This article aims to define childhood mental health, describe the main mental illnesses faced by young people and the current approaches used to treat them.

Cultural, racial and urban/rural differences are clear in many aspects of mental health and illness, but the focus here is on issues of broad relevance.

What is mental health?

In 1995, an NHS Health Advisory Service workshop drew up a definition of mental health in young people, identifying four key capacities:

the ability to develop psychologically, emotionally, intellectually and spiritually
the ability to initiate, develop and sustain mutually satisfying personal relationships
the ability to become aware of and to empathize with others
the ability to experience and integrate psychological distress without it hindering development.

Mental health seems to be about emotional well-being: welcoming and fearlessly enjoying new experience, being imaginative and flexible about other people and new people, and being curious and willing to learn.

For fuller details about the definition of childhood mental health see Treating Children Well (Reference and Resource File).

What promotes mental health?
Identifying what promotes young people's mental health is vital. One way to do this is to understand why those who have suffered very adverse circumstances do not develop mental health problems.

What keeps them well?
A 'checklist' of the following has been identified as important:

self-esteem
sociability and autonomy
family compassion
warmth and parental harmony
strong social supports
encouraging and enabling young people to make efforts and to have confidence in their ability to cope.

What is Mental Health?
This section describes the main mental illnesses of young people, and therefore those that your students may face, and for which they may need specialist help.

It is important to remember that many young people experience some form of mental health problem or mental distress, and that this can often be dealt with effectively by parents or schools, preventing it from becoming mental illness.

The most recent international figures agree that the rate of diagnosable mental illness in young people is about one in five at any point in time, and that almost 50 per cent of young people meet the criteria for at least one psychiatric disorder during childhood and adolescence.

Risk factors for mental illness

Although there are specific risk factors for certain illnesses, mental illness may ensue when those factors that promote mental health become insufficient to maintain it.

The risk factors fall into three main categories. Factors intrinsic to the child, for example, are:

Genetic influences

low IQ, learning disabilities (although mental illness in this group is by no
means inevitable - see below) and academic failure
developmental delay
communication problems
physical illness.

Family and close relationship problems:

overt parental conflict
family breakdown
inconsistent/unclear discipline
hostile and rejecting relationships
failure to adapt to young people's changing developmental needs
abuse - physical/sexual/emotional
parental mental illness, including parental criminality, alcoholism, personality disorder
death and loss - including loss of friendship - often from moving house/town etc.

External/environmental factors:

socioeconomic disadvantage
homelessness
disaster
discrimination
poor education/school support.

As well as these factors, direct stress is clearly the cause of much mental ill health. In young people these stresses most often relate to family, relationships and school - exams are a key example of this - and the problems that occur when peer support turns to peer pressure - perhaps most overtly seen in relation to eating disorders and drug and alcohol abuse.

These latter stresses must be considered in the context of mental illness as they may cause or exacerbate it, and the former may be equally a reaction to difficult emotions as a response to external pressure.

Mental Illness

The most common childhood mental illness is that of anxiety disorder, affecting about 12 per cent of young people. While anxiety is a universal human emotion, it can become severe, disabling and persistent. It may be generalized - unrelated to specific events - or triggered by external events, and its manifestations may vary in young people of different ages.

The very young may become clingy, while older children may have sleep problems or develop phobias and panic attacks.

For a fuller account of anxiety in young people see The Anxious Child . Certain things can become frightening for no apparent reason, and people may go to great lengths to avoid them - from open spaces to eating in public.

These irrational fears are called phobias, and panic attacks can follow from exposure to the cause of these or spontaneously - often accompanied by such strong physical symptoms - chest pains or palpitations - that sufferers think they are going to collapse or die.

Obsessive compulsive disorder (OCD) - is probably another manifestation of anxiety in which people repeatedly experience unpleasant thoughts which they try to resist, or carry out ritualized hand-washing or checking. OCD does occur in young people and they may go to great lengths to hide what they recognize as illogical behaviour.

Depression - also occurs in young people, albeit less commonly than anxiety. Incidence is age-related, with about 2 per cent of the under- l2s affected, rising to 5 per cent of teenagers.The common signs in school-age young people include being moodiness, irritability, difficulty concentrating, withdrawal from friends, family and hobbies, neglect of personal appearance, sleep problems, and changes in eating habits and weight.

Bipolar depression (sometimes called manic depression) -may occur, where periods of extreme lows and highs alternate. Persistent difficult behaviour, where young people repeatedly break accepted rules of family and social conduct affects about 10 per cent of young people sufficiently severely that they are diagnosed to have conduct disorder (CD).

The very young may refuse to do what they are told and throw tantrums, while older children may be aggressive and violent towards others, damage possessions, steal and lie. These problems are much more common in boys than girls, and left untreated, can lead to severe difficulties in adult life.

One of the factors which increases a child's likelihood of developing CD is hyperactivity - also known as hyperkinetic attention deficit or attention deficit hyperactivity disorder. It affects about 5 per cent of primary school children and requires specialist diagnosis - many children are inattentive and restless.

The diagnosis is best made by observing the child and getting reports of their behaviour from parents and teachers.

Eating disorders - most common in girls but becoming more so in boys, receive a lot of attention but are in fact relatively rare - about 2 per cent of young people are affected. Despite this, their seriousness should not be underestimated - they can be life-threatening. Their presence is likely to reflect emotional turmoil, and the sufferer may feel that control over what they eat is the best they can do to control what is going on in their lives (see Article 5: An introduction to the Eating Disorders for full explanation).

Self-harm - is another sign of distress, depression and turmoil, twice as common in women as in men, and may start at school age.

Cutting - or other self-inflicted wounds are much less likely to be attention seeking behaviour than an attempt by the young person to release self-hatred, anger or anxiety.

Help should be made immediately available to those who self-harm, a number of whom go on to attempt suicide. Again, young people who talk or appear to be thinking of suicide should be helped - initially by their GP, but often backed up with more specialist support.

Schizophrenia - exemplifies the psychotic' disorders in which perceptions, sensations and beliefs are severely disrupted. However these disorders are rare in the age group under focus here.

The average age of onset of schizophrenia is in the late teens or early 20s, but very occasionally the symptoms (hearing, seeing and feeling things that aren't there, combined with extreme lack of motivation and energy) occur in younger people.

The Treatment

The importance of treating childhood mental illness is made clear by the huge cost on human emotion and service resources which result from both the presence of these problems in childhood and their carry through into adulthood.

Sadly, only about 10-15 per cent of those who could be helped are referred for specialist treatment, and those that are tend to be young people with problems which are disruptive rather than those with anxiety or depression - emotional disorders which are deeply distressing for them but impinge less on those around them.

Furthermore, parents tend to seek help for their children at times of marital or other family strain rather than in calmer periods. There are two basic medical approaches to treating mental illness - psychological and physical therapies.

Mental Health and Illness in Young People: An Overview

As teachers, it is vital to be aware of the help you can give. Aside from parental, family and home influences, education and school life play the most critical role in mental health promotion.

Full evaluation of school strategies to promote mental health is awaited, but anti-bullying and anti-racism measures show promise.

Young people who are not attending school, through illness or exclusion, require targeted educational efforts, and significant benefits are gained from minimizing absence.

Advice on drug and alcohol use and provision of services for young people who are in difficulties in this regard is available from the NHS Health Advisory Service.

Ensuring that young people have access to sources of help which they find acceptable is clearly vital. Confidential school pastoral services (i.e. school-based counsellors), walk-in facilities for counselling out of school and telephone helplines are all beneficial.

It is also interesting to note that family-based mental health promotion programmes are helpful whether or not the child with problems is involved.

Ensure that the young people you teach are aware that they have support from you if needed, and that you can help them work out where to turn next, and encourage parents to keep schools informed about circumstances at home that may be distressing for the child.

Some young people may be unable to turn to their teachers, especially if their problems are causing difficulties at school and they feel a general air of disapproval around them.

In these cases, making sure they know of outside sources of help, for example making the number for Childline (0800 1111) readily available is simple but effective.