Understanding Time Trends in Child and Adolescent Mental Health: Impact of Covid-19

The research team, University of Exeter, University of Cambridge, and NatCen Social Research request access to the 2017 Mental Health of Children and Young People (MHCYP) and the 2020 follow-up. This data request derives from a National Institute for Health Research funded fellowship and associated Medical Research Council grant with the purpose of examining the influence of Covid-19 on trends over time in child mental health, the impact of the pandemic, and child mental health service use and support during the coronavirus pandemic.

The pandemic is occurring against a background of deteriorating mental health and health inequalities in young people in the UK. Prior to Covid-19, there has been a trend of rising referrals to child and adolescent mental health services and in the numbers of young people attending emergency departments for self- harm. However, there have also been changes in awareness and recognition of mental health problems, meaning that it is not clear whether and to what extent this is due to an actual increase in the numbers of children and young people experiencing difficulties.

It is important to understand these trends and the impact of Covid-19, in order to plan for the future, target risk factors and those groups most affected, and to improve access to services for children and young people who need them. To this end, this project intends to provide outputs to assist those designing, commissioning, and delivering Child and Adolescent Mental Health Services (CAMHS), providing evidence of the prevalence and nature of mental health service needs; and for education services and others working with the school-age population.

This project aims to answer the following questions in the context of Covid-19:

• Have there been changes in psychopathology, socio-economic and family factors between 2017 and 2020?

• Have there been changes in the ways that mental health problems affect young people? (e.g. in the impact on them or their families)

• Has the mental health of particular groups got worse over time (e.g. in those from more deprived backgrounds, or with certain diagnoses)?

• Are children with problems becoming more or less likely to be in contact with sources of help and support?

• How does any change between 2017 and 2020 compare with changes between baseline and follow-up in the previous national child mental health surveys – is there any evidence that outcomes have worsened?

The Mental Health of Children and Young People survey (MHCYP) 2017 included 9,117 children and young people aged 2 to 19 years old, who were recruited from a stratified probability sample taken from GP registers. The 2020 follow-up included 3,570 children and young people (now aged 5-22) who took part in the 2017 survey, who had agreed to being re-contacted, and who were successfully recruited again in 2020. In each survey, parents reported on younger children, with additional self-report questions for those aged 11-16. Young people aged 17 and over completed their own questionnaires.

The 2017 survey included the Development and Well-being Assessment (DAWBA), a validated standardised diagnostic assessment, which gathers structured data on symptoms and their impact, with semi-structured probes about problems. Both surveys included the Strengths and Difficulties Questionnaire (SDQ), which is a validated dimensional measure of mental health difficulties and impact. In addition, the 2017 survey and the 2020 follow-up also included data on the socio-economic circumstances of the family and the child or young person’s contact with services.

The 2017 and 2020 datasets which are requested are uniquely able to address the aim of this project. They are a large national representative probability sample, which has comprehensive pre-pandemic and well characterised social context data. These detailed data on baseline characteristics and mental health in a population sample, allowing examination of the outcomes for these children and young people during the Covid-19 pandemic and to identify which groups did and did not participate in the 2020 follow up. This enables identification of groups that may be theoretically higher risk and the examination of outcomes for those in different diagnostic groups at baseline.

As all of the MHCYP and earlier BCAMHS (British Child and Adolescent Mental Health Surveys) used the Strengths and Difficulties Questionnaire to measure psychopathology, the team will also compare the change in scores between 2017 and 2020 with the change in scores between baseline and follow-up in the previous surveys, allowing examination of how much change may be related to the impact of Covid-19.

The data controllers will be the University of Exeter, University of Cambridge and NatCen. All three will also be data processors. The GDPR lawful basis for the University of Exeter, University of Cambridge and NatCen to process this data is Article 6(1)(e) ‘processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller’. The legal basis for the processing of special category data is GDPR Article 9 (2)(j), for research or statistical purposes.The funders are the National Institute for Health Research (NIHR) and the Medical Research Council (MRC).

University of Exeter, University of Cambridge and NatCen will receive the whole standard dataset for each survey and their respective follow-up datasets. It is not possible to obtain individual variables. The University of Exeter will be the lead organisation for the Data Sharing Agreement with NHS Digital which will stipulate the length of time for which these data will be kept. This will be for the two years of the research project, after which the data will be securely destroyed according to the DSA unless an extension is applied for and granted.

The datasets received will not be shared with any third parties. The flow of data ends with the University of Exeter, University of Cambridge and NatCen.

The MHCYP survey data is carried out by NatCen Social Research and the Office for National Statistics, the collected data is checked, derived further, minimised and pseudonymised. The pseudonymised data asset is then sent to UK Data Service (UKDS) for agreed dissemination.

The UK Data Service (UKDS) securely transfers the datasets. All data is pseudonymised. The data processors will be the University of Exeter, University of Cambridge and NatCen.

The datasets will be securely transmitted via the UKDS using their approved pathways and then stored electronically in the secure research hubs of all three organisations, which have Data Security and Protection Toolkits (DSPTs). Analysis will also take place within these secure areas.

Data cannot be exported from secure environments without going through a checking procedure to ensure it is not identifiable in any way, and the environments also include logging procedures of who has accessed the data. Only named members of the study team and are substantive employees will have access. All data is regularly backed up on the Universities’ secure server.

This research will involve the analysis of pseudonymised data provided with the permission of NHS Digital. Personal data such as names, addresses and dates of birth are not included, only the unique serial number used to represent participants. In order to minimise the risk of re-identification in this pseudonymised dataset, the team will also follow the “Disclosure control for microdata produced from social surveys” guidance set out by the Government Statistical Service.

What will be done with the data:

The pseudonymised dataset will be analysed and only aggregated outputs will be made available to third parties in peer reviewed publications and open access reports. There will be no attempt to identify individuals.

Data from these surveys will be used to understand temporal changes in child and adolescent mental health and risk factors for poor mental health, in the context of Covid-19, and how support and services for children and young people with mental health problems has been affected.

The aims are to:

• Examine changes in psychopathology, socio-economic and family factors, and mental health-related contact with services between 2017 and 2020

• Compare outcomes in 2020 for different diagnostic groups at baseline

• Compare changes in psychopathology between 2017 and 2020 with changes between previous British Child and Adolescent Mental Health (BCAMHS) surveys and their follow-ups, to examine changes in outcomes over time and the impact of the coronavirus pandemic

Data management will be done using a statistical analysis package. All analyses will be conducted using survey weights and controlling for complex survey design where appropriate, and for non-response. Descriptive statistics will initially be used, with stratification by age and gender where appropriate, as well as cross-tabulations and pairwise comparisons. This will be followed by the use of regression models to examine the factors which may explain change over time and the association between factors, adjusting for the effect of measured confounders where possible.

Comparison with the outcomes of previous BCAMHS baseline surveys (see Aim above) will be carried out by analysis of the BCAMHS 1999 and BCAMHS 2004 datasets, which will be obtained through the usual process via the UKDS.

This project aims to contribute to a better understanding of the impact of Covid-19 on child mental health in the context of trends over time. The team will work with partners and PPI groups (through the Royal College of Paediatrics and Child Health & Us programme) including the Office for National Statistics, Association for Child and Adolescent Mental Health, Mental Health Commissioning Network, Department for Education, Department for Health and Social Care, and Public Health England to produce specific outputs. These will include:

- Peer reviewed outputs of international standing e.g. journal articles (Summer 2021), such as Lancet Psychiatry, British Journal of Psychiatry, and the Journal of Psychology and Psychiatry

- Conference presentations to a range of audiences including health and education (Summer-Autumn 2021) such as the International Congress of the Royal College of Psychiatrists, the Festival of Education and the conference of the Faculty of Public Health.

- Blogs and other public facing output, for schools, health professionals and the general public. These will be developed in conjunction with PPI groups and partners as above (Spring-Summer 2021) for networks such as the Mental Elf, Place2Be, Times Educational Supplement, The Conversation and the Association of Child and Adolescent Mental Health.

- Rapid digests (Spring 2021) – in the form of short briefings and presentations on key findings such as groups experiencing poorer outcomes, profile of most common psychopathology, and groups who appear to have unmet need for services such as CAMHS or school-based mental health services. These rapid digests will be tailored for different audiences including CAMHS, Department for Education, schools, and pathfinder areas with school mental health teams.

Outputs from this work can help mitigate the impact of the Covid-19 pandemic on child mental health. This will be achieved through the anticipated impact in three main areas: research, policy and commissioning. Findings will directly impact on policy and commissioning by providing essential information that will inform and improve impact assessments, policy development, workforce development and training and service planning. It will do this in two main ways: (1) identifying groups who experienced poorer mental health outcomes during the Covid-19 pandemic, and examining risk and protective factors; (2) identifying groups who may be experiencing inequalities in terms of access to services during the pandemic and whether these have worsened since 2017.

Policy and commissioning will be impacted at a national level, with beneficiaries including the Department of Health and Social Care and Department of Education, and the Education and Health and Social Care Select Committees, who have an important role in holding Government to account on child mental health policy. Representatives of the Department of Health and Social Care contributed to the development of the questions asked in the follow on questionnaires and so these analyses will focus on questions that are directly relevant to policy priorities. As such, it is anticipated that there will be an immediate impact of this work on the school age population. Commissioners and practitioners who work with them are desperate to better understand who is at risk and how to help them. Other relevant national bodies include Public Health England, NHS England and think-tanks such as the Education Policy Institute, with whom the team plan to link, as well as regional specialist mental health and child health commissioning networks. Policy briefings will be widely disseminated across these groups.

A major beneficiary will be those designing, commissioning, and delivering Child and Adolescent Mental Health Services (CAMHS), as the research will provide evidence of the prevalence and nature of mental health service needs. Equally, the pathfinder areas with school-based mental health teams and those offering mental health support in schools (school nurses and counsellors for example), will benefit from improved knowledge of the extent of service need and also which groups are particularly vulnerable and could benefit from targeted approaches.

Yielded Benefits is not a requirement for new applications.