Mental illness is meant to be rare. It is meant to be something at the fringes of normal experience.

Yet recent data from the NHS indicates that in the year 2021-22, there were 1.1 million referrals to Camhs in the UK. 

If each of these referrals represented just one child or adolescent, that would mean that 8.7 per cent of 0- to 17-year-olds have been referred to statutory services for mental ill-health. 

However, I think the story is more complicated than that. Some of those referrals are likely young people being referred multiple times to sub-branches of Camhs. They have either been turned away or helped inadequately, only to ricochet back again.

The data also doesn’t capture the many children who are never referred because they don’t meet the threshold. And, given that almost no babies or toddlers are referred, we can guess, from the statistics, that around 10 per cent of UK teenagers currently need mental health support.

When we are estimating that as much as 10 per cent of a population is struggling with something, I’m not sure we can still call that “rare”.

Why the rise in child mental health problems?

So, what is going on? When I talk and teach about mental health in schools, I always ask parents and teachers what they think is driving the current crisis. The answer I always hear is that the “blooming phone” is to blame. Adults, in general, believe that if children got off their phones, their mental health would be better.

From both the research data and my clinical experience, I think this explanation has some validity. There is data emerging about the disadvantages of ubiquitous phone use. For example, girls viewing perfect bodies online leads to body dissatisfaction, which is one of the contributory factors in eating disorders. Phones also have a negative impact on many of the foundations of good mental health, such as sleep and eating.

But are adults too keen to make the phone the scapegoat? Listening to and talking with young people over the past 25 years has taught me that there are no simple explanations for mental illness. It has always been a complex, intertwined mish-mash of factors that has brought a young person to my door. 

For many years, psychologists have recognised that there are some predictable negatives in children’s lives: adverse childhood experiences (ACEs) such as abuse, trauma, prejudice and deprivation are, unsurprisingly, likely to increase mental illness. The impact of the global pandemic is another factor we all know to have had an effect on children’s wellbeing - although, the start of the decline of children’s wellbeing predates the pandemic.

Perhaps one of the more surprising themes that I’ve noticed over the past couple of decades, though, is the sense of pressure that some young people feel in their academic work, and the extreme measures they are putting themselves under to deal with this. When I hear about young people’s work schedules and Ucas-driven extracurricular activities, I can’t help but think of racehorses being trained, or even flogged, to peak performance.  

Combining this experience with research data has led me to an inconvenient and uncomfortable belief: that putting children under a high level of academic pressure is one of many contributory factors in the current mental health crisis.

Not only that but the children who are often pushed the hardest - those dubbed the “high achievers” - may also be at particular risk here.

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What evidence do I have? Well, firstly, I have my own observations. I’ve watched from the sidelines, in Camhs, as an arms race in qualifications has unfolded: as the A at O level changed to an A* at GCSE and then an 8 and 9 grade, more recently. These subdivisions of excellence place the finishing line even further away - and I’ve watched as my distressed patients race ever harder to chase the new higher standards. I’ve heard how they get up at 6am to start studying and that every surface in their room is covered with revision charts.  

Alongside this, I’ve witnessed the explosion of private tutoring. Data from The Sutton Trust, published in 2019, showed that 27 per cent of 11- to 16-year-olds had received private tuition in the previous two years, up from 18 per cent when the survey began in 2005. For some of the young people I see, tutoring is a daily part of life, and the practice can begin at a young age - I have spoken to parents who are employing a tutor because they are worried that their child is going to fail their Year 6 Sats.

I’ve also seen how statutory test results have become tools to rank how “good” a school is. I’ve gone to Year 7 parents’ evenings where the opening comment has been that my child would be “OK for his GCSEs”. Somehow, the most important thing in the first term of secondary school has become what results a child might go on to achieve in a set of exams, five years down the line.

And each year, as a diligent clinical psychologist, I read The Children’s Society’s annual survey of children’s happiness. It surveys children and young people in relation to different areas of their lives, including friends, family, school and appearance - and since around 2015 the results show that children’s happiness with school has been going down.

“Putting children under a high level of academic pressure is one of many factors in the mental health crisis”

Analysis conducted by the report’s authors tells us more about this. They find that, of all aspects of school, it is the schoolwork (as opposed to, say, bullying) that is making children unhappy. They also find that, at secondary level, the older students are the most unhappy, and that school is the area, along with their appearance, that causes the most unhappiness.

In fact, in the most recent report, published last year, such was the influence of school on children’s happiness that it warranted a chapter of its own. Within it, the authors explain that analysis of international data drawn from the Organisation for Economic Cooperation and Development’s (OECD) 2018 Programme for International Student Assessment (Pisa) showed that “children in the UK may be faring less well than their counterparts in other European countries on key measures of wellbeing”.

“Of the 24 European countries included in the analysis, children (aged 15) in the UK had the greatest fear of failure and the lowest life satisfaction,” the authors of The Children’s Society report state. “Findings from the Health Behaviour in School-aged Children (HBSC) survey, published in the same year, also indicated that England, Wales and Scotland were among the six countries (out of 45) with the highest levels of schoolwork pressure among 15-year-olds.” 

To be clear, I am not saying that school pressure alone has caused the current mental health crisis, nor am I saying that teachers are to blame for young people’s anxiety.

However, I think we have to acknowledge that, for many children, academic pressure is part of a complex web of factors that contributes to their mental ill-health, and is therefore one of the factors contributing to a worsening picture of the mental health of a generation.  

We also have to recognise that some children may be more susceptible to that pressure than others. A 2020 summary article, led by Suniya Luthar, professor emerita at Columbia University’s Teachers College in the United States, highlights a growing body of evidence suggesting that young people in “high-achieving” settings are an “at-risk group”, experiencing up to seven times the levels of anxiety and depression as those in other school settings.

In this context, schools are judged to be “high-achieving” based on students’ average scores in the SAT (a standardised test used for university admissions in the US). The equivalent in the UK would be schools that top the league tables, or those that select students on the basis of prior attainment or performance in entrance tests.

Luthar draws attention to a major national policy review in the US, which suggested that there were four major environmental risk factors for adolescent wellness. Three of these would fall within the traditional ACE parameters: exposure to poverty, trauma and discrimination. The fourth was more unexpected: attendance at a “high-achieving school”. 

How to deal with exam stress

So, how does this link between high attainment and mental health play out?

The researchers place academic pressure in a social context of competition linked to globalisation and “the squeezed middle” on the one hand, and to the constant comparison that social media creates on the other. They hypothesise that this creates a “survival of the fittest” mentality, whereby young people are constantly ranking themselves in relation to their peers, leading to overextension in all aspects of their lives. Even things that are meant to be fun become stressful, with hobbies being seen as something for a personal statement rather than a genuine source of enjoyment.

Within this model, educational pressure is not seen as being created solely by the high-achieving school, but is viewed as the result of a system of pressure around the school, including parental expectations and peer comparison. The expectation of constant excellence is one part of this picture, and, as Luthar and colleagues point out, that societal expectation can have a negative impact on teachers, as well as on their students.

While this research focuses specifically on high-achieving schools, rather than individuals, the findings offer some food for thought for anyone working with high-attaining individuals or classes.

To me, it seems that the “survival of the fittest” mentality is the missing piece when we think about what makes life so stressful for young people today, compared with previous generations. 

We need to recognise that, rather than growing up in a society focused on community, driven by a sense of all being in something together, young people are now exposed to a perfect storm of comparison and competition to be the best in every aspect of life. The glorification of the high-achieving, perfect individual is ubiquitous, and yet it seems toxic for mental health. 

But what, if anything, can schools do about this? How should they balance giving pupils the best opportunities with not increasing pressure on any individual child? How can they mitigate the risks for their high-prior-attaining pupils?

I am not sure there are any simple answers to this, as many of the attitudes that the researchers draw attention to are endemic in society, and the influence of any individual teacher will be limited in comparison.

However, I do believe there are some principles that schools can aim to hit.

1. Don’t frame exams as the ‘finishing line’

Holding an attitude of giving young people a broad education that aims to spark interest, joy and a love of learning, rather than being overly focused on exam results, will help. Most schools, of course, aim to do this anyway. But despite the best intentions, it is easy to fall into the trap of positioning GCSE or A-level exams as the “finishing line”. This can be disastrous, particularly for high-attainers if they fail to recognise that they have a long life path in which exam success is not the be-all and end-all, but merely one aspect.  

2. Make wellbeing a whole-school ethos

In a bid to improve the mental health of their pupils, many schools now include a wellness component in their curriculum. Obviously, I am pro-wellness. However, I would be cautious about expecting too much from any individual wellbeing initiative, as this can sometimes be the equivalent of placing a sticking plaster over a gaping wound.

If, for example, we add a few sessions of mindfulness into a work schedule built around four A levels and an extended project qualification (EPQ), those sessions are not likely to have much impact.

Unfortunately, when I go into high-achieving schools, I sometimes see that work-life balance has become another thing students feel they have to tick off a list (yoga: tick; warm bath: tick) rather than something genuinely relaxing. 

3. Don’t unwittingly play into young people’s anxiety 

Whether intentionally or not, many schools seem to deploy tactics of anxiety in encouraging children to work. I have two pet hates that I hear in the Camhs clinic rooms: the first is calling every set of tests in Years 10 and 11 “mocks” to try, presumably, to raise motivation. This doesn’t work - it just creates anxiety among those who are already anxious.

The students who need the extra push will protect themselves from that anxiety by ignoring it and going back to FIFA 23 on the PlayStation. It’s the hard-working, anxious ones who will set their alarms for 5.30am, rather than 6am, to get in an extra half an hour of study for the end-of-unit test that has been presented as an all-important “mock”.

My second pet hate is the motivational assembly speech in which students are told that the current year is the most important of their school career, so they need to work harder than ever before. For some children in that cohort, their work schedule is already extreme, and the levels of pressure they are under are out of control and completely damaging to them. If anything, they need to work less hard and have some fun. 

This is a crucial point for thinking about how we support high attainers: when we set things up as good or right, we often forget to put outer limits on when they stop being good or right. More of something good (studying, healthy eating, training) is not always better. We can over-extend ourselves to the point of mental and physical exhaustion.

I do not claim to have all the answers here, but the questions need to be asked. Do we really want a system in which children are treated like racehorses, pushing themselves - at all costs - towards the finishing line?

And are we prepared for what we will say to the winners if, strung out and exhausted, they realise it has been the wrong race for them all along? 

Dr Tara Porter is a clinical psychologist and the author of You Don’t Understand Me: The Young Woman’s Guide to Life