Stephan Collishaw

Rationing ADHD services? A potentially risky strategy

Background: The decline of mental health among adolescents in the UK over the past two decades has occurred amidst many societal and technological changes making it difficult to identify drivers of these trends. We aimed to identify which aspect of life showed the most rapid deterioration in satisfaction in the UK since 2009 and which aspects have become increasingly correlated with mental health. Methods: Between 2009 and 2024, 15,829 adolescents aged 10-15 rated their satisfaction with life as well as five aspects of life (family, friends, school, schoolwork, appearance), via the UK Household Longitudinal Study. Population-weighted regressions were used to estimate annual summary statistics on these items (means, proportions) and the relative associations between satisfaction items and socioemotional difficulties, as measured by the Strengths and Difficulties Questionnaire (SDQ). Meta-regressions estimated linear changes over time, with interactions testing for heterogeneity across sexes, age-groups, and household income. Results: Mean satisfaction with life dropped over the 16 years of study (B=-0.028, 95% CI=-0.034,-0.022), as did satisfaction with all five aspects of life. Satisfaction with school declined most rapidly (B=-0.027, 95% CI=-0.034,-0.020), becoming accelerated in the most recent 5-year window (2020-24; B=-0.139, 95% CI=-0.178,-0.099). The proportion of dissatisfied individuals rose most rapidly for schoolwork, particularly for females. Satisfaction with appearance became increasingly associated with general life satisfaction (B=0.009, 95% CI=0.005, 0.013, p<.001) and socioemotional difficulties (B=-0.051, 95% CI=-0.073,-0.029, p<.001) over time. Conclusions: Our findings add to international evidence for academic pressure and school environments as plausible drivers of recent declines in life satisfaction, particularly among female adolescents. Future studies should aim to identify the specific aspects of school life that are influencing adolescent mental health and the impact of existing educational policies on student wellbeing should be evaluated.

Background: Child and adolescent psychiatric disorders are common, now affecting at least one in eight children. Evidence points towards an increase in prevalence over time, but very few studies have tested whether longitudinal outcomes for children with mental health problems have changed. This study is the first to test whether mental health and functional outcomes for children with a diagnosed psychiatric disorder have improved or worsened across time in England. Methods: Three national probability surveys were undertaken in England in 1999, 2004, and 2017, each with respective 3‐year follow‐ups in 2002, 2007, and 2020. We include children at baseline aged 5–13 years and compare outcomes for those with baseline psychiatric diagnosis (mental health disorder or ADHD). Three‐year mental health symptom severity and functional impairment were assessed using the parent‐ and self‐rated total difficulties score and impact supplement from the Strengths and Difficulties Questionnaire. Results: Across all surveys, having a psychiatric disorder at baseline predicted greater difficulty and impact scores at follow‐up. The magnitude of these associations increased sequentially over time, such that having a disorder at baseline was more strongly associated with parent‐ and self‐rated difficulties in the 2017 survey compared with the 1999 and 2004 surveys. Children in the 2017 survey were also more likely to report a greater impact of problems. Patterns of individual change also showed a temporal gradient. For children with a psychiatric disorder in 1999, 34% experienced deterioration in mental health at the three‐year follow‐up, compared to 52% of those with a disorder in 2017. The proportion of those who improved decreased correspondingly. Conclusions: Children with a psychiatric condition are experiencing increased difficulties in their daily lives compared to previous generations. Understanding why children are now more likely to experience impaired functioning is a major public concern.

The authors explore publication trends in the Journal of Child Psychology and Psychiatry over the past 5 years regarding associations between parenting and child outcomes, with a focus on the directionality of these effects. Bibliometric analysis revealed that far more studies have examined parent‐to‐child associations than either child‐to‐parent or bidirectional associations, reflecting a significant imbalance in what researchers publishing in JCPP intend to study. However, when evaluating evidence from a subset of robust and well‐designed studies, especially those that permit a test of bidirectionality, the authors see a more balanced picture, with a roughly equal number of studies finding evidence of parent‐to‐child, child‐to‐parent, and bidirectional effects. These studies used a range of methodologies and examined a diverse set of parenting behaviors and child outcomes. Overall, the findings suggest that evidence in favor of child effects is consistently observed despite being significantly understudied relative to that of parent effects. The authors emphasize the importance of studying both child and parent effects alongside one another to understand the complexity of parent–child interactions, and underscore how respect for the agency and perspectives of youth is essential to understanding how they shape the conditions in which they grow up.

Background: Children with mild intellectual difficulties (MID) are at increased risk of poor mental health and functional outcomes compared to typically developing children. Previous research has primarily focused on deficit‐based comparisons. However, substantial heterogeneity exists in this population, ranging from significant impairment to positive adaptation. Our aim was to test predictors of better emotional, behavioural and educational outcomes in children with MID, with a particular interest in potentially modifiable protective factors. Methods: Two UK cohorts, the Avon Longitudinal Study of Parents and Children (ALSPAC; N = 6926) and the Millennium Cohort Study (MCS; N = 8814) were used to examine the associations between independent and cumulative individual, family and social factors in childhood and adolescence and emotional, behavioural and educational outcomes at age 16/17 for children with or without MID. We additionally considered a composite measure of positive developmental outcomes capturing good outcomes across these three domains. Results: Children with MID (ALSPAC, N = 312 [4.5%] and MCS, N = 364 [4.1%]) as a group experienced fewer protective predictors compared to children without MID. Physical activity, family social advantage, school enjoyment and good peer relations were each associated with better outcomes in both groups. Cumulative counts of childhood and adolescent factors were strongly associated with better adolescent outcomes, with a ten‐fold difference in the probability of positive outcomes among those with the most and least protective predictors amongst children with MID. Conclusion: This study underscores the importance of a multi‐faceted approach to supporting children with MID. Further research is required to establish the causal nature of the observed associations, but the findings hold promise for preventative approaches that harness child strengths and build support across family, school and social domains.

Background: An increasing number of children report anxiety in early to mid‐adolescence. Early identification of risk during the transition from primary to secondary schools (age 11) could enhance family‐ or school‐based interventions. While known predictors of adolescent anxiety provide some insight, there is a need to identify and understand additional risk factors. Hyperacusis (aversive sensitivity to sound) is correlated with anxiety in children and adults and thus a candidate risk factor longitudinally. Methods: We explored the predictive potential of auditory hyperacusis using data from the Avon Longitudinal Study of Parents and Children (ALSPAC, n = 6,621). Hyperacusis at age 11 was assessed with a single question, while anxiety and related emotional problems were captured by the emotional subscale of the Strength and Difficulties Questionnaire (SDQ‐E) at ages 13, 16 and through longitudinal trajectories (4–16 years). Results: Hyperacusis significantly predicted anxiety at ages 13 and 16. This predictive effect remained for age 13 even when accounting for pre‐existing anxiety/emotional problems, autism traits and other neurodiversity characteristics (ADHD, dyslexia, dyspraxia). Similar, though less pronounced, patterns emerged at age 16. When testing the four previously identified childhood trajectories of emotional problems, hyperacusis predicted persistent versus decreasing trajectories (the two cases when preschool anxiety is already high) more reliably than increasing from low trajectories (the two cases when preschool anxiety is low). Additional exploratory analyses found that hyperacusis was most strongly associated with SDQ‐E items related to fear, worry, and nervousness; still predicted SDQ‐E scores at age 25, but not adult generalised anxiety disorder, major depressive disorder or suicidal self‐harm. Conclusions: Taken together, our findings suggest that assessing hyperacusis at age 11 can provide additional predictive insights into the exacerbation and maintenance of anxiety in adolescence.

Introduction Young people (YP) whose parents have depression are at elevated risk for developing depression themselves and could benefit from preventive interventions. However, when parents are in a depressive episode, this reduces the effects of psychological interventions for depression in YP. Moreover, parental depression is often managed suboptimally in usual care. There is, therefore, a case for identifying and optimising parental depression treatment to enhance the effectiveness of psychological preventive interventions for depression in YP. Methods and analysis This is a randomised controlled trial (Skills for adolescent WELLbeing) to determine the effectiveness of a cognitive behavioural therapy (CBT) intervention compared with usual care in increasing the time to a major depressive episode in YP by 9-month follow-up (primary outcome). The intervention offers a 12-week treatment-optimisation phase for parents depressed at study entry, followed by randomisation of the young person to a small group manualised online CBT programme facilitated by a therapist. YP allocated to the intervention will receive eight weekly sessions plus three monthly continuation sessions. Secondary outcomes include the number of depression-free weeks, mental health symptoms and functioning. Mechanisms of intervention action will be assessed with mediation analysis of quantitative data and thematic analysis of qualitative interviews. Participants (parents/carers with depression and their children aged 13–19 years) will be identified through existing cohorts of adults with depression, from primary care through health boards in Wales and England, UK, schools and advertising including via social media. Ethics and dissemination The trial has received ethical approval from Wales NHS Research Ethics Committee (REC) 5, the Health Research Authority and Health and Care Research Wales (IRAS 305331; REC 22/WA/0254). This manuscript is based on V.5.7 of the protocol (17 January 2025). Findings will be disseminated in peer-reviewed journals and conferences. Reports and social media messages will be used to disseminate findings to the wider public. Trial registration number ISRCTN13924193 (date registered: 15 March 2023).

Introduction: Previous studies have demonstrated deteriorations in young adult mental health during the COVID‐19 pandemic, but evidence suggests heterogeneity in the mental health impacts of the pandemic. We sought to identify factors which may predict changes in psychological distress and wellbeing during the COVID‐19 pandemic in UK young adults.Methods: A total of 2607 young adults from the Millennium Cohort Study were included. Psychological distress and mental wellbeing were measured using the Kessler‐6 and Short Warwick‐Edinburgh Mental Wellbeing Scale, respectively. Assessment occurred at three timepoints between the ages of 17–19: 2018/19 (pre‐COVID Baseline), May 2020 (COVID Wave 1) and September/October 2020 (COVID Wave 2). Latent change score models were used to study change in distress and wellbeing across the study period, as well as the impact of sex, relative family poverty, parental education, preexisting mental health difficulties and perceived social support on these changes.Results: The latent change score models suggested both distress and wellbeing tended to increase across the study period. Being female and in relative poverty predicted greater increases in distress and/or poorer wellbeing. Higher levels of parental education and greater perceived social support were protective against increased distress and associated with improved wellbeing.Conclusions: The impact of the COVID‐19 pandemic on UK young adult mental health is complex. We provide further evidence for a distinction between symptoms of poor mental health and wellbeing. Research is urgently needed to assess the long‐term impacts of the COVID‐19 pandemic on the mental health and wellbeing of young people, particularly in more vulnerable groups.

Over the past four decades, rates of emotional problems in adolescents have increased in many countries, and outcomes for those with mental health problems have worsened. In this review we explore existing population-based studies to evaluate possible explanations for these trends. We include population-based studies that examine both trends in adolescent emotional problems, as well as risk or protective factors previously hypothesised to be associated with trends in youth depression and anxiety. The available evidence on risk or protective factors trends related to family life, young people’s health behaviours and lifestyle, school environment, peer relationships, as well as poverty. Studies reviewed suggest that trends in emotional problems are associated with increases in parental emotional problems, youth weight-control behaviours and eating disorders, school-related stress, as well as a rise in family poverty and social inequality in the 21st Century. One of the biggest changes in young people’s lives over the last few decades has been the rise of digital media to access information and interact with others, but implications for trends in mental health remain unclear. Other trends are likely to have mitigated against even steeper increases in youth emotional problems, for example improvements in youth substance use and a possible long-term reduction in child maltreatment. Epidemiological studies of unselected cohorts testing explanations for secular trends in mental health are scarce and an urgent priority for future research. Such studies will need to prioritise collection of comparable data in repeated population cohorts. Improving young people’s mental health is a major societal challenge, but considerably more needs to be done to understand the connections between social change and trends in youth mental health.

Background: It is well-known that childhood attention-deficit hyperactivity disorder (ADHD) is associated with later adverse mental health and social outcomes. Patient-based studies suggest that ADHD may be associated with later cardiovascular disease (CVD) but the focus of preventive interventions is unclear. It is unknown whether ADHD leads to established cardiovascular risk factors because so few cohort studies measure ADHD and also follow up to an age where CVD risk is evident.Aims: To examine associations between childhood ADHD problems and directly measured CVD risk factors at ages 44/45 years in a UK population-based cohort study (National Child Development Study) of individuals born in 1958.Method: Childhood ADHD problems were defined by elevated ratings on both the parent Rutter A scale and a teacher-rated questionnaire at age 7 years. Outcomes were known cardiovascular risk factors (blood pressure, lipid measurements, body mass index and smoking) at the age 44/45 biomedical assessment.Results: Of the 8016 individuals assessed both during childhood and at the biomedical assessment 3.0% were categorised as having childhood ADHD problems. ADHD problems were associated with higher body mass index (B = 0.92 kg/m², s.d. = 0.27–1.56), systolic (3.5 mmHg, s.d. = 1.4–5.6) and diastolic (2.2 mmHg, s.d. = 0.8–3.6) blood pressure, triglyceride levels (0.24 mol/l, s.d. = 0.02–0.46) and being a current smoker (odds ratio OR = 1.6, s.d. = 1.2–2.1) but not with LDL cholesterol.Conclusions: Childhood ADHD problems predicted multiple cardiovascular risk factors by mid-life. These findings, when taken together with previously observed associations with cardiovascular disease in registries, suggest that individuals with ADHD could benefit from cardiovascular risk monitoring, given these risk factors are modifiable with timely intervention.