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Running Head: MENTAL HEALTH DIFFICULTIES IN EARLY ADOLESCENCE
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Citation: Fink, E., Patalay, P., Sharpe, S., Holley, S., Deighton, J. & Wolpert, M. (2015) Mental health difficulties in early adolescence: A comparison of two cross-sectional studies in England from 2009 and 2014. Journal of Adolescent Health.
Mental health difficulties in early adolescence: A comparison of two cross-sectional studiesin England from 2009 and 2014
Elian Finka, Praveetha Patalaya, Helen Sharpea, Simone Holleya, Jessica Deightona & Miranda Wolperta
aEvidence Based Practice Unit, University College London and the Anna Freud Centre
Author Note:
Correspondence concerning this article should be addressed to Elian Fink.
Address: 12 Maresfield Gardens, NW3 5SU, UK
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Phone: +44207 7443 2294
Abstract (250 words)
Purpose: To examine the changes in mental health difficulties in early adolescence between 2009 and 2014 in the England.
Methods: Analysis reports on data from two cross-sectional samples of adolescents (aged 11-13 years) collected five years apart in 2009 and 2014 in secondary schools across England. Samples were matched using propensity scoring, resulting in a total pooled sample of 3366 adolescents. Mental health difficulties were reported by participants using the Strengths and Difficulties Questionnaire.
Results: Overall there were similar levels of mental health difficulties experienced by adolescents in 2009 and 2014. Notable exceptions were a significant increase in emotional problems in girls and a decrease in total difficulties in boys in 2014 compared to 2009.
Conclusions: The increased prevalence of emotional problems in girls mirrors a trend found in other similar studies and the results are discussed in the context of recent economic and societal changes. The small decrease in total difficulties in boys, although promising, clearly warrants further research.
Implications and Contribution:The current study provides up-to-date information about changing mental health trends in early adolescence. Given mental health problems in adolescence have a lasting impact on adult well-being and adjustment, understanding the stability or changes in these over time have important implications for understanding healthcare needs and resource allocation.
Key words: Adolescent mental health; Behavioural problems; Emotional problems; SDQ
Introduction
It is well accepted that mental health difficulties in adolescence have a lasting impact, not only on later adult mental health, but also on physical health, educational attainment, andwork force participation and satisfaction [1-5]. As such, understanding changes in mental health problems in adolescence over time has important implications for policy-makersto inform societal resources for treatment, and practitioners and educators working to improve the mental health of young people. Furthermore, from a theoretical standpoint, understanding trends in mental difficulties can help to elucidatethe causes and correlates of mental health problems in childhood and adolescence and support the development of effective interventions and treatment approaches [6]. The current study aims to explore how mental health in young people in England may be changing over time by comparing adolescent mental health from two cross-sectional samples in England, collected 5 years apart in 2009 and 2014.
On average cross-national and across age studies suggest that approximately one in five young people have mental health difficulties [2,7]. A consistent feature of studies examining the prevalence of mental difficulties in young people is the presence of gender differences, with girls more likely to experience emotional problems, while boys are more likely to experience conduct or behavioural problems [2,7,8]. Focusing specifically on England, in 1999 the first England-wide survey of mental health in young people found that 11.3% of 11 to 15 year olds were assessed as having a mental health difficulty, and that this difficulty had a significant impact on the adolescent and their family [9]. In 2004, a national study was again undertaken with similar results (12.2%) [8]. Consistent with findings from other countries, there was a gender difference in the pattern of mental health problems in these studies. These two national studies suggest that between 1999 and 2004, rates of mental health difficulties among adolescent were relatively stable in England [8,9].
Nevertheless, there are some indications that mental health problems are again on the rise in young people, both in England and worldwide. A Global Burden of Disease study comparing prevalence of both physical and mental health worldwide from 1990 to 2010 found that the burden of mental health difficulties, particularly anxiety and depression, has increased over this period in developed countries, with the largest increase typically observed in adolescents and young adults [7,10]. In England, there are also preliminary suggestions that mental health difficulties may be increasing for young people. For example, the number of young people hospitalised for self-harm in the England has increased by 68 % in the past 10 years [11,12], and there is evidence suggesting that the incidence of eating disorders have also increased in the past decade [13].
While there have been several national surveys of child and adolescent mental health in England, the most recent of these was undertaken in 2004 [8]. There are a number of reasons why a more recent examination of mental health problems in young people in England is important. First, economic circumstances have changed in recent years, with impact of the Great Recession contributing to widening income inequality, unemployment, and so called ‘austerity measures’. Many areas report cuts to funding for statutory and voluntary mental health support services.For example, a recent cross-government committee reported “serious” problems in child and youth mental health provision across the country and the president of the Royal College of Psychiatrists recently stated that mental health services in England are“in crisis” [14, 15].
Second, in addition to a changing economic climate, has been a changing school climate. In recent years there has been an increasing emphasis on academic outcomes as a key indicator of school performance coupled with a decreasing emphasis on mental health support and child well-being [16]. Disproportionate focus on educational attainment has been shown to increase adolescent school-burn out and stress [17,18]. Third, increasing social pressures on young people have been documented in the last decade. This includes a rapidly changing media and consumer culture, and the rise of social media in particular has been associated with greater mental health difficulties, especially in young adolescents [19]. Furthermore, changing cultural expectations, critically the increasing sexualisation of young adolescents (particularlygirls), has also had a demonstrated negative impact on mental health of young people [20].
In sum, given the current evidence suggesting an increasing mental health burden on young people in England, the current study compares the prevalence of mental health difficulties across two samples of adolescents collected in England in 2009 and 2014.
Methods
Study Design
The current study reports on data from two cross-sectional samples of adolescents collected five years apart in 2009 and 2014 in mixed-gender secondary schools in England. The 2009 sample comprised students from 210 schools [21]. The 2014 sample was considerably smaller and comprised of 1683 student from 12 schools. To reduce bias in comparisons, the 2009 sample were matched based on school and student level socio-demographic characteristics to the complete 2014 sample.
Sample
In both 2009 and 2014 participants were drawn from studies investigating mental health in schools from Year 7 (11 and 12 years) and Year 8 (12 and 13 years) classrooms in state-maintained, co-educational secondary schools in England. The 2009 sample comprised 21,054 (73% response rate) participants from 188 schools across England. The 2014 sample comprised 1683 participants (86% response rate) from 12 schools across England. Non-response was due to student absenteeism, refusal to complete, and entire form groups not being able to participate due to logistic difficulties in schools.
Measures
Socio-demographic variables.The current study includes matching on a range of socio-demographic factors with links with mental health outcomes including; (1) gender (male/female), (2) age as measured by year group (Year 7/8), (3) Ethnicity, categorised by six broad groupings – White, Black, Asian, mixed, other, and not known, (4) SES, measured using free school meal (FSM) eligibility, a commonly used proxy for deprivation in school-based studies, and (5) school deprivation, indicated by the proportion of students receiving FSM divided into quintile groupings.
Mental health. Mental health was assessed using the Strengths and Difficulties Questionnaire (SDQ), a widely used self-report measure of mental health suitable for use with children aged 11 and older [22]. This measure comprises 25 items from five 5-item subscales: hyperactivity, emotional symptoms, conduct problems, peer problems and prosocial behaviour. Participants respond to each item by endorsing one of three response options: not true, somewhat true and certainly true. Each subscale score can range from 0-10 and each subscale has borderline and abnormal cut-off scores (e.g., for the emotional symptoms scale a score of 6 is borderline and 7 - 10 is abnormal). In addition to separate subscale scores, the four difficulties scales (emotional symptoms, hyperactivity, conduct problems and peer problems) are summed to create a total difficulties score, which ranges from 0 - 40 (higher scores indicate greater difficulties). A total difficulties score was only computed for participants with all four difficulties subscales. Both total difficulties and individual subscale scores were calculated using standard scoring as per SDQ guidelines, including the standard rules for missing items or scales.
Procedure
In both studies data were collected using a bespoke online system. Participants completed questionnaires during the school day in computer sessions facilitated by their teacher. Consent for the study was sought from parents and participant assent was sought prior to the completion of the questionnaire. The purpose of the study and each participant’s right not to participate was read aloud by teachers from standardised information sheets. Students also had their own information sheet with additional information about the study, as well as details about confidentiality and anonymity of their responses on a personal computer in the classroom. Once students gave assent they were able to access the online system to complete the questionnaire using a personal code assigned to them. Survey items were presented in groups and participants had the option of going back and forward through the items using arrows on the page. Ethical approval for both studies was received from the university research ethics board.
Analysis
Propensity score matching.Participants from the larger 2009 sample are matched to the 2014 sample on key individual demographic factors including gender, age, ethnicity, SES and school SES [23] as key predictors of mental health problems in this age group [8]. This method is based on a propensity score, which is derived from weighting schemes based on the criteria that are to be matched andreduces the probability that differences between samples on outcomes of interest are due to sample differences on relevant demographic variables [24]. Propensity score matching was conducted in STATA using psmatch2 [25].
Comparison of the 2009 and 2014 matched samples. First, mean scores of each SDQ subscale and total difficulties are presented and statistically compared across the 2009 and 2014 matched samples. In addition to a test of significance, it is crucial to take into account the size of a significant effect when interpreting results, as such we include Cohen’s d as a measure of effect size. Second, the proportion of adolescents above the borderline clinical cut-off score for each SDQ subscale and total difficulties are presented and compared across samples. We present odds ratios for all comparisons. Gender differences are examined and discussed throughout. Given multiple testing, to balance the likelihood of type I and type II errors, the alpha value was set at 0.01. All analyses were conducted using two-tailed tests.
Results
Results are divided into two parts. First, results of the propensity score matching procedure is presented along with sample details for the 2009 and 2014 matched samples. Second, the mental health outcome scoresfor the 2009 and 2014 matched samples are examined.
Propensity Score Matching
Participants were matched based on the following individual characteristics: gender, age, ethnicity, SES and school SES. This resulted in each participant in the 2014 sample having a closely corresponding participant in the 2009 sample. Based on the matching procedure described above, a final 2009 sample of 1683 participants were selected and used for descriptive and comparative analysis hereafter.
Table 1 presents the sample descriptive statistics for the 2009 original sample, the matched sub-sample and the 2014 sample. The distribution of gender in the 2009 (50.0% female) and 2014 (49.2% female) were not significantly different, p = .653, nor was there a significant difference between the 2009 (20.1%) and 2014 (17.5%) samples with respect to the proportion of participants eligible for FSM, p = .358 or with respect to ethnicity, with 38.3% of participants from both samples identifying as ethnic minority. There were an equivalent proportion of participants drawn from Year 7 compared to Year 8 classrooms (3.7%) across both samples. There was a significant difference in age between the 2009 and 2014, t(3364) = -10.59, p < 0.001, however the magnitude of this difference is equivalent to only approximately 1.5 months of age, which reflects different periods of data collection during the school year (2009 sample collected between October and December and 2014 sample collected in January).
The final sample was reasonably representative of national norms; the participants in this study had similar levels of deprivation (16.3/17.5% eligible for FSM), which is slightly higher than national proportions (14 -16%) and there were marginally more participants from ethnic minorities in the current study (38.3%) compared to the national average (20-25%) [26].
Mental Health Differences
Table 2 presents the five SDQ subscale scores and the total difficulties for the two samples. Table 3 presents the proportion of participants at 2009 and 2014 at-risk for mental health difficulties, that is, above the cut-off score for borderline risk for any of the symptoms subscales or for the total difficulties score. Almost one in five adolescents were found to be at risk of mental health difficulties (determined by the total difficulties). Conduct problems were more common amongst boys (e.g., in 2014 = 24% in boys, 15% in girls) and emotional problems were more common in girls (e.g., in 2014 = 7% in boys, 20% in girls).
Overall, mean scores were comparable across the two samples, with the exception of emotional problems, which was higher in the 2014 sample compared to the 2009 sample (d = 13). Conduct problems were also significantly different across the two samples, with lower levels of conduct problems observed for the 2014 sample compared to the 2009 sample, however the effect size for this result was negligible (d = .09). Looking separately across gender, there was no significant difference in 2009 and 2014 SDQ mean scores for boys. Conversely, for girls, emotional problems were significantly greater in 2014 compared to 2009, with an effect size of .23.
Proportions at-risk were compared using chi-square test of independence and odds-ratios (Table 3). Overall, comparable to the results of the t-tests above, proportions of adolescents at risk of emotional problems increased between 2009 and 2014, whereas the proportion of adolescents at risk of conduct problems decreased during this period. When examined separately by gender, girls in the 2014 cohort were significantly more likely to be at risk of emotional problems compared to girls in the 2009 cohort. There was an overall decrease in the proportion of boys at-risk based on the total difficulties score between 2009 and 2014, but no difference for any of the symptom subscales across this period.
Discussion
This study provides an examination of mental health difficulties faced by adolescents in England over the past 5 years. The two cross sectional samples included in the analyses show, for the most part, very few variations in the reporting of mental health problems over the five year period between 2009 and 2014. Where differences over time did occur they were distinctly different for boys and girls.
Girls reported higher levels of emotional problems in 2014 compared to their matched counterparts in 2009, with no such differences in emotional problems in boys. This result was also apparent when examining the proportion of girls at-risk for emotional problems, with a greater proportion of girls (an increase of 7%) in the 2014 sample at-risk compared with girls in 2009. The estimates of effect size suggest that although these differences are small, they are non-trivial. This result is consistent with previous research that has also found increases in girls’ emotional problems over time [18,27].
For boys, a small decrease in proportion of at-risk total difficulties was observed, although this finding is tempered by the fact that the mean difference between the two samples was not significant. There were no differences between any individual subscale that may aid in the interpretation of this result. However, similar small decreases in boys’ behavioural problems have been observed [27]. Clearly further research is needed to confirm if this result represents a genuine trend.
Given the nature of the current study’s design, it is only possible to hypothesise what may underpin these apparent changes in reporting of mental health difficulties in 2009 compared with 2014. First, the increase in emotional problems amongst girls, and the decrease in overall difficulties in boys may relate to lack of effective interventions to specifically tackle emotional problems in schools and a parallel increased focus on disruptive behaviours in the classroom. Much previous research confirms that teachers are disproportionally attentive to behavioural problems in classrooms (which are over-represented in boys) due to their disruptive nature, likely resulting in timely support and intervention not being available for emotional problems (which are over-represented in girls).
Additionally, various societal-level changes may be implicated in the rising incidence of emotional problems. For example, the recent climate of economic and social inequality has been associated with higher levels of depression and other emotional problems, and youth unemployment has been shown to have a direct adverse impact on older adolescent’s mental health [28]. Recent funding cuts to youth mental health services [29] may have exacerbated the impact of societal and economic issues on adolescent mental health further.