Trends in Child and Adolescent Mental Health in Sweden

Transcription

1 Trends in Child and Adolescent Mental Health in Sweden April 2010 The Royal Swedish Academy of Sciences Health Committee State of the Science Conference Statement

2 About the conference statement This statement has been prepared by an independent, interdisciplinary panel consisting of individuals with substantial scientific expertise who are without their own research within the areas relevant to the conference or other conflicts of interest. The statement is based upon: a. A systematic literature review prepared by a group appointed by the Health Committee at the Royal Swedish Academy of Sciences. b. Expert lectures at the conference. c. Questions and comments by those attending the conference. d. The panel s deliberations during the conference. This statement is the opinion of the independent panel. It is not a statement on behalf of the Royal Swedish Academy of Sciences. Documentation The State of the Science Conference April 2010 on Trends in Child and Adolescent Mental Health in Sweden was webcast and is available for viewing at The systematic literature review and other documents from the conference is available at Conference venue Beijer hall, Royal Swedish Academy of Sciences, Stockholm. 2

3 Summary The panel s evaluation is that there has been an increase in some types of mental illness among young people, for instance mild depression and anxiety, between the mid-1980s and the mid-2000s. The proportion of girls with problems has in some cases doubled or even tripled. The proportion for boys has also increased, but considerably fewer of them state that they experience mild depression or anxiety. The statement above is based upon how adolescents themselves feel about their situation; what they report themselves in various surveys. There are, however, also more objective signs indicating that some forms of mental illness are on the rise. For instance, more girls are treated in hospitals following suicide attempts. It is also remarkable that the adolescent age group does not exhibit the same drastic decrease in suicides that has been observed for all other age groups. The suicide rates for adolescents have remained stable. It is striking how little scientifically-based knowledge there is regarding changes in children s mental health, particularly as regards young children. Based on the material available, the panel could not make any statement about children in the age group 0 10 years. Furthermore, the material available did not enable the panel to make a statement about how perceived mental illness affects the lives of adolescents; for example, their contacts with friends, their school work or during other daily activities. The opinion of the panel is that it is important that the scientific community begins to work towards finding the most important causes behind the increase in mental illness. In this work, scientists need to pay attention to the child s perspective, to gender aspects and the perspective of particularly vulnerable groups. In order to better understand how young people currently feel, how mental illness during childhood and adolescence affect their future, and how their mental well-being can be promoted, the existing scientific infrastructure needs to be reinforced. This is a requirement for producing relevant research and obtaining high quality results. It is a field where interdisciplinary approaches would be particularly beneficial. 3

4 Introduction Since the financial crisis at the beginning of the 1990s, we have seen the publication of many studies suggesting an increase in mental illness among adolescents. This has given rise to the public view that more and more adolescents do not feel well. This perception has influenced both the media and political discourse. The scientific community, however, has been debating how much scientific evidence there actually is to support such a negative trend. In order to clarify this issue, the Health Committee at the Royal Swedish Academy of Sciences decided in 2006 to undertake an overview of the scientific literature on the subject. A working group established by the Health Committee steering group (planning committee) has systematically mapped and reviewed the Swedish scientific literature on the subject. In order to thoroughly and systematically assess the scientific evidence, they applied methods similar to those used by Cochrane Collaboration and The Swedish Council on Health Technology Assessment (SBU). The results of their review have been presented in the report: The Mental Health of Children and Adolescents in Sweden. The panel s statement is based upon that literature review, as well as information presented in lectures and discussions during the State-of-the-Science Conference Trends in Child and Adolescent Mental Health organized April 2010 at the Royal Swedish Academy of Sciences. Based upon this material, the panel was given the task to answer the following four questions: 1. How has the mental health of children and adolescents in Sweden changed over time? 2. Are there regional and/or socio-demographic variations as regards changes in the mental health of children and adolescents in Sweden? 3. How do changes in the mental health of children and adolescents in Sweden differ depending on various definitions of mental health and different sources of information? 4. Which questions and fields should be focused upon in future research? When conducting the literature review, the working group studied a wide array of scientific publications, reports and non-published material. The panel noted that the working group has excluded certain types of studies from the literature review due to relevancy and time constraints. This applies to, for example, studies addressing suicide, substance abuse disorders, criminality, as well as studies with data from one or more points in time but with a time-span shorter than four years between the first and the last data collection. This means that the working group has refrained from evaluating changes over time based on combinations of data from different sources. Moreover, the limits that were set for the working group ruled out the possibility of the working group making its own analysis of existing register data ( e.g., from the National Board of Health and Welfare). Seven different aspects of mental health have been addressed in the literature review: mood and anxiety disorders, psychosomatic and somatic disorders, disorders of attention and hyperactivity, normbreaking behavior, self-destructiveness, other mental disorders (e.g., attachment disorder, autism, schizophrenia); they also addressed positive aspects of mental health. The panel has chosen to focus on these seven aspects although they are not the only ones that could have been studied. Apart from death by suicide, neither the literature review nor the conference included presentation of data for the period Among the studies analyzed by the working group, 90% were from the 1990s or later, and only 10% pertained to the 1980s and earlier. This statement, therefore, deals 4

5 primarily with trends during the last 20 years as regards the mental health of children and adolescents between 0 19 years of age. Evaluation Based upon the material made available to the panel, the following assessments can be made: 1. How has the mental health of children and adolescents in Sweden changed over time? When it comes to the mental health of preschool and younger school children under the age of 10, the panel cannot make any statement. The material available to the panel does not contain a sufficient amount of reliable data. When it comes to adolescents, the panel estimates that there has been an increase in certain types of mental ill health, for instance minor depression and anxiety, since the middle of the 1980s until the middle of the 2000s. The proportion of girls having such problems has in some cases doubled or even tripled. The proportion of boys has also increased but boys, to a significantly lesser degree, state that they feel low or anxious. The statement above is based on subjective data from the adolescents themselves; what they state in various surveys. There are also more objective signs indicating that some forms of mental illness are increasing (e.g., indications of increasing number of suicide attempts among girls). The National Board of Health and Welfare in-patient care register shows that more girls are treated in hospitals following suicide attempts. This applies to girls aged The suicide rate over time among adolescents has not changed to any particular degree. It should be noted, however, that suicide rates have decreased drastically for all other age groups. The proportion of deaths among adolescents due to suicide has increased, because in absolute numbers, accidents and other causes of death have sharply decreased. 2. Are there regional and/or socio-demographic variations as regards changes in the mental health of children and adolescents in Sweden? Within the literature review, it is possible to discern a similar pattern, visible over time, when it comes to gender and age differences in several of the regional studies. In all studies reviewed, problems are more frequent among girls and also more pronounced among girls in late adolescence than for younger girls. There is, however, one important exception, namely that in absolute numbers, more boys than girls commit suicide. It is not possible to state whether the trend is more pronounced in some parts of the country than in others, because this aspect has not been studied in a systematic manner. The same applies to changes within different socio-demographic groups. There are, however, large variations at the municipal and school levels for 2009, according to a new survey of the mental health of Swedish adolescents in grades 6 and 9 that was presented at the conference. 5

6 3. How do changes in the mental health of children and adolescents in Sweden differ depending on various definitions of mental health and differing sources of information? The panel has chosen not to address the issue of different definitions of health and illness. Instead it has used the same seven aspects of mental health that were used by the working group. Mood and anxiety disorders When it comes to assessing trends, the material available is limited. Based upon this limited material, however, the panel estimates that there has been an increase in mild depression, anxiety, uneasiness, irritation and bad temper among year-olds during the last decades. More girls than boys report problems and for girls, the increase is also more pronounced. In a WHO study from 2005/2006, as many as half of all 15-year-old girls reported that they had felt low, sad and lonely at least once a week. We lack reliable knowledge regarding the development of mental health for children below 10 years of age. Psychosomatic and somatic disorders As with mood problems, psychosomatic and somatic problems also have increased, particularly among adolescents. Some studies, however, show that such problems have increased also among younger children. The majority of the studies address teenage children. All studies show that the complaints are more frequent for girls than for boys. Hyperactivity and disorders of attention There is not much material available that enables a statement about trends over time. Existing studies, however, do not point to any changes over time. Norm-breaking behavior Self-reported norm-breaking behavior was stable between 1995 and According to several studies, bullying and truancy also have remained unchanged during the last decades. Self-destructiveness There are some indications that suicide attempts are increasing for girls. The in-patient registry at the National Board of Health and Welfare shows that more and more girls aged have been treated in hospitals following suicide attempts. It is also remarkable that young people do not exhibit the same drastic decrease in suicide frequency that has been identified for all other age groups. Instead, the numbers for adolescents committing suicide has remained stable. For adolescents, the proportion of deaths due to suicide is now increasing since accidents and other causes of death have decreased radically. Other mental disorders (e.g., attachment disorder, autism, schizophrenia) Neither the literature review, nor the conference supplied any firm basis for a statement on this issue. Positive aspects of mental health Subjective life-satisfaction is good or very good for the large majority and remained essentially unchanged from 1985 to 2005, with a tendency to decrease for 15-year-old girls. However, the proportion of girls that were very satisfied with overall life at this moment declined from around 50% in 1985 to less than one-third in 2005/

7 Girls do report a lower degree of well-being than boys; so do older adolescents compared to younger adolescents. Sources of information The representations of young people s mental health vary according to the source of information. In surveys where adolescents subjectively evaluate their health, girls appear to experience more uneasiness and depression and have more stomach- and headaches than boys. This indicates that girls feel less well than boys. However, data from the Cause of Death Registry at the National Board of Health and Welfare show that more boys commit suicide. Society as a whole could reach a better understanding of the mental health of young people if researchers would make use of more sources of information (see question four). 4. Which questions and fields should be focused upon in future research? More knowledge is required in order to follow trends and find early signs of mental illness for children aged 0 6. The same applies to children aged 7 10 years. When it comes to older children and adolescents, the panel is to a large extent basing its statement upon self-reported health. The picture needs to be supplemented with studies based on information from, for instance, parents and teachers. There is a need for knowledge as regards mental health trends for children and adolescents with functional disorders, chronic diseases and diagnosed physical or mental illness. There is a need for data and more profound analyses in order to explain the causes of the negative trends in young people s mental health. For instance, variables such as family situation, schooling, the surrounding community or substance abuse of various kinds need to be included. In order to understand how mental illness affects children s lives, a simultaneous assessment of functional ability, activity pattern and participation is needed. The scientific community should also investigate whether mental illness entails different consequences for different groups, for instance girls, boys and vulnerable people. In order to understand the considerable differences between the sexes, a gender perspective in research is also required. Are the questions addressed in research relevant for how boys and girls look upon their situation and how they are affected by it? It is important to include children s and adolescents subjective perspectives in research. This could mean, for instance, trying out new methods so as to allow smaller children to participate, or allowing young people to influence the framing of questions so that they become more adapted to the relevant age category. The publication database that was established by the Health Committee working group can and should be used for further trend analyses. Methods development There are methodological problems present in the studies that have been presented in the literature overview. In almost all of the studies, the attrition rate has increased with time; fewer and fewer young people answer the surveys. In order to properly assess the effects the non-response bias, the group that did not respond must be analyzed. Who are they? Can it be 7

8 assumed that their mental health is worse than average? In order to guarantee that the change observed over time is real, the panel calls for a documentation of the validity and reliability of the measuring tools used. In order to better understand what the general change in the mental health of children and adolescents means to the individual, it could be beneficial to combine quantitative methods of analysis with qualitative data gathered through in-depth interviews, focus group discussions and observations. What infrastructure is needed for further studies? In order to gain a better understanding of the causes behind trends and consequences of mental illness, an infrastructure is needed that enables linking information about mental illness to, for instance, socio-demographic data at the National Board of Health and Welfare, Statistics Sweden (SCB) and other responsible authorities. The infrastructure should be located at the National Board of Health and Welfare and Statistics Sweden in order to ensure sufficient protection of privacy and continued world class quality. It is also important to maintain and reinforce competence at these authorities. They constitute an invaluable and necessary resource for the scientific community. The Living Conditions Survey of Children carried out by Statistics Sweden should continue to be the measuring tool for further studies of children s mental illness. A location at SCB would also enable analyses of non-response bias, which are needed in order to understand trends. The panel also recommends that the Medical Birth Registry should be linked to data at the Child Health Services. Height and weight development in small children mirror both physical and mental illness, such as a depression. The National Board of Health and Welfare should take further measures in relation to quality assurance of child psychiatric diagnostics in institutional and non-institutional care, in order to enable equivalent diagnoses in the whole country and over time. 8

9 Participants Conference panel Stig Wall, Chair, Professor in Epidemiology and Health Care Research, Umeå University Kristina Alexanderson, Professor of Social Insurance, Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Fredrik Almqvist, Professor in Child Psychiatry, Helsinki University Margareta Blennow, Chief Physician Children s Health Care, Sachs Children s Hospital, Södersjukhuset, Stockholm Gisela Dahlquist, Professor in Pediatrics, Umeå University Anders Ekbom, Professor in Epidemiology, Department of Medicine, Karolinska Institutet Anne Fisher, Professor in Occupational Therapy, Umeå University Urban Janlert, Professor in Public Health, Department of Public health and Clinical Medicine, Umeå University Michael Tåhlin, Professor of Sociology, Stockholm University Speakers Prof. Gunnar Öquist, Permanent Secretary, Royal Swedish Academy of Sciences Dr. Arne Wittlöv, Chair of Health Committee, Royal Swedish Academy of Sciences Prof. Stig Wall, Chair of the conference panel Prof. Bruno Hägglöf, Chair of the working group preparing the systematic literature review Assoc. Prof. Curt Hagquist, Director, Centre for Research on Child and Adolescent Mental Health, Karlstad University PhD Jonas Ring, Researcher, the Swedish National Council for Crime Prevention Prof. Sir Al Aynsley-Green, Children s Commissioner in England Prof. Måns Rosén, Director, Swedish Council on Health Technology Assessment Prof. Sir Michael Rutter, Institute of Psychiatry, London Research Scientist Helen Sweeting, Medical Research Council, Social and Public Health Sciences Unit, Glasgow Prof. Bengt Haglund, National Board of Health and Welfare Assoc. Prof. Mara Allodi Westling, Department of Special Education, Stockholm University Prof. Danuta Wasserman, Director, National Prevention of Suicide and Mental Ill-Health, Karolinska Institutet Assoc. Prof. Sven Bremberg, Swedish National Institute of Public Health 9

10 Planning committee Curt Hagquist, Chair, Associate Professor of Public Health, Karlstad University Håkan Stattin, Professor in Psychology, Örebro University Anders Hjern, Professor in Pediatric Epidemiology, National Board of Health and Welfare Viveca Östberg, Associate Professor in Sociology, Centre for Health Equity Studies (CHESS), Stockholm university/karolinska Institutet Ann-Charlotte Smedler, Associate Professor in Psychology, Stockholm University Marianne Cederblad, Professor emerita in Child and Adolescent Psychiatry, Lund University Olle Söder, Professor & Chair, Department of Women s and Children s HealthKarolinska Intsitute at Karolinska University Hospital, Astrid Lindgren Children s Hospital Anne-Liis von Knorring, Professor, MD, PhD, Child and Adolescent Psychiatry, Uppsala University Peter Friberg, Professor in Clinical Physiology, Sahlgrenska University Hospital Stig Wall, Professor, Professor in Epidemiology and Health Care Research, Umeå University (Chair of the conference panel) Per-Anders Rydelius, Professor, Chair of the planning committee for the conference on School, learning and mental health. Working group for systematic literature review Bruno Hägglöf, Chair, Professor in Child and Adolescent Psychiatry, Umeå University Solveig Petersen, Project manager, PhD in Pediatrics, Umeå University Erik Bergström, Professor of Pediatric Epidemiology, Department of Clinical Sciences, Pediatrics, Umeå University Marianne Cederblad, Professor emerita in Child and Adolescent Psychiatry, Lund University Anneli Ivarsson, MD, PhD in Pediatrics, Associate Professor in Epidemiology and Public Health Sciences, Umeå University Lennart Köhler, MD, PhD, Professor emeritus in Social Pediatrics Nordic School of Public Health, Göteborg Ann-Margret Rydell, Professor of Psychology, Uppsala University Magnus Stenbeck, MA, PhD, Docent Sociology, Karolinska Institutet Claes Sundelin, Professor emeritus, Department of Women`s and Children s Health, Uppsala University Eero Lahelma, Professor in Medical Sociology, University of Helsinki (August 2008 February 2009) Svend Kreiner, Associate Professor in Biostatistics, University of Copenhagen (August December 2008) 10

11 Administrative staff: Birgitta Bäcklund, Administrator Jeanette Hörnqvist, Psychologist Margaretha Karlsson, Administrator Hans Löfgren, Bachelor of Science in Social Work Medical Library, Umeå University (assistance literature search) The Health Committee at the Royal Swedish Academy of Sciences Arne Wittlöv, Dr.Hc, Chair, Health Committee Leif Andersson, Professor, Department of Medical Biochemistry and Microbiology, Uppsala University Görel Bråkenhielm, former Chief Medical Officer at the School Health Care of Stockholm Per-Anders Rydelius, Professor, Department of Women s and Children s Health Karolinska Institutet Olle Söder, Professor & Chair, Department of Women s and Children s Health Karolinska Institute at Karolinska University Hospital, Astrid Lindgren Children s Hospital Lars Terenius, Professor, Department of Clinical Neuroscience, Karolinska Institutet Denny Vågerö, Professor, CHESS, Centre for Health Equity Studies, Stockholm University/ Karolinska Institutet Project manager Curt Hagquist, Associate Professor of Public health, Karlstad University 11

12 Sponsors The project run by the Health Committee is sponsored by the following foundations and organizations: Swedish Council for Working Life and Social Research The Swedish Research Council The Knowledge Foundation Riksbankens Jubileumsfond The Marcus and Amalia Wallenberg Foundation Bristol-Myers Squibb Foundation Erling-Persson Family Foundation The Royal Swedish Academy of Sciences Clas Groschinsky Memorial Foundation The Kempe-Carlgrenska Foundation The Sven Jerring Foundation The Swedish Society of Medicine 12