Professor Tamsin Ford offers her insights on lessons learnt during COVID-19, including the need to improve the quality and accessibility of data for child mental health research.
Last month, the NHS published startling figures on the state of child mental health in England. Children and young people receiving open referrals for NHS services totalled 420,000, although experts warn this number underestimates the true toll of the crisis. It’s thought that much of the blame lies with COVID-19 and the consequences of lockdowns, and indeed many researchers in the COVID-MINDS Network paid particular attention to the effects of the pandemic on young people’s mental health, conducting at least a dozen separate studies in multiple countries.
In particular, Professor Tamsin Ford at the University of Cambridge worked with national data to track how the mental health of children, young people and families changed between 2017, 2020, 2021 and 2022 to give the best indication of how the pandemic affected these groups. In a conversation with COVID-MINDS, she explains how socioeconomic conditions and financial adversity play major roles, and she outlines why the emerging adult age group has been disproportionately affected throughout the pandemic.
1. How do the latest NHS figures on the vast number of young people requiring mental health care fit with your research?
TF: I think for me, there were three things that became apparent during the pandemic. Firstly, most of the population did OK. But secondly, there were subgroups of all ages who were much more vulnerable who we really need to think about. And the third thing is there were some distinct trajectories over time. So if we unpack those a little bit, the signal from lots of different studies in the UK was that there was either no change overall or a sharp rise in anxiety and distress at the beginning of the pandemic and the beginning of lockdowns. This was also true in other countries, whether the studies were convenience samples or whether they were selected on a particular frame like the OxWell Student Survey or the National Children's Surveys. That spike then settled reasonably quickly.
2. Can you tell us more about the subgroups among young people whose mental health didn’t improve?
TF: The School for Public Health-funded study around Bristol, led by Emily Widnall, found that the children who were struggling in October 2019 with high levels of anxiety, depressive symptoms or low levels of well-being were actually doing better in April 2020. But then there was another spike in anxiety across the whole cohort when schools reopened in September 2020.
So I think we know that lockdowns do not seem to be great for mental health. There is a sense that families with resources actually valued additional time with family and adjusted fine. These were people, and I would count myself as very fortunate to be amongst this group, who could work from home with adequate Wi-Fi and who had access to sufficient devices for all the family to access school and work. But that ignores those who ended up with financial or housing challenges or even food insecurity, which were strongly associated with poor mental health.
So for children and families where there was overcrowding or even housing and food insecurity, domestic violence, substance misuse or poor mental health in either the child or the parent seem to have been more vulnerable to adverse outcomes. It was quite easy to get into a vicious cycle of deteriorating mental health, escalating domestic violence and hostility, escalating substance misuse, which then fed into each other.
So as many people have said, we may all have weathered the same storm, but some of us were in stronger boats than others to get through it.
3. What do you think will be the long-term effects of the pandemic on the mental health of children?
TF: I think that's a really interesting question. I do think they have paid a very heavy price. We don't have a huge amount of empirical evidence yet, but we are seeing children coming into school with delayed language and social skills. Most of us come from very small families these days. And so if you were born since the onset of the pandemic or if you were born in the first lockdown, you may well have not interacted with anyone outside your immediate family, which might mean no other children for 18 months or so. And all that kind of socialization that goes on with antenatal classes, group meetings to support each other, mother and baby groups where children get language stimulation and learn to negotiate about toys and things, that just hasn't happened. And then you've got 30 in a class with a teacher and a couple of nursery nurses or teacher assistants. And that's really quite hard to deal with. Now, whether or not they will be able to catch up the language and social skills, I don't know. I think gaps in education and knowledge worry me less than gaps in skills.
4. What kinds of skills do you think children and young people have missed out on as a result of the pandemic?
TF: The most important impacts I think have been on the essential life skills that young people learn at school but which are not necessarily formally taught inside the classroom. Particularly those in their teens will have missed out on essential peer to peer interaction which is a major part of normal adolescent development. They will also have missed important rights of passage, such as the school leavers prom, freshers’ week, as well as lacking confidence in their qualification. Social and practical life skills, such negotiating public transport, seem delayed among many in this group.
Furthermore, our education system has become very focused on particular ways of responding to test and exam questions rather than stimulating curiosity and building critical analytic skills, particularly at GCSE level. And I think this is something that employers talk about all the time. What they really value is not what GCSEs and A-Levels measure but problem solving, emotional regulation, social skills, and being able to communicate with others. As a result, these skills, I think, are probably much harder to develop today even when schools were open. You can always go and learn more facts, but skill development takes time and repetition. The particularly vulnerable points are language and social development in very young children coming into school. Then it’s basic literacy and numeracy skills in primary school-age children. Because how on earth teachers managed to do any kind of remote teaching with four-, five- and six-year-olds… I have no idea how you even begin to do that. I have huge respect for teachers who did their utmost and worked extraordinarily hard to try and manage [during the pandemic].
The other group I really worry about, who were doing particularly badly before the pandemic hit, is the emerging adult age groups of 16 to 24 and particularly young women. From both our adult morbidity surveys and from the National Children's Survey, we saw a deterioration in mental health. That sort of anxiety, depression and self-harm… that was the group whose A-Levels and GCSEs were disrupted.
Then if they went off to university, they spent a lot of time sitting in a single room all day on their own, trying to access education online; the same room was used for attempting to sleep, eating and on-line socialising. Again, I think universities worked extraordinarily hard to produce good content, but I can’t think of a better way to induce mental ill health in people than to have them live in a tiny room 24 hours a day without any social contact, particularly at that age when your peer group is everything and it’s all about establishing your identity.
5. Do you think these are the important groups to watch moving forward? Those who may have missed crucial social and developmental stages during COVID-19?
TF: Yes and it’s not only to do with education. The work opportunities for people of that age group just shut down. Hospitality shops, restaurants, clubs. If you're trying to set yourself up or even if you're lucky enough to have a job, there's a lot of implicit learning that happens around your team in an office. This type of learning is very difficult to reproduce remotely. I've got PhD students who are now two thirds of the way through their PhDs and may not have set foot in the office with the rest of the team since the pandemic started. And similarly, people who are just coming out of their PhDs looking for postdoctoral positions, I really worry about that group in terms of their skills and confidence being a bit behind. I notice it in myself. For so long, I wasn’t able to put my head around someone's office door when I wanted a bit of advice. It became harder to ask for advice if it required a zoom meeting.
So I think there will be certain age groups that carry this with them, but the whole cohort won’t be affected equally. It’s children who were born during the pandemic or were toddlers, as well those who entered the emerging adult age group. These are the young people I'm worried about.
6. Are there any other groups apart from children and young people who caught your attention during the pandemic?
TF: Our work with Matthew Pearce and Catherine Abel on adults from the UK Longitudinal Survey, suggested that parents with young children were a very vulnerable group. I can totally imagine why. Dealing with very small children is tough. But if you're doing it without any support and you're trying to keep work going, and if you do come from a family where you have two or three children under five and no respite and no help… I can totally see how that really hurts your mental health. And of course, depressed and stressed parents do not make the best parenting decisions. So there are impacts from both maternal and paternal depression on children's development and also their mental health. And then if the children are struggling this can again create a vicious circle. So I think the other group that we need to really worry about is parents with small children.
7. What should we as researchers remember for future pandemics or health crises?
TF: I am really impressed at how we have managed to collaborate together. The fact that you and I are talking and that the COVID-Minds Network exists is a credit to us.
But from a research perspective we do have a real data gap in children. There is the most heroic living systematic review being done by Brett Thombs’s team at McGill University. When I last looked on 20th June, they had screened over 100,000 abstracts and titles related to the impact of the pandemic on mental health. Search criteria included a defined population sample frame and a validated measure. Of tens of thousands of abstracts, only 222 studies were good enough to include. Then of those 222, only 18 related to those under the age of 18. So we know much less about children. And that brings me to my final point, which is we really need to ensure that people understand that we should use data gathered at huge expense, often to the public purse either by research funders or through university giving up their time or through national surveys, that a quick, descriptive analysis and a report is not the end of the story. There is much more that we can do. So the signal to noise ratio is huge, and we need to do something about that.
8. What can we learn from previous data collection and analysis undertaken throughout the pandemic?
TF: Studies like Daisy Fancourt’s COVID-19 Social Study and Co-Space were convenient samples which were great because they collected data quickly and the surveys were done as well as they possibly could be done. That kind of data is really, really valuable during a fast-changing pandemic. But I think quality rather than quantity is important, and these two were high quality. In comparison, we didn't manage to get the National Survey swinging into action until July 2020, and while I totally accept the need for governments to protect data access, not breaching confidentiality, privacy, etc., the problem is the 2020 data still has not been accessed by anybody other than a necessarily brief and descriptive analysis for government as of July 2022. That is a criminal waste of data gathered with consent for the purposes of policy related research at a time when people consider there to be a mental health crisis among young people.
In the wake of the open science movement which calls for transparency and replicability, this high signal to noise ratio within mental health research is a paradoxical phenomenon. These difficulties in accessing data present a real problem as studies like the National Survey have transformative potential for research.
We really need to make the best use of the data that we do have and collaborate. And if we can keep some of these networks of mental health epidemiologists going, then I think we'll be really well placed to respond quickly next time.
9. What do you think about the mental health research landscape as a whole in the UK?
TF: Without wanting to blow our own trumpet, I think we did rather well in the UK. We are not a big country, but actually we have more than our fair share of high-quality studies on mental health during the pandemic. Obviously we can always do better and we should aspire to do better. But I think we’ve shown we can be good at data collection, collaboration and produce high quality findings, and this is what we should be aiming for next time.