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1999 Health in Scotland

YOUNG PEOPLE'S MENTAL HEALTH

Background

Despite the fact that the mental health of young people is now firmly on the policy agenda in Scotland, remarkably little is known about both the prevalence and correlates of mental health problems in community samples of Scottish youth, particularly minor psychological morbidity which may not come to the attention of services. One source of evidence on this issue is the West of Scotland Twenty-07 study, a cohort study of around 1000 young people, resident in the Central Clydeside Conurbation, who were first surveyed at age 15 in 1987 and have been followed up at age 16, 18, 21 and 23, using a mix of home interview and postal questionnaire methods. At each age (except 23) the principal measure of mental health has been the General Health Questionnaire (GHQ-12) which is a general measure of psychological distress or malaise (containing 12 items relating to worries, anxieties and depressed mood). The GHQ can be used as a screening instrument, a score of 3 or more indicating 'caseness' (a level of symptomatology of potential clinical significance).

Prevalence of GHQ caseness

Figure 2.17 shows rates of psychological distress (GHQ caseness) at ages 15, 16, 18 and 21 for males and females separately. At age 15, around 1-in-10 males (10.7%) and 1 in 5 females (18.5%) score in a range indicative of caseness. These rates increase quite dramatically by age 16 (17.3% males, 33.1% females), and peak at age 18 when 1-in-3 males (33.3%) and 2 in 5 females (41.8%) exhibit symptoms of psychological distress. The rates decline slightly by age 21, but still involve almost 1-in-3 males (30.5%) and more than 1-in-3 females (37.2%). At each age, females have higher caseness rates than males, particularly at the two earlier points (age 15 and 16) when their level of psychological distress is almost twice that of males.

Figure 2.17 GHQ Caseness (3+) for males and females at ages 15, 16, 18 and 21

Overall, these rates of psychological distress are extremely high, especially at age 18, and indicate a mental health problem of some considerable magnitude in youth. Provisional findings from a second cohort study, involving 15- year olds in the same area surveyed in 1999, suggest that (using the same GHQ measure) the mental health of young people has deteriorated.

Correlates

In contrast to the pattern observed in adulthood, in the Twenty-07 study at age 15 GHQ caseness was not differentiated by young people's social class background, psychological distress being just as likely among those with parents in professional as compared with unskilled occupations. These results held with other measures of socioeconomic status. The kind of family young people were in did however make a difference, though not (in this sample) the family structure (two birth parents, step- and lone-parent families). The dimension of most importance was family conflict, as reflected in arguments between young people and parents reported at age 15.

Figure 2.18 (lower part) shows the likelihood (odds) of being a 'GHQ case' at age 15 and three years later according to the degree of family conflict reported at age 15, controlling for social class and gender. Caseness rates at age 15 are almost 50% higher among those reporting 'high' conflict compared with those with 'low' conflict, and even higher three years later at age 18. The fact that the relationship holds over a three-year period suggests that conflict precedes psychological distress though the possibility of reverse causation cannot be ruled out.

Figure 2.18 Likelihood of physical symptoms (high) and psychological distress (GHQ caseness) according to conflict with parents, social class and gender, aged 15 and 18

Another factor related to psychological distress is unemployment, both in terms of the experience and expectation of being out of work. Results from the Twenty-07 study on this issue come from information provided by respondents at both age 18 and 21.

Figure 2.19 shows the likelihood of being a 'GHQ case' at age 18 according to labour market position, again controlling for social class and gender, and in addition for prior GHQ caseness at age 15. Being unemployed elevates the likelihood of psychological distress by a factor of 2.7, bigger than the effect of prior mental state and much bigger than the 'gender effect'. Very similar results were found in a comparable analysis at age 21. The fact that prior levels of psychological distress are taken into account means that the relationship between unemployment and psychological distress is not explained by those in poorer health at age 15 becoming unemployed (though this does occur) but rather that the experience of unemployment has deleterious consequences for mental health.

Figure 2.19 Likelihood (Odds) of GHQ caseness (3+) at age 18 by social class, economic position, sex and prior GHQ (age 15)

Figure 2.20 shows the results of an analysis of GHQ caseness, this time at age 21, focusing on expectations of unemployment among those who were in work or tertiary education at the time (i.e. excluding the unemployed), and again controlling for prior mental health (at age 18). Those who thought it very likely or quite likely they would be unemployed in five years had caseness rates 2.4 times higher than those who thought unemployment was very or quite unlikely.

Figure 2.20 Likelihood (Odds) of GHQ caseness (3+) at age 21 according to predicted chances of future unemployment and prior GHQ (age 18)

The conclusion from these analyses is that while psychological distress is not directly influenced by social class or deprivation in youth, there are other more indirect ways in which it works to promote health inequalities in adulthood, notably via unemployment which remains more likely among those from lower than higher class backgrounds. That this is not the only factor is indicated by the fact that family conflict is important regardless of class of background, and by the gender findings. The higher rates among females are a puzzle, especially as females now out-perform males educationally and labour market opportunities on balance favour females rather than males. Other factors relating to gender identity are almost certainly implicated in this picture.

Service implications

The evidence from the Twenty-07 study is consistent with the view that there is a mental health problem in youth of some considerable magnitude which affects young people from quite different social backgrounds. Recognising this, even at the most general level, is important given that our assumptions about youth have been, and often continue to be, that youth and health go hand in hand. That assumption was, and remains, dangerous because it justifies disattention to the issue.

It is important to recognise that the GHQ measure reported here is general in nature and does not distinguish types of mental health problems (e.g. depression from anxiety) and certainly not specific psychiatric disorders. It does however direct attention as much to minor psychological morbidity as to more serious disorder, which is easily written off as of little clinical or social significance. This is a regrettable tendency since even minor problems can have large consequences for educational attainment and success in the labour market, as well as other aspects of young people's lives. Given that the research evidence shows that young people are unlikely to go to their GP to talk about mental health problems, and that GPs often lack training in this area, there is a role for other health-workers to fill this gap, and especially in situations where young people are found. Chief among these is the school. Getting mental health onto the school curriculum is important, as is promoting an ethos which facilitates recognition of problems.

Having someone to talk to is crucial. A school nurse (as currently envisaged in the new community schools programme) may go a long way to resolving problems which manifest as psychological distress. Similar provision is possible in further and higher education settings but not for those young people who are working, training or unemployed. The last group in particular are cut-off from services, and imaginative thinking is required to meet the needs of those whose mental health problems are often the worst.

CHILDREN WITH SPECIAL NEEDS

Children with special needs as a consequence of physical handicap and/or delayed development have in the past been a particularly disadvantaged group. However with the development of geographically based child development teams and multi-disciplinary child development centres their needs can be and are being met. Such services have pioneered the "joined-up" and one-stop services envisaged in the modernised health service. The Raeden Centre in Aberdeen is one such unit; it is core funded jointly by the NHS and the Local Authority and was founded more that 25 years ago. A wide range of staff contribute to the team approach in assessing and identifying the educational and physical needs of children and families referred from a range of services. Such units and services operate best in combined child health services in which there is a single management structure for both acute and secondary community services. The present challenge is to maintain such multidisciplinary teams in a location convenient for children and families in the face of increasing financial pressures both within the NHS and local authorities. A major challenge for the Aberdeen and Grampian service, along with similar units in Scotland, will be to maintain the multi-disciplinary nature of the team and the one-stop nature of the service. Outreach services to ensure equity of access for children and families from Morayshire and Orkney and Shetland have been established but the wider development and continuation of such services will require strong advocacy. The establishment of Child Health Commissioners in health boards should help to maintain and further develop such services in the new NHS.

As discussed earlier in this Section, Clinical Networks as envisaged in the Acute Services Review are emerging in a number of areas of paediatric practice. Their underlying purpose is to maintain and improve the quality of specialist secondary and tertiary services and ensure equity of access. Such networks will help to maintain and develop clinical skills, ensure adequate training for the senior staff of the future and ensure that Scotland maintains its contribution to basic and applied clinical research. The arrangements for provision of the Cystic Fibrosis service provides an example of the challenge and the need for such networks.

Cystic fibrosis is relatively uncommon, affecting 1 in 2,500 of the population. The gene mutations responsible for the condition are widely distributed within the population and there are cases in all Health Board areas. The condition produces gradually progressive lung damage, with the result that few patients survive beyond their mid thirties and survival is generally associated with considerable reduction in lung function. For adults, specially designated Cystic Fibrosis Clinics are established in Glasgow, Edinburgh and Aberdeen, with an Edinburgh satellite in Dundee. However, the logistics of travelling with young children mean that it is more appropriate to provide locality based services for younger patients. This is a view supported both by the patients (as represented by the Cystic Fibrosis Trust), and by the clinicians who comprise the Scottish Cystic Fibrosis Group. The paediatricians involved are currently in the course of establishing formal networking arrangements to enable the larger clinics to support the smaller clinics. The establishment of these managed clinical networks has so far been undertaken in a financially neutral environment, but the additional workload for the larger clinics, inevitable is such arrangements, may have to be recognised.

ORAL HEALTH OF CHILDREN

Oral health of children continues to be a significant problem in Scotland despite increasing health service resources and improvements in dental health over the last 30 yrs. Oral disease in 14-year olds reached the lowest (best) recorded in modern times with on average, less than 3 of the permanent (adult) teeth affected by disease. One-third (32%) of children aged 14 years had not experienced any dental disease in their adult teeth. However while many children show no signs of dental disease, at the other end of the spectrum 6% of the children in the survey population had 50% of the untreated dental disease.

The 1998/99 SHBDEP report on 14-year olds confirmed the previous strong relationship between deprivation and dental decay with almost four times as many children with no caries experience in DEPCAT 1 (most affluent) compared with DEPCAT 7 (most deprived). Deprivation in itself is not the cause of the disease, it is the inherent attitudinal and behavioural factors associated with deprivation which can both cause the disease and influence its prevention.

Figure 2.21 highlights the large variation in dental disease between Health Boards in Scotland. The West of Scotland Health Boards have some of the highest rates of disease as do regions such as Highland and the Western Isles. Deprivation is not easily measured; using DEPCAT as an index of deprivation in rural areas is imprecise and the NHS should review how deprivation influences health and especially oral disease in these remote and rural areas of Scotland.

Figure 2.21 Proportion of 5 year old Children with no Caries. Experience by Health Board in Scotland 1997/8, (Scottish Health Boards' Dental Epidemiological Programme)

General anaesthesia was one of the main treatments used to combat anxiety during dental treatment, especially for the extraction of teeth in children. The use of general anaesthesia for dental treatment has continued to fall with a reduction of over 50% in its use in general dental practice over the last 18 months. Small reductions in the use of this treatment in the community and hospital dental services have been recorded despite continued high numbers of referrals from general dental practice. The Scottish Executive plan to phase out this service in primary care as soon as planning allows. In future the use of general anaesthesia for dental treatment will be restricted to acute hospital settings.

The age group with least improvement in oral health in recent years is pre-school children. Children in this age group often do not exhibit protective behaviours such as limiting sugar consumption and regular toothbrushing with a fluoride toothpaste. The 1999/2000 SHBDEP survey continues to show small improvement in this age group but the most recent survey confirms that over half of 5 year olds show signs of dental disease when they start school. Some Health Boards have shown a continuing trend of improvement over several surveys and review of local initiatives in such areas may indicate possible national programme developments. The Possilpark project in Glasgow involves community intervention from birth and has indicated how targeting activity to those in most need can significantly reduce dental disease.

Diet deprivation and oral disease

The main factors associated with dental disease are diet, oral hygiene, failure to use fluoride in various forms and failure to use supportive dental services. The main causative agent (sugar) is so common in the diet that it can become difficult to link directly to dental disease in surveys of children and infants. Individual cases of sugar abuse and misuse can often be seen in individual patients with children under three years presenting with "bottle caries" - rampant dental decay affecting multiple teeth due to frequent use of high sugar baby foods and drinks. The main issues seem to be the high use of sugar and sugar products from a young age and this is closely linked to high frequency of use of such products. Regular snacking between meals with items rich in sugar is encouraged from the earliest years by parents, relations and even some professionals. These behaviours, while not exclusive to areas of deprivation, are most commonly associated with such areas and as they are not accompanied by positive lifestyle behaviours they often result in high disease levels. The most common abuse of sugar in these age groups seems to be the use of bottle feeders where healthy milk type drinks are supplemented by parents adding sugar to the bottle and using it as a comforter. In a similar way comforters (dummies) are used with high sugar products such as jam, chocolate and other sweet products. These products are often used at an age when new teeth are erupting into the mouth and at times of the day when they can cause most damage, for example at bed time to encourage sleep.

Multi-professional education by health visitors, dentists, pharmacists and doctors that provides advice on healthy food choices for young children must be encouraged. This should be complemented by activity in local communities to ensure easy availability and marketing of low sugar healthy products such as fresh fruit and vegetables. It is only through such community programmes that the effects of deprivation will be minimised.

Self-care and positive oral health behaviours such as toothbrushing and oral hygiene combined with supporting professional care can influence disease. These behaviours are often closely correlated with deprivation. Many children from DEPCAT 1, 2 and 3 attend the dentist in a caries-free state to acclimatise them to the dentist and dental treatment. However the first visit of those in DEPCAT 5, 6 and 7 to a dentist is closely related to treatment of pain (toothache) with its subsequent consequences; extraction or other treatment. Traditionally many of these extractions have involved general anaesthesia. Thus the disease seen in areas of deprivation is self-perpetuating in that it leads to negative association with health services (pain and suffering) and this results in even poorer preventive behaviours and less appropriate use of services. There is a need to break this negative cycle of events and support people to influence their own and their child's health through self-care. For people to change they need support from many sources including the community in which they live and health services, and often a change in the environment in which they live. Professional-led schemes such as the Ayrshire dental programme, have persuaded parents from all backgrounds to change attitudes and encouraged children from all walks of life to attend early for dental care. This means that the general dental practitioner is able to intervene with early preventive measures and give best advice on diet, self-care and professional care. Ayrshire and Arran have the highest registration for 0-2 year olds with general dental practitioners in Scotland at 42%. Community-based projects such as those been piloted in Possilpark, Glasgow show initial success through community support for parents. If these two approaches could be combined with health and community services working together, then it would be possible to minimise substantially the effect of deprivation on oral health.

Fluoridation of the water supply is the one approach that has been shown to overcome the effects of deprivation in relation to oral health. Fluoridation remains the most effective way of reducing dental decay and is most effective in areas of deprivation.

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