| الوصف: |
Mental ill health is the largest single cause of disability in the UK (1). Research suggests that lifetime trajectories of common mental disorders are established by mid-adolescence, with half of all mental health problems starting by the age of 14 and three-quarters by 25 (2). According to the Mental Health of Children and Young People Survey, between 2017 and 2020, rates of probable mental disorders increased from 11.6% to 17.4% in the age group of 6-16 year-olds and by over 7% among 17-19 year-olds (10.1% vs 17.4%) in the UK (3). Although WHO estimates that roughly 10% of children and adolescents between 5 and 16 years have a diagnosable mental disorder (4), a recent study among 28,000 adolescents reported that the prevalence of mental health problems in children across many schools in England is much higher than previous estimates, with roughly two in five young people scoring above clinical cut-offs for emotional problems, conduct problems, and hyperactivity (5). However, only a fraction of them receives appropriate care. The Office of the Children's Commissioner found that from nearly 400,000 children and young people who were referred to NHS mental health services in 2018-2019, only 19% of children entered treatment within six weeks after the referral, while 33% stayed on the waiting list for over a year and 34% were not accepted into treatment (6). Mental health services further report that even among children with an official mental disorder diagnosis, only one in four children could access the necessary support in 2020 (7), while young people with psychological and emotional difficulties who do not meet the clinical criteria for a formal diagnosis are not eligible even for that, despite presenting a number of symptoms of physical and behavioural problems (8). It is unclear whether this increase in rates of mental disorders in youth is due to a genuine decline of mental health in children and young people, or it is instead due to greater awareness and less stigmatisation of reporting mental health problems for both children and their parents. Yet, the public mental health crisis is evident and tackling the causes and the development of effective early intervention and prevention programmes is urgent. The Children's Society's Good Childhood Report, the longest-standing report on the wellbeing of children in the UK, indicates that in 2022 a larger proportion of children aged 10 to 17 were unhappy with school (14.2%) than with the other nine aspects of life (e.g., home, family, friends) (9). Among the areas of school life, young people were most happy with the feeling of safety and relationships with their peers, and they felt least pleased with the amount of schoolwork and how much they were listened to in school (9). Similarly, Childline, a free counselling service for children in the UK, reported that children's primary concern was stress and anxiety related to schoolwork and exam performance (10,11). However, there is a lack of research exploring the role of the school context in young people's mental health. A systematic review of 48 studies reports strong evidence of the importance of the school climate, comprised of social connectedness, school safety, school connectedness, and the academic environment, for adolescents' mental health (12). Correspondingly, a qualitative study among adolescents and school staff across three secondary schools in the UK identified four dimensions of school culture (structure and context, organisational and academic, community, and safety and support) as important contributors to student mental health (13). A large longitudinal study of young people across 20 schools in England found strong and consistent associations between student-level and school-level (average student responses in each school) reports of positive school climate at baseline and better mental health outcomes at 36 months follow-up (14). However, these associations were compromised to borderline significant for student-level measures and non-significant for school-level climate after adjustment for baseline measures of student mental health (14). Thus, while the existing studies show that students' subjective perceptions of the school environment are significantly associated with their mental health, these reports are prone to bidirectional bias, so mental health outcomes measured after children and adolescents had been at the school for some time, may already have been influenced by the school climate, while mental disorders may, in turn, corrupt the perception of school environment. Furthermore, according to the NHS reports, children with a higher risk of having a mental disorder were twice as likely to miss more than 15 days of school than those from a lower risk group (3). Thus, having a mental disorder presents further risk of exacerbating worries about school and compromising the perception of school environments, making it more complicated to design effective intervention and prevention programmes. Additional objective measures of school-related risk factors, such as school-staff ratio, number of students eligible for free school meals (FSM), or Ofsted school rates, could provide valuable evidence for better understanding the associations between school environment and child and adolescent mental health. Indeed, a recent study across 97 schools in England which linked survey responses with the National Pupil Database (NPD) showed that having special educational needs (SEN) and being eligible for FSM significantly increased the odds of experiencing any of the four mental health problems, namely emotional symptoms, conduct problems, peer-relationship problems, and hyperactivity/inattention problems (5). Furthermore, students with a child in need status were also at significantly increased risk of experiencing all mental health problems except for emotional symptoms (5). However, the schools explained very little variance in mental health problems (intraclass correlations ≤0.02). Moreover, other studies have concluded that school composition and resources (e.g., staff-student ratio) were not associated with students' mental health (15). The mixed findings might indicate a complex relationship between the objective and subjective measures of school environment and their effects on young people's mental health; nevertheless, even fewer studies included both objective and subjective factors in one cohort. A large study that did use both the NPD data from 648 primary schools on school composition (number of children in the school, student gender and ethnicity ratio, and school deprivation indexed as the proportion of students eligible for FSM) and child-reported school climate explored their association revealed that among the school composition factors only school deprivation was associated with adolescents' mental health, such that young people in schools with higher proportions of students eligible for FSM had on average more behavioural symptoms and were more likely to have mental health difficulties above the clinical cut-off, whereas a subjectively-reported more positive school climate was associated with both lower levels of emotional and behavioural symptoms, and lower rates of clinically significant levels of mental health problems (16). The authors further explored the interaction between the school composition and school climate but found no significant effects on mental health outcomes (16). However, to date, there is no evidence whether the objective and subjective measures of school environment may complement each other and explain more variance of child and adolescent mental health problems. Even less is known about whether objective school-level characteristics provide different contexts and present different levels of risk to children with individual biological differences in mental health characteristics. Thus, studies exploring the association between school environment and child and adolescent mental health remain scarce and lack a comprehensive approach, considering both objective and subjective measures of school environment and the individual predisposition to mental disorders. Furthermore, they are often designed as cross-sectional studies, limiting the opportunities of exploring the cumulative risk of objective and subjective school environmental factors for young people's mental health across their development. Accordingly, the main goal of the present study is to clarify the longitudinal associations between school experiences and developmental psychopathology from childhood to emerging adulthood using both objective and subjective data. We have previously investigated mental health associations with subjective parent-, teacher-, and twin-reported measurements of school environment using the data from the Twin Early Development Study (TEDS), a cohort of twin pairs born in England and Wales between 1994 and 1996, utilising the data collected when twins were 7, 9, 12, 16, 18, and 21 years old (17). Our preliminary results show substantial associations between multiple school environment factors, such as classroom environment, homework and attitudes to school, and psychopathology (r~.25). They show additive effects over the years, possibly indicating that these environmental experiences might pose a cumulative risk for child mental health outcomes (Rimfeld et al., in preparation). Furthermore, prediction increased when previous school experience was added to the contemporary predictors in the model. We aim to extend these findings in the present study by focusing on the objective measurements of school environment, such as the number of absences, exam results, and school quality, by utilising data from the UK-wide registers, namely the NPD and the Ofsted ratings. Contrary to the subjective reports, these objective measures are not affected by the possible rater's bias due to existing mental health problems. Furthermore, decades of twin studies have shown that mental health problems are highly heritable (30-80%), thus, it is important to use genetically sensitive designs when exploring the links between school environment and mental health (18). Our preliminary results show that both mental health and educational experiences across the school years are highly heritable (~50%), and that genetic factors largely explain the correlation between subjectively reported school environment and psychopathology (~90%) (Rimfeld et al., in preparation). The present study will explore the links between objective school environment (National Pupil Database school records on school quality, Ofsted ratings) and mental health using a longitudinal genetically sensitive design (age 7-21) and will combine subjective (parent-, teacher- and self-reported school experiences) and objective school measures to explore the additive prediction from school experiences to mental health both contemporaneously and over time. |
