Guidance

Improving the mental health of babies, children and young people: methodology, literature review and stakeholder feedback that informed the framework

Published 8 January 2024

Applies to England

Overview

The document titled Improving the mental health of babies, children and young people: a framework of modifiable factors identifies factors where there is scope to intervene to create the conditions that help to keep babies, children and young people (BCYP) mentally well.

This document outlines the methodology of and findings from the literature search and stakeholder engagement that informed that framework.

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 the framework.

Methodology

A systematic literature search was undertaken by the UK Health Security Agency (UKHSA) library services to explore the risk and protective factors associated with babies, children’s and young people’s mental health.

A UK and systematic review filter was applied to the database searches. The terms used in the searches are set out in ‘Appendix: search terms’ at the end of this document.

To make the results obtained and screening manageable, primary or secondary sources of evidence were collated so as to focus on children and young people and risk or protective factors and mental health or illness.

While the search was transparent, it did not constitute a systematic review nor was it fully comprehensive. Fairly broad terms were used when referring to mental health conditions and it was not possible within the resource available to undertake targeted searches on defined mental health conditions. 

This literature review was complemented by a grey literature review (in other words, review of literature produced outside of traditional publishing and distribution channels) that focused on additional reports, data and toolkits. These literature reviews were completed in July 2022, meaning that material published subsequently has not been included. Evidence was also identified through engagement with wider Department of Health and Social Care (DHSC) staff and stakeholders.

DHSC officials analysed the results of the literature searches and feedback from the stakeholder engagement process. Evidence was grouped according to the level at which the action to modify the factors is most likely to be taken. This is explained further below:

• ‘individual level’ covers factors that are amenable to modification through actions that target individuals - for example, influencing an individual’s personal wellbeing and resilience or their health behaviour
• ‘interpersonal relationship level’ covers factors that are amenable to modification through action that addresses the interaction between a BCYP and their family or carer, peers and wider social networks
• ‘local community level’ covers factors that are amenable to modification in the context of the local communities in which BCYP live, the education settings in which they learn and, for older young people, in workplaces during transitions into employment
• ‘wider environment and society level’ covers factors that are amenable to modification at a macro level and which may influence social, economic or environmental circumstances that favour or impair BCYP mental health

Sub-headings were generated within the domains to group together and describe the range of factors identified through the literature searches and stakeholder engagement process. A summary of the findings from the literature search and stakeholder engagement process is set out below.

A comparative assessment was not made of the relative strength of evidence for each modifiable factor, nor were the views of children, young people or families sought about the perceived relevance to their mental health. 

The stakeholders consulted included: policy officials across government; regional public health leads; a sample of local authority public health leads; public health nursing experts; and representatives from the Children and Young People Policy Advisory Group ​within the Association of Directors of Public Health network, the Children and Young People’s Mental Health Coalition, the Health Foundation, the National Institute of Health Research, NHS England, the Office of the Children’s Commissioner, the Royal College of Child Psychiatrists, the University College London Millennium Cohort Study, and UNICEF UK.

Findings from the literature search and stakeholder engagement

Through the literature search and stakeholder engagement, the following factors were identified for their potential to influence BCYP mental health. A short summary narrative is provided with supporting references.

Individual level

Exposure to adversity or traumatic events

There is a strong association between exposure to high and prolonged stress in pregnancy and the early years, and mental health problems in childhood and adolescence.^{[footnote 1] [footnote 2]} Early experiences affect the development of brain architecture. There is evidence that young children whose brain architecture has been disrupted by latent vulnerability and/or toxic stress - for example, abuse, neglect and/or parental addiction - are at a much higher risk for later physical and mental health problems, including addiction.

Adverse childhood experiences (ACEs) are traditionally understood as a set of 10 traumatic events or circumstances occurring before the age of 18 that have been shown through research to increase the risk of adult mental health problems and debilitating diseases. The 10 ACEs are:

• physical abuse
• sexual abuse
• psychological abuse
• physical neglect
• psychological neglect
• witnessing domestic abuse
• having a close family member who misused drugs or alcohol
• having a close family member with mental health problems
• having a close family member who served time in prison
• parental separation or divorce on account of relationship breakdown

Exposure to prolonged, repeatedly harmful events or adversity from combined sources during childhood and adolescence, in the absence of nurturing relationships, impacts throughout life on many health and social outcomes including mental health and wellbeing. Child adversity has been found to be associated with 45% of all child onset mental disorders and 26 to 32% of adult onset mental disorders.^{[footnote 3] [footnote 4]} The death of a primary caregiver is a traumatic event and can lead to some children experiencing a distressing range of emotional, psychological and behavioural difficulties that can extend into adulthood.^{[footnote 5]}

Premature birth

The prenatal period has a significant impact on physical, mental and cognitive function. There is evidence that, compared with term births, extreme prematurity and premature birth is associated with a higher risk of mental disorders and other adverse outcomes such as inattention, socio-communicative problems and emotional difficulties across the life course.^{[footnote 6] [footnote 7] [footnote 8]}

Attachment

There is a well established and growing international consensus on the importance of infancy and early childhood as the period during which the foundations for an individual’s cognitive, socio-emotional, behavioural and physical development are established.

An important element of this is good parent or carer relationships that nurture secure attachments (see the part of the ‘Interpersonal relationships’ section below on ‘Quality of relationships with parent or caregiver’).^{[footnote 9] [footnote 10] [footnote 11]}

Research shows that children can benefit from a network of attachment relationships that extend to familiar people such as grandparents and early education professionals. The significance of the influence that attachment has on cognitive, social and emotional functioning extends right across the BCYP life course and is not limited to the early years.

Speech, language and communication abilities

Language is important for many aspects of our lives. It is harder to understand and communicate emotions and to build relationships if children have language and communication problems.

Children with vocabulary difficulties at age 5 are 3 times more likely to have mental health problems in adulthood.^{[footnote 12]}

81% of children with emotional and behavioural disorders have unidentified speech, language and communication needs.^{[footnote 13]}

Physical health and health behaviour

[Children and young people with poor physical health, especially long-term conditions, are at higher risk of poor mental health(https://lx.iriss.org.uk/content/three-years-survey-development-and-emotional-well-being-children-and-young-people.html).]^{[footnote 14]}

Babies’ and young children’s mental health depends on the core elements of nurturing care, which include:

• good health
• adequate nutrition
• responsive caregiving
• safety and security
• opportunities for early learning

Supporting a child’s good physical health, development and nutrition is vital for their mental health.^{[footnote 15]} Adequate nutrition can impact a child’s early brain development, and wellbeing and practising responsive feeding in infancy (and making the most of mealtimes for connection for young children) is part of supporting children’s early mental health.^{[footnote 16]}

Childhood overweight and obesity can be associated with psychological comorbidities, such as:

• depression
• lower scores on self-reported quality of life measures
• emotional and behavioural disorders
• disordered eating (in young people)
• higher levels of body dissatisfaction
• lower self-esteem during childhood

Children with severe and persistent obesity are at greater risk. Many children living with obesity, however, remain psychologically well with high self-esteem and do not experience psychological comorbidities or psychiatric consequences.

Having enough good-quality sleep throughout childhood and adolescence is a key protective factor for mental health and wellbeing. The Mental Health of Children and Young People in England 2022 report found that, among children with a probable mental health disorder, 72% reported having a sleep problem 3 or more times over the previous 7 nights compared with 23% of those unlikely to have a mental disorder. Sleep duration during adolescence has been found to be predictive of subjective wellbeing.

Physical activity can confer protection in mental health and decreasing symptoms of mental health difficulties like depression.^{[footnote 17]} The Active Lives Children and Young People Survey (undertaken in 2022 and covering over 300,000 children and young people aged 5 to 16) has shown a small but positive association between higher levels of engagement in sport and physical activity and decreased feelings of loneliness. The survey also found that self-reported happiness scores are higher for those who are active compared with those who are less active, and that children and young people who volunteer also score higher on this measure than those who do not.

Oral health can affect children’s and young people’s ability to sleep, eat, speak, play, learn and socialise with other children. Children and young people also report oral health-related negative impacts on their self-esteem and self-confidence (see also the technical report on the 2003 Children’s Dental Health Survey (PDF, 276 KB).

Substance misuse

Risk-taking behaviours such as substance misuse can be an unhelpful strategy to cope with emotional difficulties and can severely impact an adolescent’s mental and physical wellbeing.

Cannabis use in adolescence has been found to increase the risk of psychotic outcomes with a number of factors moderating this including:

• age of first use
• frequency of use
• exposure to childhood trauma
• concurrent use of other substances and genetic factors^{[footnote 18] [footnote 19]}

Gambling

As evidenced in a systematic review of the harms associated with gambling, gambling has a complex bi-directional relationship with mental health. A meta-analysis of longitudinal studies into early risk and protective factors by Dowling and others found that depression is significantly positively associated with subsequent problem gambling, but that anxiety symptoms, psychological distress and suicidal ideation are not.

Resilience

Resilience in young people can protect mental health^{[footnote 20]} and is associated with a range of skills and attributes, including:

• problem-solving and confidence in overcoming difficult situations
• self-regulation skills
• perceived self-efficacy and locus of control
• confidence and self-worth
• achievement motivation
• faith, hope and spirituality
• belief that life has meaning

Resilience is also shaped by the range of contexts and circumstances that enable some children and young people to thrive despite experiencing difficult circumstances.

Enhancing community, school and family resources and opportunities are important alongside individual-level factors in helping to create opportunities to build on the many strengths of BCYP - see key findings from research conducted by the Evidenced Based Practice Unit at University College London on the themes of risk, resilience, change and choice.

Body image

Evidence from longitudinal population studies^{[footnote 21]} shows that body dissatisfaction in early to mid-adolescence predicts poor physical and mental health outcomes, including behaviours that pose a risk to health, eating disorders and depression.

The 2023 Good Childhood Report by the Children’s Society highlighted concerns with one’s appearance as a leading cause of unhappiness among young people and that appearance concerns are increasing year on year.

Hobbies and leisure time, including arts, culture and play

Engaging in stimulating activities, being creative and playing have been identified as important building blocks for building children’s wellbeing.^{[footnote 22]}

Adolescent participation in positive activities both in and outside school - such as sports, drama and art groups, youth clubs or religious groups - has consistently been associated with small but significant effects on wellbeing, and social and emotional skills. See, for example, a report from the Early Intervention Foundation on what works in enhancing social and emotional skills development during childhood and adolescence.

Social media and screen time

Research into the impact of screen time and social media on young people’s mental health and wellbeing is an active but very challenging area of research.

A systematic review of reviews found evidence that higher levels of screen time are associated with depressive symptoms for children and young people.^{[footnote 23]} A commentary from the UK Chief Medical Officers found an association between screen time and mental health problems in children and young people, but that the evidence was not sufficiently clear to confirm whether screen-based activities were the cause of these problems. Overall findings suggest that it is excessive screen time that is more problematic for children and young people’s mental health.

Research by Ofcom found children aged 13 to 17 were more likely to feel positive than negative about their online use and that 53% said that being online was good for their mental health, with a minority (17%) disagreeing with this. Eight in 10 children aged 13 to 17 used online services to find support for their wellbeing. More than a third (36%) of children aged 8 to 17 said they had seen something ‘worrying or nasty’ online in the past 12 months and 84% of 8 to 17-year-olds reported having been bullied online compared with 61% reporting having been bullied face to face. 

The Mental Health of Children and Young People in England, 2017 survey found daily social media use to be more common in young people with a disorder (87%) compared with those without a disorder (78%). It also found that 29% of daily users with a disorder were on social media for more than 4 hours on a typical school day.

Interpersonal relationships

Quality of relationships with parent or caregiver 

Sensitive and responsive caregiving^{[footnote 24]} (the ability of the parent or caregiver to notice, understand and respond to their child’s signals in a timely and appropriate manner), particularly in the first 2 years of life, is important for secure attachment^{[footnote 25] [footnote 26] [footnote 27]} and lays an important protective foundation for mental health across the BCYP life course.

A child’s early mental health is shaped by their relationship with their primary caregivers and trusted adults and, when these are consistent, responsive and nurturing, they form the foundations for strong mental health across childhood and beyond.^{[footnote 28]} Early sensitive caregiving has been found to predict lower costs to society many years later and that this is independent of poverty, child and youth antisocial behaviour levels and IQ. This reflected costs to the family, education, health, social and justice services.^{[footnote 29]}

Disorganised attachment is associated with many poor outcomes, including personal and contextual risk for self-harm^{[footnote 30]}, suicide attempts^{[footnote 31]}​ and eating disorders^{[footnote 32]}, in adolescence. ​​

Having sensitive, responsive, trusting relationships, parents that provide stimulating activities and positive discipline are all important for wellbeing and development throughout childhood.

The national survey of the Mental Health of Children and Young People in England 2021 found that living in families with least healthy functioning resulted in increased risk of mental disorder compared with families with most healthy functioning. The survey also found that children and young people (aged 11 to 23 years) with a probable mental disorder had lower levels of family connectedness than those unlikely to have a mental disorder.

Analysis of data from the Millennium Cohort Study found “arguing with a parent” is a risk factor associated with mental illness, and research drawn from the Effective Pre-school, Primary and Secondary Education Project found that family discord and regular quarrelling with parents predicted poorer mental wellbeing. Students who rarely ate an evening meal with their family also reported lower levels of mental wellbeing.

Quality of relationships between parents or carers

The quality of how parents or carers communicate and relate to each other is recognised as a primary influence on effective parenting practices, and children’s long-term mental health and future life chances. Strong relationships between parents or caregivers supports good mental health in BCYP, and inter-parental or caregiver conflict can be a risk factor.

Parental interventions that only address the parental-child relationship in the context of ongoing inter-parental conflict do not lead to sustained positive outcomes for children. Where family break-up is associated with high levels of inter-parental conflict, economic pressures or loss of contact with either parent, there may be adverse impacts on children’s wellbeing (PDF, 389KB).

Paternal departure in later childhood has been found to be associated with an increase in internalising problems (for example, withdrawal, anxiety, depression or emotional problems) in both males and females, and increased externalising (for example, aggression, deviance or hyperactivity) symptoms for males only.^{[footnote 33]}

Relationships with peers and adults outside of the home

The quality of social connections with other trusted adults and peers outside of the home can influence mental health. This is relevant across the BCYP life course. The quality of childcare and early education, for example, and the relationships that children have with adults in those settings contribute to their social, emotional and behavioural development.

During adolescence, important personal connections are built up in the family, at school, with friends and peers, in the community and neighbourhood, and through contacts with advisers and work contacts. Qualitative insights from young people indicate that they value mental health support from sources such as youth workers, friends or trusted adults outside of the home and statutory settings such as schools or healthcare providers. As a report from the Health Foundation shows, there is an increasing body of evidence on the importance of these kinds of positive social capital on young people.

Strong connections with prosocial peers can be protective from a variety of risk factors and are also associated with increased wellbeing, including in relation to later life experiences. The national survey of the Mental Health of Children and Young People in England 2022 found that children with a probable mental disorder were less likely to say they have at least one friend they can turn to for support than peers unlikely to have a mental disorder. The Effective Pre-school, Primary and Secondary Education Project also identified friendship groups as being important for mental wellbeing (PDF, 745KB) with lower mental wellbeing found for students who spent most of their time alone or excluded from friendship groups in year 9.

Abuse and neglect

Experience of abuse and neglect in childhood is linked with the development of a wide range of mental and physical health problems. See, for example, this report from the Office of the Special Representative of the Secretary-General on Violence against Children and this review of intersections of violence against women and violence against children by Gudes and others.

Prenatal intimate partner violence can have significant adverse impacts on both mother and foetus.^{[footnote 34]} There is also a strong association between exposure to intimate partner violence throughout childhood and children’s externalising problems.^{[footnote 35]} Domestic abuse also affects child internalising behaviour and has been found to predict depression, anxiety and post-traumatic stress disorder (PTSD) in later life.

Adverse impacts on mental health and wellbeing are regularly reported by victim-survivors of sexual abuse during both childhood and adulthood.

Multiple forms of abuse can co-occur in the same family, and the amount of exposure that children have to both maltreatment and violence in the home increases their risk of abuse in adulthood, either as victims or as perpetrators.

Parent or carer physical and mental health

Parental capacity to support their child’s mental health may be impacted by their own physical and mental health, and their lived experience of mental health conditions. The Millennium Cohort Study found that poorer parent mental and general health predicted greater mental illness symptoms in children .

There is some emerging evidence to suggest that maternal obesity may have an impact on health outcomes (including mental health) in their offspring - however, the evidence is not well established.

In general, studies examining maternal depression or anxiety during pregnancy and other indices of gestational stress have shown significant associations with low birth weight^{[footnote 36]} and emotional problems in children​.^{[footnote 37]}

While perinatal mental health difficulties^{[footnote 38]} and parent mental health more generally can impact on insecure attachment relationships between parents or carers and infants, this is not inevitable and there is evidence that providing timely support can help to mitigate this. 

Evidence suggests that children of parents or carers experiencing high levels of psychological distress may have lower attainment in communication, language and literacy, mathematical development, and personal, social and emotional development.^{[footnote 39]} Offspring of parents with bipolar personality disorder present as a high-risk group for a range of mood and non-mood disorders in childhood, adolescence and young adulthood.^{[footnote 40]}

Parent anxiety disorders pose specific risks of anxiety disorders to offspring without the right support. However, there is limited evidence for transmission from adult to child of the same particular anxiety disorder.^{[footnote 41]}

Parental substance misuse

Maternal behaviours such as smoking or substance misuse during pregnancy have been identified as a risk factor associated with attention deficit hyperactivity disorder (ADHD),^{[footnote 42] [footnote 43]} schizophrenia,^{[footnote 44]} and child depressive and anxiety behaviours in early years (18 and 36 months).^{[footnote 45]} Alcohol use of any quantity during pregnancy is the sole risk factor for foetal alcohol spectrum disorder, a lifelong neurodevelopmental condition affecting intellectual, emotional and physical development, and often leading to behavioural, emotional and psychological difficulties.

Although family or caregiver substance misuse may not necessarily cause children harm, evidence shows children who are exposed are at greater risk of adverse outcomes that impact throughout the life course (see also this report on the effect of parental problems, such as substance misuse and mental illness, on children’s welfare by Cleaver and others).

Parental or carer substance misuse often co-exists with other problems, such as mental illness and domestic abuse. As a report by Harwin and others on children affected by parental alcohol problems shows, affected children can experience a range of related issues including emotional and mental health problems, such as depression, anxiety disorders, obsessive-compulsive disorder and attachment-related psychological adjustment.^{[footnote 46]}

Family or caregivers receiving treatment for drug or alcohol dependence is a ‘protective factor’ for children, as well as improving systems and support for these vulnerable families, which can lead to positive outcomes across the health, social, education, employment and criminal justice sectors.

Poor experience of being in care

Looked-after children, also referred to as children in care or those living with foster parents, have higher rates of mental health disorders than those of the general population as a response to either the circumstances that led to being removed from their homes or the experience of being placed in foster care.^{[footnote 47]}

The experience of being in care as a child can have a long-term impact on mental health in adulthood. Analysis of the Millennium Cohort Study indicated that, compared with mothers with no care experience before the age of 17, mothers with care experience had increased levels of poor general health and longstanding illnesses, struggled with their mental wellbeing and depression, and were more likely to report a lower ‘locus of control’ over their life and feeling dissatisfaction with their life in general.^{[footnote 48]}

Evidence also indicates that teenage children of care-experienced mothers were more likely than their peers to experience a range of poorer health outcomes and health behaviours and reported higher levels of behavioural and mental health problems, including self-harm and suicide attempts. See the findings from the Looked-after Children Grown up Project by Sacker and others.^{[footnote 49]}

Bullying, including cyber bullying

Bullying in childhood and adolescence is a leading risk factor for subsequent mental disorders. Prospective cohort studies have demonstrated that being a victim of bullying is associated with a wide range of mental health problems, such as depression, anxiety, suicide attempts and illicit drug use.

There are strong negative associations between cyber bullying, and mental health and psychosocial outcomes.^{[footnote 50]} The Mental Health of Children and Young People in England, 2017 survey found that 11 to 19-year-olds with a mental disorder were nearly twice as likely to have been bullied in the past year (59%) as those without a disorder (33%), and that young people with a mental disorder were also more likely to have bullied others in the past year (28%) than children with no disorder (14%). Those with a probable mental disorder were more than twice as likely as those without to have been cyber bullied in the past year (42% compared with 18%). Young people with a mental disorder were also more likely to report having cyber bullied others (15%) than those without a mental disorder (7%).

Local community level

This domain captures factors that influence BCYP mental health in the context of the education settings in which they learn, the local neighbourhoods in which they live and, for older young people, the places in which they work.

Educational attainment and attendance

The total number of years spent in education and higher levels of education predict later mortality, physical health and mental health. This includes effects on later depression, obesity, smoking and take-up of preventative care.

Evidence suggests the potential for bidirectional effects between educational attainment and mental health with slightly more evidence for mental health problems undermining academic attainment than vice versa.^{[footnote 51] [footnote 52]}

The 2022 Attendance Audit from the Children’s Commissioner found the rate of persistent absence to be 1 in 4 children in autumn 2021, compared with 1 in 9 in 2018 to 2019 before the COVID-19 pandemic.

There are a wide range of reasons why children and young people avoid school and often these are inextricably linked with mental health. Emotionally based school avoidance (EBSA) reflects the fact that school avoidance often has its roots in emotional, mental health or wellbeing issues. The Mental Health of Children and Young People in England, 2022 survey found school absence rates were higher in children with a probable mental disorder - 13% missed more than 15 days of school compared with 4% of those unlikely to have a mental disorder. Children with a probable mental disorder were also less likely to have positive views of school than those unlikely to have a mental disorder.

Safe, calm, supportive and inclusive learning environment

Research points to there being an association between the psychosocial climate in an education setting. and mental health and wellbeing.^{[footnote 53]} Taking a co-ordinated and evidence-informed whole institution approach, with commitment from senior leadership and supported by external expertise, contributes to creating the conditions for a safe, calm, supportive and inclusive environment, which helps to improve pupil and student wellbeing and, in turn, can improve learning.

Children and young people with a strong sense of school-belonging have a range of improved outcomes including better mental health and emotional wellbeing. School-belonging is associated with reduced incidence of risk behaviours, including antisocial behaviour, drug taking and truanting.

Relationships are one of the most important aspects of school for primary school children. The relationship that pupils build with their classroom teacher is key to their ability to learn. When this is disrupted - for example, as a result of factors adversely impacting teacher wellbeing and mental health - this has a knock-on effect for pupils, and their chances to progress and attain their full potential.^{[footnote 54]}

Student perceptions of teacher support and school connectedness are associated with better emotional health among adolescents.^{[footnote 55]} The quality of teacher-student relationships may also explain why better teacher wellbeing has been found to be associated with better student wellbeing and lower student psychological distress. See, for example, research by Harding and others.

Mental health literacy and social and emotional learning

The personal, social, health and economic (PSHE) education curriculum in the school can impact positively on young people’s health and wellbeing, as well as equipping them with important life skills. Teaching children and young people about mental wellbeing can help to improve their knowledge about mental health and shape the development of positive attitudes towards it, thus reducing stigma.^{[footnote 56]}

The majority of universal social and emotional classroom-based interventions implemented in the UK demonstrate significant positive outcomes on children and young people’s social and emotional skills, improved behaviour problems and academic outcomes. Universal social and emotional learning interventions not only enhance young people’s social and emotional skills, but also reduce symptoms of depression and anxiety in the short term.^{[footnote 57]}

Transitions between stages of education or into employment

During education transitions, children can suffer emotional distress or a decline in progress and commitment to learning, as research from Galton and others shows. A good transition from home or childcare into school is important, particularly for children living in more difficult circumstances, those with special needs or for whom English is not a first language. See a report from the Institute of Health Equity on good-quality parenting programmes and the home-to-school transition. Experiences of transition from primary to secondary school affect health and wellbeing later on in life.

Being the first in a family to attend university and having to take up paid work while studying due to financial pressures have both been identified as risk factors for poor mental health among students.^{[footnote 58]} Alongside the developmental transition to adulthood, young people entering higher education can experience academic pressures, social challenges, separation from their usual support networks and financial problems, which together constitute a potentially high-risk period for maladaptive coping and onset of psychopathology.^{[footnote 59]}

Having the right personal connections with advisers and work contacts has been identified by young people as an important factor influencing their confidence as they enter into employment.

Quality, security and nature of employment

The quality and security of work is extremely important for mental health and wellbeing, with permanent work identified as a protective factor.

Younger workers are disproportionately likely to be in involuntary insecure working patterns: 8% of 16 to 24-year-olds in employment are on a zero-hours contract compared with 2.7% of all people, and younger workers in temporary jobs are 29% more likely to experience mental health problems than those in permanent jobs as shown in this infographic (PDF, 78.2KB). 4.1% of employed people between the ages of 16 and 24 either want to work more hours or cannot find a permanent role. An insecure job can act as a stressor that affects health due to the unpredictability and lack of self-efficacy that people can have when they are in insecure employment.

Younger workers in temporary jobs are more likely to experience mental health problems than those in permanent jobs and 1 in 5 (19%) younger workers aged 16 to 24 are underemployed - more than double the rate among workers aged 25 and above. See this publication on millennials and mental health in the modern labour market from the Institute for Public Policy Research.

[Unemployment, job and financial insecurity, and recent job loss are known risk factors for suicide attempts.

Fulfilling employment offers a platform for structured routines, positive relationships, and gaining a sense of purpose and achievement, as well as providing access to an income. Good work improves health and wellbeing across people’s lives, boosting quality of life and protecting against social exclusion (see government guidance on employment and health).

Community networks, engagement and inclusivity  

The communities in which babies, children and young people live are important spaces for facilitating wellbeing, safety, and social and emotional development. Communities can serve as a platform to foster neighbour and friendship networks, providing sources of social support that promote positive mental health outcomes.

Mental health-promoting communities offer increased opportunities for engagement and participation in social action, which can be a powerful influence on sense of identity, particularly during the adolescent period and the transition to adulthood (see the Helping Adolescents Thrive Toolkit published by the World Health Organization (WHO). The toolkit includes a core set of evidence-informed strategies to promote and protect adolescent mental health.

There is evidence that programmes such as the National Citizen Service and Duke of Edinburgh Award Scheme have a significant positive impact on participants’ wellbeing, promoting life satisfaction, a feeling that the things they do in their life are worthwhile, happiness and reduced anxiety, self-belief, sense of agency, problem-solving and confidence in overcoming difficult situations. Youth participation in Guides or Scouts is associated with better mental health and narrower mental health inequalities at age 50.^{[footnote 60]}

Community services can play an important role in promoting mental health awareness, reducing stigma and discrimination, supporting social inclusion and preventing mental health problems. The 2021 Youth social action rapid evidence assessment found evidence that participating in social action can improve character-building, wellbeing and mental health, active citizenship, and a sense of belonging.

Providing social support for children (opportunities for experiences that allow children to build and engage in social relationships - for example, by engaging in recreational activities) has been associated with the development of less depressive symptoms over time.^{[footnote 61]} Some studies have found that increased access to information and better links between schools and other services in the local community lead to improved child development and wellbeing. The importance of developing adolescents’ social skills and enabling them to improve interpersonal relationships has been identified as central to improving their mental health.^{[footnote 62]}

Safety, crime and violence

There is evidence that a perceived lack of school and community safety is a risk factor for emotional distress and poor mental health.^{[footnote 63]}

There is also some more mixed evidence that neighbourhood violence, discrimination and socioeconomic disadvantage may negatively impact psychosocial adjustment among early adolescents.

Loneliness and isolation

The absence of meaningful contact with others can engender feelings of loneliness and have a negative impact on mental health.

The national survey of the Mental Health of Children and Young People in England, 2022 found that children and young people with a probable mental disorder were significantly more likely to report feeling lonely often or always compared with those without a mental disorder. 18% of 11 to 16-year-olds with a probable disorder, compared with 2% without, reported feeling lonely often or always. This rose to 29% of 17 to 22-year-olds with a probable disorder compared with 5% without.

Access to health, care and support services

With 75% of mental disorders beginning by the age of 24 and most risk factors for mental disorders exerting their influence before the age of 25, the optimal window of opportunity to improve the outcomes of mental disorders is the prevention or early treatment in individuals aged 0 to 25.

Accessible, available and high-quality health, care and support services are protective factors for mental health. For BCYP, effective identification of mental health difficulties and, where necessary, early intervention are critically important. When parents or carers and infants, children and young people have access to specialist interventions at an early stage, there is the potential for them to make a good recovery and there need not be long-term effects.

Trained and skilled professionals can prevent the onset, escalation and negative impact of mental health problems. Specialist midwives, health visitors and school nurses have a crucial role alongside other professionals operating across multidisciplinary pathways delivering effective mental health care for mothers, fathers, infants, children and young people. NHS England has published guidance on specialist health visitors.

The quality of childcare and early education, including the relationships that children have with adults in those settings, influences the social, emotional and behavioural development of BCYP. See this report into the impact of early education at ages 2 to 4 on child outcomes at age 4, and the importance of the early years home environment.

Wider environment and society

Poverty

The association between poverty and mental ill health across the early life course is very well established (see also research from Patalay and others on psychological distress, self-harm and attempted suicide in UK 17-year-olds).^{[footnote 64] [footnote 65]}

Poverty has a cumulative negative effect on people’s health throughout their life. During early childhood, it influences cognitive and physical development. Children living in poverty are more likely to suffer from poor health and are over 3 times more likely to suffer from mental health problems than children who are not poor. See this briefing on reducing the impact of poverty from the British Medical Association.

Poverty and low income places babies, children and young people at increased risk of food insecurity and hunger, and housing insecurity. See WHO’s Helping Adolescents Thrive Toolkit. Family food insecurity has been found to predict high levels of children’s mental health symptoms, particularly hyperactivity and inattention.

Starting life in temporary accommodation may impact on access to universal healthcare, and frequent changes in residence during childhood have been found to be associated with emotional and behavioural problems and poor academic attainment in children, and negative outcomes late in life. See this resource on Housing and the Health of Young Children from the National Children’s Bureau.

The mental health risks to young homeless people are well established, with particularly high rates of conduct disorder, PTSD, major depression and substance misuse reported.^{[footnote 67]} Homeless children are more likely to experience stress and anxiety, resulting in depression and behavioural issues. There is evidence that the impact of homelessness on a child’s health and development extends beyond the period of homelessness. Homelessness may ‘single out’ a child in a new school, increasing the likelihood of bullying and isolation.

Quality of housing and the built environment

Studies have been published showing that mould or damp, inadequate indoor temperature and energy poverty and frequent residential moves adversely impact outcomes such as behaviour, sleeping problems, emotional difficulties and anxiety.

Those living in privately rented housing are most likely to experience damp problems. See, for example, papers from Baird and others on the role of physical environmental characteristics and intellectual disability in conduct problem trajectories across childhood, Midauhaus and others on the quality of air outside and inside the home, and Rumbold and others on the effects of house moves during early childhood on child mental health at age 9.

Children and young people are at particularly high risk of developing or worsening mental health conditions due to living in a cold home. 28% of young people living in cold homes were found to have multiple negative mental health symptoms, compared with 4% of young people living in warm homes. See research from the Institute of Health Equity on cold homes and fuel poverty and government guidance on data sources to support local services to tackle the health risks of cold homes.

Living in a home with damp and mould affects children and young people’s mental health due to the impact of unpleasant living conditions, destruction of property and belongings associated with damp and mould, anxiety related to the health impacts for themselves or a family member, and/or looking after a relative suffering from cold or damp and mould-related illnesses. The symptoms of respiratory and other infections associated with cold and damp homes can also affect young children’s mental health and development, as they can cause sleep loss and restrictions on children’s daily activities.

Factors that might underlie a link between psychological distress and occupancy of high-rise housing include poor access to spaces that foster social interaction contributing to isolation and restricted play opportunities for children (see research on the built environment and mental health by Evans).

Poor-quality built environments (unattractive, mistreated and ‘forgotten’ places) have been found to contribute to psychological and emotional stress. See an assessment on the role of transport in supporting a healthy future for young people by Sustrans and the University of West England.

Conversely, well planned and accessible built environments such as mixed land use developments that prioritise access to schools, recreational centres and social amenities with opportunities for walking and cycling can increase physical activity among children and adolescents, thereby contributing to building the conditions for positive mental health. See the government’s evidence review into spatial planning for health.

Access to quality green and blue space, and engagement with nature

Evidence suggests a beneficial association between exposure to green space (land with natural vegetation including grass, trees and other plants), blue space (rivers, lakes or the sea), engagement with nature and aspects of mental health.^{[footnote 68]}

Outdoor learning can provide the building blocks for successful learning and attainment of engagement, enjoyment, social skills and self-regulated behaviour, experiencing success, wellbeing and confidence. For children and young people, the evidence suggests a beneficial association between green space exposure and improvement of children’s emotional and behavioural difficulties, particularly with hyperactivity and inattention problems. There is limited evidence suggesting a beneficial association with mental wellbeing in children and depressive symptoms in adolescents and young adults.^{[footnote 69]}

Quality and accessibility of transport

Transport influences subjective wellbeing via 3 pathways: 

• accessibility - enabling access to activities that are important to people’s lives
• mobility - providing freedom to travel and opportunity to be physically active
• via infrastructure - impacting directly or indirectly on physical and mental health through people’s exposure to traffic

Access to digital resources

While moderate use of digital technology tends to be beneficial for children and young people’s mental wellbeing, no use or excessive use can have a small negative impact (PDF, 6,171KB). Ofcom research found that 8 in 10 children aged 13 to 17 used online services to find support for their wellbeing.

Digitally excluded adolescents experienced greater educational and social disruption, social isolation and worse mental health during COVID-19 than those who had access to a computer. Young people may struggle to engage with mental health services online if they do not have enough data or do not have a safe and confidential space at home from which to speak.

Discrimination, stigma and prejudice

Discrimination is widely recognised as a risk to mental health, although the connection can be complex.

Stigma has been identified as an especially important barrier to help-seeking in the use of mental health services by children and can be recognised as prominent among certain groups - for instance, the Gypsy, Roma and Traveller communities and more widely across populations with protected characteristics (see the section below on ‘Targeting populations at risk’). Children and young people with mental health conditions, when they speak out, say the rejection, misunderstanding and discrimination associated with stigmas about mental health can be more disadvantageous than the condition itself.

Racism affects mental health in multiple ways: it interferes with children’s and adolescents’ school performance, harms cognitive functioning, limits access to healthcare and damages self-esteem. It can lead to symptoms of poor sleep, loneliness, depression, anxiety or distress, and increase rates of substance use or delinquency. Experiences of racism can extend to impacting negatively on families and communities including, for example, inequality in access to support. Racial discrimination may also aggravate the stigmatisation of mental illness.

Exposure to online, media and advertising harms

There are complexities associated with investigating links between online harms and impacts on children’s mental health and it is difficult to infer direct causality between the two - see a report on content and activity that is harmful to children within scope of the Online Safety Bill from the National Centre for Social Research.

There is evidence to suggest that most cyber bullying victims report negative consequences on their wellbeing and psychological state - however, the reported level of harm varies. Data from the nationally representative Crime Survey for England and Wales (March 2020), surveying children aged 10 to 15, estimates that 22% of cyber bullying victims were emotionally affected by the experience, 47% were a little affected and 32% were not affected at all. The Mental Health of Children and Young People in England survey found that children with a probable mental disorder who used social media were more likely to have been bullied online; they were also less likely to agree that they felt safe online.

There is some evidence to suggest a correlation between excessive viewing of pornography online and poor mental health. The evidence is less clear when considering the impact caused by viewing self-harm and suicide content online. There is some evidence to suggest that viewing such content can exacerbate self-harm behaviour and suicidal feelings, as well as evoking other negative emotions in children and young people.

Conflict, natural disasters and humanitarian crises

Children exposed to conflict, natural disasters and other humanitarian crises can suffer severe psychological and social consequences. War and conflict impacts on children and young people’s mental health in wide-ranging ways including:

• immediate stress responses
• the broad consequences of separation from parents
• endurance of violence
• injuries
• loss of safety
• being cut off from fundamental services

This increases the risk of specific mental disorders such as PTSD, depression and anxiety.^{[footnote 70]}

PTSD is a frequent and prevalent psychological disorder among the survivors of natural disasters and can remain prevalent 18 to 24 months after a disaster. Children and adolescents, especially girls, are more vulnerable to suffering from PTSD.^{[footnote 71]}

Crisis situations also put parents and caregivers under mental and psychosocial duress, which can prevent them from providing the protection, stability and nurturing care their children need during and after an emergency.

Climate change

There is evidence to suggest that some young people feel a sense of distress and anxiety about climate change. The increase in occurrence of extreme weather events and a heightened awareness of the impact that these events have on rising food insecurity, water insecurity and conflicts increases the perceived likelihood of these events occurring in their lifetime.

Targeting populations at risk

Data and evidence highlight a range of characteristics as being associated with disproportionately poorer mental health and/or higher prevalence of mental health conditions.

The list below is indicative and not exhaustive. There are other categories not listed below by which to describe BCYP populations at risk.

Data and evidence for the relevance of each factor for BCYP mental health is summarised below.

Being of adolescent age

The Mental Health of Children and Young People in England 2022 survey found that 1 in 6 children and young people aged 7 to 16 have a probable mental disorder compared with a rate of 1 in 4 among 17 to 19-year-olds.

Being lesbian, gay, bisexual or transgender

Evidence suggests that sexual minority adolescents are more likely to experience high depressive symptoms, lower life satisfaction, lower self-esteem and all forms of bullying and victimisation compared with their heterosexual counterparts.

The Mental Health Survey of Children in England, 2017 found that young people who identified as lesbian, gay, bisexual or with another sexual identify were more likely to have a mental disorder (35%) than those who identified as heterosexual (13%).

There is some evidence that bisexual individuals may experience more psychological distress and mental health problems than individuals who identify with a homosexual or heterosexual orientation.^{[footnote 72]}

International literature suggests that gender-diverse children and young people are at increased risk of thoughts and acts of self-injury compared with cisgender peers.

Being in contact with social care

In 2021, 45% of children and young people who were looked after in England had emotional and mental health problems compared with a rate of 10% among 5 to 15-year-old children in the general population - see an evidence review on interventions to promote physical, mental and emotional health and wellbeing of looked-after children, young people and care leavers from the National Institute for Health and Care Excellence.

Having a parent with a mental disorder

A report on public mental health: evidence, practice and commissioning by Campion shows that parental mental disorder, including psychosis, is associated with a range of impacts on children, which contribute to increased risk of child mental disorder.  

Having a traumatic brain injury

Research, for example, from Schachar and others, shows that a wide range of mental health problems can begin to emerge following traumatic brain injury (TBI), and that most mental illnesses that were present prior to TBI will persist or worsen.

Schachar and others describe TBI as occurring when the head is struck or undergoes a rapid movement or displacement without direct external trauma to the head.

Having a special educational need or disability (SEND)

‘Special educational need and disability’ (SEND) is used to define those children and young people who have a significant difficulty with their learning and need additional support from school. There is a complex relationship between poor mental health and special educational needs and/or disabilities. Children and young people with SEND can be at higher risk of mental health difficulties than those without SEND. Meanwhile, mental health difficulties may also be a cause of SEND. 

In 2021, more than half (57%) of 6 to 16-year-olds with a special educational need or disability had a probable mental disorder compared with 13% of those unlikely to have a disorder - see the Mental Health of Children and Young People in England 2021 report from NHS England.

Having diverse cognitive functioning brain development is influenced by a range of genetic and environmental factors. Neurodiversity refers to the diversity of human minds. Autism, attention deficit disorder and dyslexia are examples of brain differences of ‘neurotypes’. Most neurodiverse people are likely to experience challenges because of living with their condition, although not necessarily a mental disorder. See this guide to neurodiversity in the early years from the Anna Freud Centre.

Experience of poverty or deprivation  

Children from the poorest 20% of households are 4 times more likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%. See a position statement from the Royal College of Paediatrics and Child Health on child health inequalities and child health in the UK.

The Mental Health of Children and Young People in England, 2022 survey found that children with a probable mental disorder were more likely than those without a disorder to live in households facing financial, energy or food insecurity or that had fallen behind with bills, rent or mortgage payments.

Experience of youth and criminal justice system

Children with experience of youth and the criminal justice system are 3 times more likely to have mental health problems than those who do not and are very likely to have more than one mental health problem.^{[footnote 73]}

Experience of displacement (being an immigrant, asylum seeker or refugee)

For many migrant children and young people, and unaccompanied asylum-seeking children, the experience of displacement can cause serious stress, anxiety and trauma at critical moments of child development.

Not being in education, employment or training

The national survey of the Mental Health of Children and Young People in England, 2022 found the rates of probable mental disorder were higher (27%) in those not in education or employment (NEET) (aged 17 to 24 years) compared with those in education and employment where the rates were 22% and 21% respectively.

50% of all ages claiming employment support allowance in the UK is due to mental health conditions; for those aged under 24, this rises to 70%.

Those who are NEET after the age of 16 are at increased risk of depression and suicide, and the damaging effect of unemployment at this stage of life lasts into later life. Spending time [NEET has been shown to have a detrimental effect on physical and mental health and can result in unhealthy coping behaviours, such as smoking and drinking. This effect is greater when time spent NEET is at a younger age or lasts for longer - see government Evidence review 3: reducing the number of young people not in employment, education or training.

Unemployment early in life can impact negatively on later employment opportunities and wages, while resultant health impacts such as depression may similarly increase chances of subsequent unemployment. Unemployment can have effects beyond the individual directly affected, with financial difficulties or associated stress increasing the risk of poor mental health among the families of those unemployed - see government Evidence review 5: increasing employment opportunities and improving workplace health. The 2018 Prince’s Trust Macquarie Youth Index revealed that a quarter of NEET young people think their life will amount to nothing, no matter how hard they try.

Being a carer

Qualitative research on young adult carers at school by Sempik and Becker exploring the experiences and aspirations of young adult carers aged 14 to 25 years found that 38% reported having a mental health problem and a quarter (26%) were bullied at school because of their caring role.

A systematic review on the mental and physical health of young carers by Lacey and others found that many studies suggest young carers had poorer mental health, on average, than their non-caregiving peers, although the evidence is relatively weak.

Living in a rural area

Access to mental health support can be particularly problematic for young people who live in rural areas and are dependent on public transport for access to face-to-face mental health support - see Mental health for all?, the final report of the Commission for Equality in Mental Health.

Experience of homelessness

Qualitative research into the impacts of homelessness on children, published by Shelter, found the psychological effect of homelessness to impact children negatively in a range of ways including:

• being socially isolated
• being sleep deprived
• being more vulnerable to adverse childhood experiences
• a heightened risk of adolescent drug abuse
• experiencing anxiety linked to uncertainty and disruption
• the loss of personal belongings and a sense of place

Ethnicity

There are also disparities in the prevalence of mental health disorders between children and young people from different ethnic backgrounds.

A survey of children and young people in England in 2021 suggested that rates of probable mental disorder were higher among 6 to 23-year-olds in the white British (19%) and the mixed or other (23%) groups, than in the Asian or Asian British (8%) and black or black British (8%) groups. However, small survey sample sizes of minority ethnic groups, cultural differences in self-reporting and the way ethnic identities are grouped for survey purposes can interfere with and mask an understanding of differences.

Among those children responding to The Big Ask survey of children in England, those from Gypsy, Roma and Traveller communities reported lower levels of happiness than their peers and were less happy with their mental health compared with other ethnic groups. However, fewer Gypsy, Roma and Traveller children (38%) selected mental health as important, compared with 52% of all children.

Gender

There are differences in the prevalence of mental disorders for boys and young men compared with girls and young women according to age.

Findings from a report conducted in 2022 show that more boys (20%) than girls (11%) aged 7 to 10 years had a probable mental disorder, more girls (33%) than boys (19%) aged 11 to 16 years had a probable mental disorder, and more young women (31%) than young men (13%) aged 17 to 19 had a probable mental disorder.

Appendix: search terms

The search selected literature that included a variation of one of the following terms (that is, it included cognate words containing the same word stem as those in the list below. For example, the search selected for ‘adolescents’ as well as ‘adolescent’ and for ‘children’ as well as ‘child’):

• adolescent
• antepartum
• babies
• baby
• boy
• child
• college
• early years
• fifth-grader
• first-grader
• foetal
• foetus
• fourth-grader
• girl
• high school
• infant
• intrapartum
• juvenile
• kid
• kindergarten
• maternal
• minors
• mother
• neonatal
• newborn
• paediatric
• paediatric intensive care unit (PICU)
• perinatal
• postnatal
• preconception
• pregnant
• preschool
• school
• second-grader
• seventh-grader
• stepchild
• sixth-grader
• teen
• third-grader
• woman
• women
• youngster
• one of the following when no more than 2 words away from ‘young’:
  • adult
  • person
  • individual
  • people
  • population
  • man
  • men
• one of the following when no more than 2 words away from ‘secondary’ or ‘high’:
  • school
  • education

In addition to a variation of one of the following terms:

• anorexia
• anxiety
• behavioural disorder
• bipolar
• bulimia
• depression
• eating disorder
• emotional disorder
• mania
• mental disorder
• mental health
• mental ill health
• mental illness
• mental wellbeing
• mood disorder
• OCD
• personality disorder
• schizophrenia
• self-harm
• suicide

And a variation of one of the following terms:

• life course
• life span
• lifetime
• one of the following, when no more than 5 words away from ‘characteristic’:
  • preventative
  • protective
  • predictive
  • risk
• one of the following, when no more than 3 words away from ‘factor’:
  • risk
  • preventative
  • protective
  • predictive

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