Where once public health was about clean water supplies and infectious diseases it is now mental health – and in particular depression, stress and anxiety amongst children – that has become the defining public health issue. This is not surprising when we see that 1 child in 10 in the UK suffers from a diagnosable mental disorder, and the numbers are rising
So we have been speaking to contributors to a new publication from the Faculty of Public Health, The Way Ahead: Why We Need to Improve Children’s Mental Health and Wellbeing (2011).
It seems that the more we find out about brain development, the more pressing this issue becomes. Early intervention is crucial.
Each of our contributors looks at a different aspect of children’s mental health.
- Prof Alan Maryon Davis provides an overview of the importance of parenting in the early years
- Dr Philip Wilson – looks at how doctors and health visitors need to look out for language delay in young children as a predictor of possible long term mental health problems
- Dr William Bird – Explores the role of the natural environment in children’s wellbeing, how having access to green space builds mental resilience.
Prof Alan Maryon Davis: Unless children have an upbringing which is positive and presses the right buttons, which provides them with emotional wellbeing, unless they feel happy and secure in their early years, they go on to have all sorts of problems later on – conduct disorders (that is, challenging behaviour), emotional problems such as anxiety, perhaps depression, problems with their self image, their self confidence. This affects their learning, they have problems assimilating knowledge. They can have all sorts of behavioural problems and it tracks on up as they go through childhood. So as young people they reflect those early problems, perhaps in anti social behaviour. This then affects their chances of employment – getting a job – it affects their whole life really.
Then, in turn, when they themselves become parents, it affects what sort of parents they become. So there is a cycle, an intergenerational cycle. It is very important. It is a chicken and egg thing, you have to catch this as early as possible and do something about it – encouraging really positive parenting and a positive environment in the very earliest days of somebody’s life.
Dr Philip Wilson: Language delay can be caused by a range of factors. It can be caused by genetic factors eg autism spectrum disorders. But it can also be caused by neglect. We know, for example, that the vast majority of children in the care system have language delay, and the vast majority of prisoners have communication difficulties. Had we been able to go back and assess their language as young children we would almost certainly have found significant abnormalities in their communication abilities.
We know that language delay is associated with a range of problems. For example, the vast majority of children excluded from school have communication difficulties. If a child arrives at school unable to understand what the teacher is saying their behaviour is likely to be perceived as disruptive to the class and that is likely to lead to a range of negative consequences that can be very difficult to put right by the time they are 5, or 6, or 7. It can be virtually impossible to put it right. If language is an important issue, then the time to get things right is before the child reaches that age.
There is a growing body of evidence of types of intervention that can support families to develop the language of their child. In Glasgow now we are just starting a universal contact between health visitors and families when children are 30 months of age. Health visitors are using a very simple tool to assess children’s language development. In fact we think the tool could be as simple as asking the parents whether the child has a vocabulary of 50 words and whether they are able to put 2 words together to make a meaning. If the answer to either of those questions is ‘no’, then that is worthy of further investigation and a likely need for help. 30 months is a good age, when there are some relatively simple things we can do to identify vulnerability.
The point of early intervention is that it produces more benefits than late intervention. The case for investing in the early years is about getting a bigger bang for your buck.
At a universal level there are messages we can promote to improve the quality of interaction between parents and their children, improve their sensitivity, improve the enjoyment parents have in being parents! For example, encouraging parents to talk with their babies, to use backward facing buggies. There are also policy issues that can impact on the environment children are brought up in, – the obvious one being maternity leave and paternity leave.
We have produced a fair bit of evidence that GPs and health visitors in general are not very well trained in the issues surrounding early brain development, for example knowing about the importance of the identification of language delay, so it is clear that there is a fair bit of scope for further education.
Prof Alan Maryon Davis Training is vital, not only for parents and children themselves, but also for the professionals that come into contact with them. They need training in how parenting works, how that early environment works, what the influences are – all that is very important.
I also think we need much more research, particularly in the whole business of promoting mental health in children and young people – that whole positive side of things, promoting positive health and well being. Wellbeing is not a word we often use, but it is coming into the parlance now. What do we mean by wellbeing? Particularly as applied to children. Let’s understand that, let’s do more research into what wellbeing is, what the factors are. If we can get that right, we might be making real inroads into this.
Dr William Bird There are 2 effects [of not having access to green space] – both immediate and long term. The first one is physical inactivity, children are much less active than they used to be and that has a direct impact on their development – on balance, on bone structure, on their muscles and on their ability to do physical activity as an adult – that is all determined by their level of activity as a child. And the reason they are not doing activity is that there is a direct correlation between being physically active and being outdoors. For children it’s a straight line, the more they are indoors, the less activity they do. What we say as adults is ‘they’ve got sport’. But sport tends to be in a short, sharp period for an hour or so, it’s highly structured and for the rest of the time they don’t do very much. Sport is good, and we want to encourage more of it, but it doesn’t appeal to all children. So we need to encourage both sport and playing in the natural environment where children of every ability are far more active.
A lot can take place in an inner city park. There is no doubt that if you introduce a child to a park, and give them a football or give them just time to run around – and if there is some kind of vegetation, perhaps a tree that has fallen down, that’s where they’ll go. They have an inquisitive nature, they want to catch the bug, they want to catch the beetle. Even a small patch of green space in an inner city area is enough to get a child excited – a window box, just turning over a stone, So children have a natural relationship with nature.
So there are inactivity problems, and also mental health problems. The mental health problems perhaps being the most important.
Children living in inner cities have incredible mental stress, they’ve got problems in their environment, they can have problems with their family which may be falling apart, they may even be being abused, they have crime around the corner, they are surrounded by concrete, a school which may not be very supportive. They are having to cope with a huge amount of stress. Coping with that stress depends on people helping them, but it also depends on the place. If they have a natural environment – green space – around them, they can cope with more stress than children who just have concrete around where they live.
There were a series of studies in Chicago where there were 13 miles of concrete blocks, where thousands of African Caribbean children and adults lived. There were some blocks that had trees and grass around them, and other blocks where the trees and grass died and were concreted over. Families were allocated a flat randomly, so you have a perfectly randomised control trial. Domestic violence, violence of all types was greater in the flats surrounded by concrete and no trees, and children could cope with stress better when they lived in the flats with trees and grass, compared with the children in the flats surrounded by concrete. Academic achievement too was better in the flats with the trees and grass.
What are the longer term implications?
Firstly, children who have mental health problems under the age of 16 are far more likely to have mental health problems as an adult – so anything that can help offset that creates much better prospects for long term mental health.
Then, inactive children are likely to become inactive adults.
So you have this foundation of mental health and physical activity which is so important. Thirdly, there is the relationship with the natural environment. This sounds almost spiritual, but it’s not, it’s about learning how to use the resource of the natural environment. It’s a resource like many other resources, and if they don’t understand it by the time they are 12 the evidence shows that they won’t understand it as an adult. The consequences of that for the environment are that you are creating a whole new generation that doesn’t understand why it should be saved – but more than that, for the human – for children becoming adults, the inability to connect with the natural environment is an opportunity lost of being able to create that resilience for your health, of being able to be out doors, use it to handle stress when things are difficult, basically being able to use it as a buffer against the stresses of an urban area. So if you don’t understand it, you can still do it, but it doesn’t have the strength. So there is a generation for whom activity, mental health and the environment are all being lost.
What can be done to ensure people feel part of their environment
You create a modern city, an exciting city. I’ve been to Shanghai helping them to create their new city – and green space is going to become a huge part of it. They know, and New York likewise (where green space is going to have the highest priority), Bogota have done it already – cities have to be for all life, not just people, but the greater the connection the better for the life of the people. The mayors of these cities aren’t doing it for sentimental reasons, or because it looks pretty, they are doing it because they know it will make for a more vibrant and healthy city for the people.
Phil Wilson is a GP and senior lecturer in infant mental health at the University of Glasgow. He trained in medicine after completing a research doctorate in neurochemistry. He became a partner in a general practice in south-east Glasgow in 1988, where he continues to work part-time. He was appointed to his research post in 1995 where his work has focused on the development and evaluation of a range of interventions in primary care. His current research deals with the role of the primary care services in improving infant mental health. He contributed to the Scottish Needs Assessment Programme on Child and Adolescent Mental Health and the HeadsUpScotland Infant Mental Health report, and has published numerous academic papers on early childhood mental health. He is currently involved in evaluating the parenting support strategy for Glasgow and in research designed to improve early identification and treatment of psychological and psychiatric problems in infancy.
Alan Maryon-Davis FFPH FRCP HonFRCGP is honorary professor of public health at Kings College London. He was the former head of health sciences at the Health Education Council (later Authority) and worked on a number of health promotion programmes aimed at parents, teachers and children. More recently he has focused on reviewing evidence for health improvement and preventive interventions focused on disadvantaged communities. Alan currently chairs the NICE Public Health Topic Consideration Panel and is a trustee of Alcohol Research UK. He is also vice-chair of the National Heart Forum and immediate-past President of the UK Faculty of Public Health. He has worked closely with the media for over 35 years with extensive experience in writing and broadcasting on health matters.
William Bird is a strategic health advisor to Natural England and a GP. He is also the founder of Intelligent Health. William has pioneered the research and promotion of physical activity, the natural environment and sustainability as a health benefit for over 15 years. Author of several research papers which have influenced current thinking on the benefits of outdoor physical activity, William currently advises the UK Government through the Department of Health and Defra (Department for Environment, Food and Rural Affairs) on the financial and health benefits of exercising in the natural environment.
This podcast is based on a publication from the Faculty of Public Health edited by Rachael Jolley: Thinking Ahead – why we need to improve children’s mental health and wellbeing
- Why invest in the pre-school years?
- Family culture and its impact on childhood wellbeing
- Why parenting support matters
- Improving mental health and wellbeing through schools
- Building a better environment for children’s wellbeing
- The natural environment and its impact on children’s mental wellbeing
- The impact of the media and advertising on children and their mental health
- Further related reading
- Useful organisations