Children's mental health
* About 10 per cent of young people in the UK have a mental health problem
* Boys are more vulnerable than girls; they are also more likely to commit suicide when they are older
* At least 2 per cent of under-12s and 5 per cent of teenagers struggle with significant depression. That's at least one deeply unhappy child in every primary school
* The World Health Organisation predicts a 50 per cent rise in the level of child mental disorders by 2020. This would put them in the top five most common causes of childhood disability, sickness and death
* Inner-city children are twice as likely to suffer as rural ones. Black youngsters have the highest rate of any ethnic group
Let's talk about Stacey. She thinks no one ever does. Certainly not her dad, who left home when she was two. Nor her stepdad, who fathered her two stepbrothers before he left as well. And not her mum, who is still suffering from postnatal depression. The family lives on benefit in a rented flat in a run-down area of the city. When Stacey started school she didn't talk much. She didn't play much and she struggled with the work. She was tired because she didn't sleep well, and she often complained of tummy ache. Her teachers said she was depressed, and it wasn't surprising - poor kid. Then the school got a new headteacher. She wanted to help troubled children cope with the sadness and frustration in their lives. She set up circle time and ran a nurture group, which Stacey joined. She also developed links with the mental health and social services and reached out to parents. The whole staff became involved in a drive to understand and help children like Stacey. Now Stacey knows there are people talking about her. Last week she played tag in the playground for the first time.
Loss of resilience
Stacey lacks resilience, a key word in the mental health dictionary. Forget happiness. No one is happy all the time. But if you are resilient you bounce back from what life throws at you and generally feel good about yourself and your achievements. There is evidence that children are finding it increasingly difficult to grow up resilient. Childhood is a time of change, but for some, change - be it the loss of a grandparent or the experience of starting school - can be a huge hurdle. Four-year-olds are diagnosed with depression. Six-year-olds attempt suicide. Youngsters face bigger challenges than they did, say, 30 years ago, and more, particularly boys, are falling by the wayside. Schools can help put them back on track.
At least 10 per cent of young people in the UK have a mental health problem, according to the first government survey of the issue in 2000. The study of more than 10,000 five to 15-year-olds, their parents and teachers, revealed that 5 per cent suffered clinically significant disorders, 4 per cent had emotional problems such as anxiety and depression, 1 per cent were hyperactive, and 0.5 per cent had rarer conditions such as anorexia (The Issue, Friday magazine, May 31, 2002) and autism (The Issue, Friday magazine, May 10, 2002 ). A third of these problems are likely to carry on into later life - for those who do grow up. According to the Samaritans, 12 young people commit suicide every week, three times more than 20 years ago (The Issue, Friday magazine, January 30).
In a typical 250-pupil primary school, four children will have phobias, three will have anxiety disorders, one will be seriously depressed, 12 will have serious behaviour problems and four will be hyperactive. Many more, according to the child mental health charity Young Minds, will be suffering distress that may develop into a diagnosable disorder unless they get help.
Not seen and not heard
Question: when did the Surgeon General of the United States release his first report on mental health? Answer: five years ago. The shrouds of ignorance surrounding mental disorder have only recently started to lift - and children have waited longer than anyone.
That they suffered at all was not acknowledged until the late 19th century.
Autism and attention deficit hyperactivity disorder were not recognised until the 1940s and depression not until the 1950s, and then only slowly. A 1996 Encyclopedia of Child Health published by the UK's Royal Society of Medicine lists delinquency, but not depression, reflecting the belief that children lacked the emotional maturity to become seriously sad.
Who is at risk?
Poverty, violence and stress will condemn an increasing number of youngsters to life with a troubled mind, says the World Health Organisation. It is predicting a 50 per cent rise in the level of child mental disorders by 2020, which would put mental ill-health in the top five most common causes of childhood disability, sickness and death. Currently, says the WHO, 400 million people around the globe struggle with mental ill health. These conclusions tie in with the results of the UK survey.
The offspring of well-educated, professional parents who stay together are two to three times less likely to suffer than youngsters growing up in a single-parent household. It is not the single-parenthood that is the real risk factor, but the tensions and problems that usually go with it. A fifth of youngsters living in such difficult circumstances have a mental disorder. Even children in "reconstituted families" - where their parents have found new partners - are twice as vulnerable as those who live with their birth parents. Currently, only slightly over half of the UK's children grow up with their two birth parents.
Poverty and stress lurk behind other statistics. Inner-city children are twice as likely to suffer as rural ones. Black youngsters have the highest rate of any ethnic group at 12 per cent. Children from families with a history of mental illness or suicide are vulnerable. So, unsurprisingly, are those who are in care, have been abused, are chronically ill or have lost a parent at a young age. Youngsters with neurological problems such as epilepsy are also at increased risk. Boys are more vulnerable than girls - and they are more likely to commit suicide when they are older. Recent guidance from the Government lists "being female" as a plus in the resilience league table. About 11 per cent of boys suffer compared to 8 per cent of girls.
Risk into reality
The issue of what turns a risk of mental disorder into a reality for some children and not others is horrendously complex and not helped by the fact that those looking for the answers are compartmentalised in disciplines such as neuroscience, biology, psychiatry and social science. A major US report on child mental health in 2001 called for "truly interdisciplinary researchers" to help bridge the gaps between research, policy and practice.
But after 40 years of analysis of the cellular and molecular development of the brain, the report says there is one "unassailable conclusion": a child's environment, in the womb and out, plays a large role in shaping his or her brain circuitry and subsequent behaviour. Extremes of abuse and neglect affect brain cell survival, neuron density and the mind's neurochemistry. Poor diet and a dull, isolating environment also affect brain development and thus behaviour.
Even if neglected children grow into competent adults, they are likely to suffer some emotional or cognitive handicap. Almost all child mental disorders result from the interaction of many factors. While genetics is one of these, scientists now generally regard the search for a "gene" for schizophrenia or manic depression as a misleading simplification.
Studies with animals have revealed how nurture can overcome nature. In 1999, scientists at McGill University, Montreal, fostered baby rats born to "good" mothers, which groomed and licked their young a lot, with "poor" mothers, which did not - and vice versa. Despite their genes, the fostered rats born to the tactile mothers grew up to be low groomers that responded badly to stress and change. The scientists drew parallels with the problems displayed by month-old human babies of depressed mothers.
The complex origins of mental disorder are also revealed by the discovery of a biological reaction that may help identify children at risk of depression. Researchers at the University of Pittsburgh tested children with a family history of depression and found that they produced less growth hormone than their peers when given growth releasing hormone. But, and here's the rub, the researchers cannot tell whether the response is inherited or the result of growing up in a stressful family. The scientists who struggle with these questions can congratulate themselves in one respect. Their work is helping to erase the stigma that stops many families seeking help.
Anxiety and phobias are among the most common childhood mental health problems. All young children develop fears - most six to 12-year-olds have at least seven - but for between 5 and 10 per cent of the age group they make ordinary life difficult. Another emotional disorder, depression, is rising fastest among young people. At least 2 per cent of children under 12, and 5 per cent of teenagers, struggle with significant depression.
That's at least one deeply unhappy child in every primary school. And it is a long-term problem, with episodes lasting, on average, eight months. At least half are likely to become depressed again in the next couple of years.
The increase is not simply because the problem has been ignored for so long. Society has changed in the past few decades - and children are suffering. Family breakdown, poverty and violence are not the only problems. According to Dinah Morley, director of Young Minds: "Life is so much more commercially pressurised than it was 30 years ago. If children don't look the way they want to, they get bullied, and there are more ways children can be bullied these days. They are also under increasing pressure from tests and exams. I haven't yet found a child who is not aware that their Sats results affect their school's league table position. It is a huge pressure."
The influence of the UK's commercialised celebrity culture was backed up by research in Australia last year. Studies of 400 nine to 12-year-olds found that 16 were clinically depressed and 112 were at risk. The depressed children were more likely to believe happiness came from money, fame and beauty. Happier youngsters tended to believe feeling good was about healthy attitudes and the experience of pursuing goals, whatever the outcomes might be. "Adults have created a dreadful place for children to grow up in," says Ms Morley. "Even if you are David Beckham or Tim Henman and you have done well, you are slagged off in the press for the slightest thing. Most children looking at that think, 'Why should I bother? I'm never going to be the best.' It must be so demoralising."
Aggressive, antisocial and a persistent rule breakerI These are the hallmarks of a "conduct disordered" child. Teachers will be dealing with 12 such unhappy children in a typical primary school. Arson, theft, truancy, violence, lying and running away from home are all disasters waiting to happen. Mental health specialists would judge such a child to have a clinically impaired social and educational life. He - they are usually boys - is in trouble. Conduct disorders appear between the ages of five and 16.
A third of affected children also have reading difficulties - one early study found they were 28 months behind their peers.
Few mental disorders exist in isolation. ADHD (see The Issue, Friday magazine November 14, 2003) and Tourette's syndrome are so often found in children with conduct disorders that they may have the same neurological cause.
Again, environment takes its toll. Poverty, joblessness, sickness, and large families in small houses all add to the problems. Parents with conduct disordered children have been found to struggle with two to four times more stress than luckier households. Another worry is the knowledge that how they react to their "difficult" children can affect whether or not the disorder persists. Impatient, inconsistent, and demanding parents make things worse. For example, depressed mothers tend also to be bossy and critical, exacerbating their children's defiant and disobedient stance.
Their plight is not helped by conduct disordered children's lack of empathy and social skills. They are prone to misinterpret or distort other people's words or intentions, often seeing hostility where none exists.
How to help
Many schools do not step in quickly enough to help troubled youngsters, Surrey University researchers said earlier this year. Yet there is plenty of advice out there. Detailed guidance on how to spot and help a child with a mental disorder is available from the Department for Education and Skills (see resources). Schools with strong anti-bullying policies, good relations with parents and healthy pastoral systems are best placed to make a difference.
Links with the other public services are also vital and are being formalised in the new Children Bill. Many schools now offer counselling services or run circle time. Emotional literacy for all pupils is accepted as a desirable goal. Children are urged to talk about themselves more than ever. Youngsters with mental disorders need to be able to articulate their problems. Their self-confidence and self-control is often in tatters, their social skills are lacking and their work is suffering. Helping them depends on improving their skills and making them feel better about themselves.
There are many initiatives and schemes to help children with mental disorders. One is nurture groups, where at-risk children leave their class to explore relationships and behaviour in a haven set up within the school (see next week's Issue). The youngsters learn through homely experiences such as cooking, sharing a meal, or watching television together.
After-school clubs promoted by the National Pyramid Trust have similar aims, hoping to help children make friends and gain confidence.
Both these schemes must be seen as a perk, not a punishment. They also depend, like all such initiatives, on the ethos of the school being right, says Dinah Morley of Young Minds. "The whole school has to be coming from the same place. There cannot be some teachers supporting children who indulge in a lot of acting-out behaviour and others getting angry.
Everyone, including the playground supervisors and classroom assistants, has to be on board for managing that child. It must be a shared view, and a shared sympathy. That is still hard to find in schools."
Links with child mental health services need to improve too, she says.
Primary schools would benefit from a specialist visiting maybe once a month, so teachers can check they are on the right track. This would mean many problems managed by the school without the child being referred to what are still seen as stigmatising services.
Schools today have to accept a new role, says Ms Morley, and they have to get smaller. "When the big comprehensives were set up, society was different. Children were contained in their families and they had futures to look forward to. Children with mental disorders have none of that.
Schools cannot see themselves as just a place for learning. They have to do the nurturing so many kids are missing out on. Good schools and good teachers already do this. If you have another adult rooting for you, the fact that your parents couldn't give a monkey's can be overcome."
Main text: Stephanie Northen Illustration: Brett Ryder Additional research: Sarah Jenkins
Next week: Nurture groups
* Clear and substantial guidance on how to spot and help a child with a mental disorder is available from the Department for Education and Skills.
Includes case studies and is downloadable at www.dfes.gov.uk mentalhealthindex.shtml, or order it from DfES publications, tel: 0845 6022260.
* Guidance on developing children's social, emotional and behavioural skills is also available from the DfES. Part of the national primary strategy. Downloadable at www.standards.dfes.gov.uk.
* Mental health handbook for schools, by Mary Atkinson and Garry Hornby (Routledge, pound;25.99). Suicide, anxiety, bullying and bereavement are just some of the childhood and adolescent mental health problems covered in this study, which won the 2002 NasenTES academic book award.
* Emotional health and well-being : a practical guide for schools, by Helen Cowie, Chrissy Boardman, Judith Dawkins and Dawn Jennifer (Paul Chapman Publishing, pound;18.99).
* The Mental Health Foundation (www.mentalhealth.org.uk).
* Young Minds (www.youngminds.org.uk) is committed to improving the mental health of children and teenagers. Its book, Young Minds in School, is an accessible guide for teachers. There are also booklets for children, such as Stay Cool in School. Tel: 020 7336 8445.
* The mental health charity Mind (www.mind.org.uk) has useful information on all aspects of children's disorders. Search "children" on the website.
* Mental Health amp; Growing Up is a series of 36 factsheets for parents, teachers and young people from the Royal College of Psychiatrists. To order, contact book sales at the RCP, 17 Belgrave Square, London SW1X 8PG.
Tel 020 7235 2351; email: email@example.com. Also on www.rcpsych.ac.ukinfomhgu
* Antidote (www.antidote.org.uk) is a campaign to create an emotionally literate culture. Working with schools and other organisations.
* ChildLine (www.childline.org.uk) is running Boys Allowed a campaign to tell boys and young men that it's OK to admit to problems and to seek help and advice.
* The National Association for Special Educational Needs (www.nasen.org.uk). Tel: 01827 311 500.
* Kidscape (www.kidscape.org.uk) works to prevent bullying and child abuse.
* The National Self-harm Network (www.nshn.co.uk) is a campaigning organisation led by survivors. Email: firstname.lastname@example.org.
* SEBDA (www.sebda.co.uk) is a social, emotional and behavioural difficulties association that supports children with these problems. Tel: 01768 210510.
* Winston's wish (www.winstonswish.org.uk) is a support service for bereaved children. Helpline: 0845 203 0405.
* Samaritans (www.samaritans.org). The organisation's youth pack enables teachers to introduce young people to issues that affect emotional health and wellbeing. Workshops allow young people to examine feelings around emotional wellbeing and to explore the impact of emotional ill health and distress. Tel: 08457 909090.
For full list of resources, see www.tes.co.uk