a way that seeks to level-up inequalities in outcomes between population groups. Therefore, those designing programmes and interventions aimed at improving the mental health of BCYP may want to consider how actions can be targeted at population groups most at risk. Data and evidence for the relevance of the factors underpinning the mental health of BCYP is included in ‘Improving the mental health of babies, children and young people: methodology, literature and stakeholder feedback that informed the framework’.

Examples of approaches that can positively influence the mental health of babies, children and young people

Understanding the range of modifiable factors that underpin BCYP mental health helps to steer approaches to promote the mental health of BCYP and prevent poor mental health outcomes among BCYP. However, building evidence to demonstrate the causal impact of upstream interventions on BCYP mental health is challenging.

The wide range and variation of influencing factors and the unique contexts of people’s lives makes it difficult to distinguish impact measures that are attributable to specific interventions or approaches that can then be replicated across the population. It is also helpful to take into consideration an assessment of the ease of implementation of different approaches or interventions.

A collective understanding of what works to improve BCYP mental health is strengthened when research evidence and insights from data is triangulated alongside the views of children, young people and their families as well as feedback from a wide range of professionals and organisations that work across the system to provide support.

Figure 2 summarises examples of approaches for promoting good mental health and for preventing poor mental health across the BCYP life course. Some of the identified approaches are supported by research evidence, including qualitative feedback from children and young people. Other approaches were identified as important and relevant to include as a result of feedback from local public health teams and wider stakeholders.

For information about the strength of the evidence for public mental health interventions, see the Summary of evidence on public mental health interventions undertaken by the Royal College of Psychiatrists Public Mental Health Implementation Centre in 2022.

Figure 2: examples of approaches for BCYP mental health promotion and prevention

Figure 2 contains 4 wide rectangles stacked on top of each other. The rectangles are labelled respectively (from bottom to top):

• individual BCYP level
• interpersonal relationships level
• local community level
• wider environment and society level

Running horizontally across the top of figure 2 are images depicting the stages of the BCYP life course. These represent:

• preconception
• pregnancy
• birth
• early years and infancy
• childhood
• adolescence
• young adulthood

Listed inside each rectangle are different approaches to promotion and prevention, positioned to reflect the stage(s) of the life course to which they apply.

There are 32 approaches listed in figure 2. This is not an exhaustive list.

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Wider environment and society level

Approaches for BCYP mental health promotion and prevention at wider environment and society level that apply across all stages of the life course include:

• global, national and local actions to reduce pollution, reverse climate change and prevent natural disasters
• accessible green and blue spaces
• reducing alcohol, drugs and tobacco-related harm - including action on price, availability, marketing, licensing, screening and brief interventions
• tackling obesogenic environment
• tackling online harms
• social and economic development - education, food security, housing, financial security and income equality
• mass media anti-stigma campaigns tackling prejudice
• violence reduction strategies, programmes and interventions

Local community level

Approaches for BCYP mental health promotion and prevention at local community level that apply across all stages of the life course include:

• community networks, engagement and volunteering
• suicide prevention
• promotion of use of community assets to encourage meaningful activities that promote wellbeing and build resilience
• Family Nurse Partnership and healthy child programme: health visitor and school nursing

Approaches at local community level that apply across the early years and infancy stage of the life course include programmes that promote school readiness, speech, language and communication.

Approaches at local community level that apply across the early years and infancy and childhood stages of the life course include whole education setting approaches to mental health.

Approaches at local community level that apply across the childhood, adolescence and young adulthood stages of the life course include approaches to reduce bullying.

Approaches at local community level that apply across the young adulthood stage of the life course include workplace mental health training and support, and debt advice.

Interpersonal relationships level

Approaches for BCYP mental health promotion and prevention at interpersonal relationships level that apply across all stages of the life course include:

• early interventions to help address and prevent violence and aduse
• promotion of positive parent or caregiver to child relationships
• promotion of positive inter-parental or caregiver relationships
• parental mental disorder prevention, treatment and mitigation

Approaches at interpersonal relationships level that apply across the pregnancy, birth, and early years and infancy stages of the life course include promotion of attachment, including breastfeeding support, and psychological intervention to help prevent perinatal depression.

Approaches at interpersonal relationships level that apply across the pregnancy, birth, and early years and infancy, childhood and adolescence stages of the life course include universal and targeted parenting programmes.

Approaches at interpersonal relationships level that apply across the childhood, adolescence and young adulthood stages of the life course include poor wellbeing or ambassador programmes.

Individual BCYP level

Approaches for BCYP mental health promotion and prevention at individual BCYP level that apply across all stages of the life course include promotion of balanced diet, sleep and physical activity, and promotion of engagement in positive hobbies and leisure, including arts, culture and play.

Approaches at individual BCYP level that apply across the preconception stage of the life course include preconception care.

Approaches at individual BCYP level that apply across the childhood, adolescence and young adulthood stages of the life course include psychological interventions to help prevent depression and anxiety, and promotion of resilience and effective self-care.

Approaches at individual BCYP level that apply across the adolescence and young adulthood stages of the life course include efforts to help prevent teenage pregnancy and provide intensive support.

Glossary of terms

Determinants

‘Determinants’ (of mental health) are factors from genetic inheritance to experiences throughout life that influence mental health

Domain

‘Domain’ describes the shared basis for grouping the identified factors

Life-course approach

A ‘life-course approach’ recognises that there are particular opportunities at different stages of the life course - before birth, for babies, during early childhood, throughout school age and adolescence, and for young adults - to address risk and protective factors.

The critical 1,001 days from conception to age 2, in particular, have been identified as having more influence on a child’s future than at any other time in their life, laying the foundations for cognitive, emotional and physical development.

Risk and protective factors may manifest in different ways at different stages of the life course and it can therefore be helpful to take a segmented approach by age when addressing the factors that influence mental health.

Mental health

‘Mental health’ is defined by the World Health Organization (WHO) as:

a state of wellbeing in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.” 

It encompasses people’s emotional, psychological and social wellbeing, and affects how they think, feel and act, relate to others and make choices.

Mental health conditions

‘Mental health conditions’ describe a wide range of mental health challenges, including disorders that affect an individual’s cognition, emotion or behaviour and interfere with a person’s ability to learn and function in the family, at work and in society. Some conditions can be successfully prevented or treated.

Mental disorders

‘Mental disorders’ are more specifically defined by the International Classification of Diseases 11th Revision (ICD-11) and examples include:

• attention deficit hyperactivity disorder (ADHD)
• anxiety
• autism
• bipolar disorder
• conduct disorder
• depression
• eating disorders
• intellectual disability
• schizophrenia

These disturbances are usually associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning (WHO, 2022).  

Mental health promotion

‘Mental health promotion’ is mainly concerned with addressing the determinants of mental health and is about improving positive mental wellbeing across the whole population. It includes action to:

• improve the quality of the physical environment and reduce structural barriers to mental health
• strengthen communities
• strengthen interpersonal relationships
• strengthen individuals

Modifiable

‘Modifiable’ means to be capable of being changed.

Population health approach

‘Population health approach’ is an approach aimed at improving the health of an entire population.

Prevention

‘Prevention’ focuses on addressing the causes of risk factors to avoid ill health. Primary prevention involves taking preventative measures delivered at a population level to reduce the incidence of mental ill health. Secondary prevention involves targeting those known to be in higher risk groups to prevent the onset of mental illness or who have early signs and symptoms, and intervening to apply evidence-based preventative measures to help stop or delay the progression of mental illness.

Protective factor

‘Protective factor’ refers to a characteristic associated with a lower likelihood of negative outcomes or one that mitigates or reduces the influence of a risk factor.

Risk factor

‘Risk factor’ refers to a characteristic associated with a higher likelihood of negative outcomes.

Socio-ecological model

‘Socio-ecological model’ emphasises multiple levels of influence, and supports the idea that behaviours both affect and are affected by various contexts.

Upstream

‘Upstream’ refers to a focus on prevention strategies for the whole population as opposed to a downstream focus on individual treatment.

1. Dahlgren G and Whitehead M. ‘The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows.’ Public Health 2021 (October): volume 199, pages 20-24. ↩

2. Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, Greaves F, Harper L, Hawe P, Moore L and others. ‘The need for a complex systems model of evidence for public health.’ Lancet 2017: volume 390, issue 10,112, pages 2,602-2,604. ↩