Medicine and wellbeing
Child and adolescent mental health in a post-lockdown world: a ticking time bomb?
The third national lockdown and the return of home schooling for the majority of children has reignited debate around the impact of the pandemic on their wellbeing.
Much has been said about the trade-off between risk of disease transmission and impact on educational outcomes, and the wider economy. Very little consideration has been given to the voices of the children and adolescents, and to the impacts on their wellbeing and mental health.
From the beginning of the first national lockdown many in the research community, and in frontline practice, were concerned about the impact on those with existing mental health problems and those who may be vulnerable to developing them whilst in lockdown (literally anyone). As Professor Rory O’Connor put it: “Increased social isolation, loneliness, health anxiety, stress and an economic downturn are a perfect storm to harm people’s mental health and wellbeing.”
Following the return of national restrictions, I remain especially worried about the lack of ‘big picture thinking’ in relation to lockdown policies and the impact of these on mental health. We still did not know who was advising the government from a ‘meta’ or holistic position weighing benefits and costs. We learned from Professor Robert Dingwall, a colleague at Nottingham Trent University who sits on the group advising the government on respiratory viruses, that the mental health dimension of the response to the pandemic was ‘neglected’ by government. He said in April that the advice offered by eminent psychiatrists in relation to the psychological impact of lockdown was not being heard. Professor Dingwall was talking about the impact on older adults but here I’m going to discuss children and adolescents as that is my area of expertise, and because global research and policymaking consistently neglects their health and wellbeing.
From the start of this crisis I was concerned about the impact of the pandemic and lockdown. Key risk factors for suicide include lacking a sense of belonging, feeling defeated, trapped and hopeless. Our research, and that of others, shows that mental health problems such as depression and anxiety also loom large in self-destructive thoughts and behaviour. Environmental and social risk factors for vulnerable young people are also stacking up in lockdown: relationship problems, social isolation, abuse, poverty, violence and neglect.
We have shown that anger is also important in youth self-harm (sometimes to protect others from anger). Young people are sacrificing so much socially, educationally and economically during this crisis, despite their infinitesimally small chance of their health being adversely affected by Covid-19. One writer doing bigger picture thinking about the crisis notes that, ‘With no serious pre-existing conditions, the young-ish and healthy are far more likely to be hit by lightning than to die of Covid-19.” Given their lack of risk and the magnitude of their sacrifice who could blame young people for being angry?
"Data collected since the start of the pandemic demonstrates incontrovertibly that the overwhelming harm to young people has been to their mental health."
So, how are young people doing? A number of studies are tracking young people’s experiences. One study of those 16 years and above suggests increasing levels of anxiety, with much higher levels than seen in previous years. Work at the University of Oxford shows 35% of young people are reporting high levels of loneliness and feeling more lonely and isolated than their parents. This is worrying given the association between loneliness and suicidal thoughts and behaviours. Public Health England is reported to be increasing real-time surveillance of self-harm and suicide as part of new suicide prevention measures. An important new study from Cambridge indicates that “increases in stress across the entire population due to the coronavirus lockdown could cause far more young people to be at risk of suicide than can be detected through evidence of psychiatric disorders.”
Data collected since the start of the pandemic demonstrates incontrovertibly that the overwhelming harm to young people has been to their mental health. Half of young people aged 16-25 report deteriorating mental health, with 1 in 4 feeling ‘unable to cope’ and the number likely to have clinically significant mental health problems has increased from 1 in 9 in 2017 to 1 in 6 in 2020 after the first English lockdown – that’s 5 children in a class of 30 now likely to need clinical support.
You may be surprised to hear that suicide is already the leading cause of death in 5-19 year olds in England and the second leading cause of death in young people globally. Thankfully, that will never be the case for Covid-19.
Experts have been at pains to stress that increases in self-harm and suicide are not inevitable during these times, but significant mitigations will be needed to prevent this. However, there is cause for concern that the “future is dark for young people” (as one young person put it to me). In order to minimize the blast range of the ticking time bomb of child and youth mental health, policymakers must prioritise young people and include their voices in post-lockdown policies and strategies.
Public engagement and public patient involvement are now cornerstones of research practice. So why does this not extend to policy practice? We know that young people feel left out of the discussions about the pandemic. From my perspective as an academic I wonder whether students have been consulted about returning to school or university? We know from our work on risk perception that children as young as seven can make probabilistic decisions so there is no reason not to support them to be included in decisions moving forward. We surely owe this to them given the disproportionate impact the pandemic/lockdown has had on their lives.
Factors underpinning self-harmful behaviour are complex but also offer many opportunities to intervene and make a difference in the lives of young people who are struggling. The evidence base suggests that whole school approaches to suicide prevention using Youth Awareness of Mental Health (YAM) programs are effective – but this will require children and adolescents being back at school.
A robust evidence base for digital mental health prevention and intervention strategies should also be considered, since current demand for face-to-face mental health services and supports cannot be met. We have recently embarked on some engagement work in this space funded by the Medical Research Council.
Of course, the implementation and evaluation of such approaches in the UK requires funding, but self-harm and suicide prevention are the poor relations in the mental health funding landscape. It is high time this is addressed. Economic policies in relation to the mental health of young people, who are likely to be disproportionally affected by the post-lockdown downturn and shrinking job markets, should also be considered.
However, the one policy decision that could have the most significant impact for young people to protect their mental health both now and in the future, would be to release them from the lockdown as soon as possible. If I had a magic policy wand, that is what I would use it for.
Ellen Townsend is a Professor in the School of Psychology and leads the Self-Harm Research Group.
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