Session 1: Setting the scene by looking at the past

In the first session of this course, you will look at the history of children’s mental health. Until the middle of the twentieth century, following the Second World War and the formation of government welfare services, children’s mental health was not recognised as the significant issue it is today. However, some children will have experienced mental health problems, even if these were left undiagnosed, and you will be examining some of the reasons why this might have happened.

You will look at a news account about children’s mental health and consider why there are currently reported increases in the numbers of cases of children with compromised mental health, and you will be encouraged to identify some of the reasons why this might or might not be the case. You will also be introduced to some of the ‘language’ associated with children and their mental health. This will hopefully make the content in later sessions more familiar to you. And finally, you will be encouraged to think about the resources within the child, the family, their community and wider society that can help children to develop ensuring good overall mental health.

It is important to highlight that contemporary Western views about children and mental health are not going to be held globally; some cultures as well as religions hold beliefs that mean they do not recognise mental health issues as an illness. Instead, the causes of behaviours in children that are outside the norm are sometimes attributed to other explanatory models, a contentious example being that a child is possessed by evil spirits.

Now listen to the following audio in which Liz Middleton, one of the course authors, introduces the session.

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Transcript: Audio 1

LIZ MIDDLETON

To understand what's happening in the present, it's often helpful to look at the past. Childhood in the past is often viewed as being idyllic and carefree, however that's not really a true representation of how childhood was experienced.

Charles Dickens highlighted the living conditions of poor children in his novels such as Oliver Twist, which was written about 160 years ago. The story of The Water-Babies by Charles Kingsley highlights the terror and abuse that young children experienced as chimney sweeps. Thankfully, it's no longer acceptable for small boys to be sent up chimneys to clean them.

The events during the Second World War had a profound impact on children, many were separated from their families. In England, children as young as three years of age were evacuated from the cities to the safety of the countryside where the risks of bombs were less.

This week's content gives some examples of how children's mental health were affected by events in the past. You'll also gain an overview of contemporary mental health issues in very young children. Very importantly, the content will explore the ways that children's mental health and wellbeing can be supported within the family, the community, and the society. And we'll have a look at some of the terms that are used in relation to children's mental health.

There is a quiz for you to do. This won't contribute to the badge for the course this week. But it's a great opportunity for you to practise, ready for the quizzes in week 4 and 8, which will contribute to successful completion and your final badge. We really do hope that you enjoy this first week of the course.

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By the end of this session, you will be able to:

• describe an overview of the history of children and mental health
• outline the reasons why there is an increase in awareness of children’s mental health
• identify selected factors that can impact children’s mental health and wellbeing.

The recognition that children may be vulnerable to developing diagnosable mental health conditions has started to emerge over the last hundred years or so. This is partly because, until modern times, children were regarded as little more than ‘adults in waiting’ and childhood was not regarded as a distinct life stage as it is today. There was a different understanding about how children develop and a lack of awareness that children think differently to adults. Another reason why it was thought that children could not be regarded as being mentally unwell is because behavioural problems were viewed as being caused by children being ‘bad’ rather than ‘mad’ (Rey et al., 2015). Children who did not conform to the expected norms of behaviour were often marginalised from society, punished harshly and labelled in pejorative ways.

The next section includes a timeline of some of the key events relating to societal views and developments in relation to children’s mental health. The sources used for this timeline include historical accounts from the field of child psychiatry as well as recently written reflections on the history of children’s mental health.

Below is a timeline of key events, predominantly drawn from the United Kingdom, that have influenced the ways that children’s mental health is viewed in countries such as the UK.

1800s: lunatic asylums emerged and children regarded as psychiatrically unwell, including those with learning disabilities, were institutionalised and removed from mainstream society.

1895: Henry Maudsley, a pioneer of psychiatry, wrote a psychiatry textbook posing the question ‘how soon can a child go mad? … obviously not before it has some mind to go wrong, and then only in proportion to the quantity and quality of mind which it has’.

Figure 1 A poor child in Victorian times

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This is a black-and-white illustration of a child.

Figure 1 A poor child in Victorian times

The late 1800s: there was a lack of clarity about the causes of mental health conditions in children. However, during this time, a growing understanding developed that children could be affected mentally by the ‘psychological damage’ caused by grief, such as melancholia, or, to use a more contemporary phrase, depression.

1889: adolescence started to become recognised as a distinct stage of life, and puberty was recognised as a significant ‘cause of insanity’. Maxime Durand-Fardel (1889), another doctor who was a pioneer in psychiatry, highlighted the existence of suicide in children.

1919–1930: educationists such as sisters Rachel and Margaret McMillan (1919) and Susan Isaacs (1929), who were pioneers in nursery education, published books to explain their views about the importance of early childhood education. Their work made significant contributions to understanding how children develop emotionally and socially. Their work and practice remains an influence in contemporary nursery education.

Figure 2 Susan Isaacs with children at The Malting House School

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This is a black-and-white photograph of Susan Isaacs sitting with a group of children.

Figure 2 Susan Isaacs with children at The Malting House School

1936: Jean Piaget, a psychologist, developed his theory of children’s cognitive development, which clearly demonstrated that children think in different ways to adults.

The Second World War (1939–45) had a profound impact on many children’s mental health. The experiences of many children in the UK included being evacuated to places of physical safety away from their families to live with people who were unknown to them. In many cases, children’s experiences had a negative effect on their emotional development and on their mental health.

In order to see the connection between challenging life events and how this impacts on children’s mental health, in the next section you’ll read about the real-life account of a woman remembering her experiences as a child during the Second World War.

Read the following case study about Sheila, a 6-year-old girl living in Birmingham in 1943 during the Second World War. Sheila’s experience is based on the account of a woman in her 80s, but she vividly recalls the experience of this period of her life.

Figure 3 Evacuee children in the Second World War

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This is a black-and-white photograph of a group of children at a train station.

Figure 3 Evacuee children in the Second World War

In Europe, the Second World War meant that many children were displaced from their home country and consequently suffered physical and emotional trauma. These accounts about children and war from Western Europe are historical, but it is important to remember that children in the present day are experiencing similar challenges in conflict zones around the world. In the next activity, you’ll look at another child’s experience of the war.

Activity 2 Irja’s story

Timing: Allow about 10 minutes

This video recounts the experience of Irja, who as a child had to leave her home in Finland during the war. As you watch this short video, consider the factors that may have helped her to survive this experience.

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IRJA

We knew the war was coming closer to our home. My mother threw some clothes into a bag. My father took his army bicycle. We also had a grey blanket with us. We left in such a hurry that this was all we managed to take. Many people had to leave in the middle of baking, others had to leave their cattle behind in the barn. We had no idea where we were going. No idea at all … That’s what I remember.

We travelled the whole day. We had nothing to eat and it was cold sitting at the back of the truck. People, even adults, were crying. None of us children could understand what was going on, why we had to leave. Everyone was talking about ‘evacuation’. I didn’t understand the word. I was six years old.

For many years we didn’t have enough to eat. We were malnourished because of scarce and unvarying food. We always felt hungry. I have often wondered how we survived through those years.

TEXT ON SCREEN

UNICEF - Friend of Finnish Children

IRJA

An official came to our house and told us about an organisation that was helping people. We were told that my brother and I would get shoes.

TEXT ON SCREEN

During and after the war Finnish children haven’t had enough food and clothes. UNICEF has distributed food supplements to our children in hospitals, children’s homes, nurseries and summer camps. In schools, children have received milk powder and lard in addition to school meals. UNICEF has also provided clothes and shoes to our children. In the spring of 1949, over 60,000 children received three metres of flannel fabric for underwear.

IRJA

Someone drove into our yard and gave packages to my brother and me. In my package there was a pair of beautiful brown shoes. For a while I was just caressing them and finally put them on. They were a bit too big, but mother said I shouldn’t worry because we could put on extra socks. I could wear them for many years to come. She said that now that I had shows I could go to school in the autumn. The first nights I kept the shoes next to my bed. They were so precious to me. My own shoes. Beautiful brown shoes. I understand refugees and it’s easy for me to relate to them. They are living through exactly the same experiences as we were back then. There’s a war in their home country. Nobody leaves their home unless it’s absolutely necessary. There’s no place like home.

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Discussion

Irja highlights the harshness of living as a displaced person; however, what is evident in her story is the importance of remaining part of a family. The video also illustrates the importance of having a person’s physical needs met; for example, having enough to eat. The video also makes a link between the importance of having the basic physical need of clothing supplied as a factor that can contribute to positive mental health and wellbeing. The gift of the brown shoes meant that Irja was able to attend school, where she would have had the opportunity to develop emotionally, socially and intellectually.

Below is another timeline, focusing on post-Second World War events.

1949–1969: John Bowlby, who was a psychiatrist, started his pioneering work about children’s emotional development shortly after the Second World War by studying the effect on children of separation from their mothers. From this work he developed his theory of attachment, which was first published in 1969.

Figure 4 John Bowlby – the pioneer of attachment theory

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This is an illustration of John Bowlby.

Figure 4 John Bowlby – the pioneer of attachment theory

1949: The United Nations International Children’s Emergency Fund (UNICEF) was set up to improve the lives of children who had been affected by the Second World War.

1953: UNICEF became part of the United Nations and their name was changed to the United Nations Children’s Fund. The work of UNICEF continues today, helping to improve the mental and physical health of children who are caught up in war and conflict around the world.

1959: The United Nations introduced the Rights of the Child, which meant that children became regarded as citizens with rights in many places in the world. Other significant events included the development of evidence-based therapies and forms of medication which were effective and safe to use in the treatment of children with mental health conditions.

Figure 5 Children in post-war Europe from UNICEF

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This is a black-and-white photograph of a group of children.

Figure 5 Children in post-war Europe from UNICEF

1989: The United Nations Convention on the Rights of the Child was a global event that turned a spotlight on children and their welfare. Around this time, a number of cases emerged that highlighted the exploitation of children and this led to the creation of policies designed to protect children and improve their mental health. In England, the Children Act (1989) is an example of legislation that was passed to improve children’s lives and wellbeing.

Figure 6 Convention on the rights of the child

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This is a poster with the text ‘Convention on the rights of the child. Adopted by the General Assembly on the United Nations on 20 November 1989.

Figure 6 Convention on the rights of the child

1995: Children and Adolescent Mental Health Services (CAMHS) began to be set up across England and Wales, and elsewhere, to bring together multi-disciplinary teams of professionals to diagnose, treat and support children and young people with mental health conditions.

This brief overview of the history of children’s mental health highlights that children have always experienced mental health problems. However, it is only in relatively recent times, that is, since about 1940, that this has become recognised as such and that specialist services and treatments have been developed. This section summarises some of the key events that have influenced the shift in the belief that children are not capable of experiencing mental health problems to the contemporary situation in many countries, where it is recognised that children can experience profound mental health conditions.

The previous section explored a brief snapshot of the history of children’s mental health and highlighted that children experiencing mental health problems is not a new phenomenon. Children have always had mental health problems, but because of their status in society, their needs have not always been recognised and addressed. Nowadays, in part due to advances in our ability to diagnose mental health conditions in children, it has been estimated that as many as 10%–20% of children have a diagnosable mental health condition (World Health Organization, 2019). For many, their issues will be in the ‘mild-to-moderate’ range, while others will have severe and possibly enduring mental health conditions. This situation is of concern to individuals and their families and also has long-term consequences for society. However, at this point, it is important to have a look at some of the evidence relating to the relatively high prevalence of mental health conditions in children.

Figure 7 Thinking about mental health in young children

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This is a photograph of a child with a teddy. They are sitting on the floor and looking out of a window.

Figure 7 Thinking about mental health in young children

Although this report states there has ‘only’ been a 2.3% increase in the number of children being diagnosed with a mental health condition between 1999 and 2017, this still means that there is a sizeable proportion of children living with a mental health condition. Clearly, it is important to consider the reasons why there are such significant numbers of children with compromised mental health, both to further our understanding, but also to support children to develop positive mental health. You will explore these issues in the rest of this course.

There are many factors in children’s lives that can help to contribute to their wellbeing which in turn can help them to have good mental health.

To illustrate this point, you will now look at the work of Urie Bronfenbrenner, an American sociologist who researched the interaction between the individual and their environment. Bronfenbrenner developed a theory of how each child’s development is influenced by their relationship with the groups and communities around them as well as with wider society. His theory was named the bioecological model (1979) and he illustrated the theory in a diagram which put the child in the centre of a nest of circles. Moving out from the child, each circle represented a system around the child. This theory is useful to illustrate the influences on children’s mental health.

In Figure 8, the systems around the child have been separated out to illustrate how we can think about the factors within each system.

Figure 8 Systems around the child (adapted from Bronfenbrenner, 1979)

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This is a diagram with a set of circles inside one another. In the smallest, inner circle are the words ‘Child Microsystem’. In the next circle are the words ‘Family Mesosystem’. In the next circle are the words ‘Wider community Exosystem’ and in the largest, outer circle are the words ‘Society Macrosystem’.

Figure 8 Systems around the child (adapted from Bronfenbrenner, 1979)

The inner circle represents the resources within the individual child (the microsystem), then moving outwards, the resources within their family (mesosystem) and local community (exosystem) such as pre-school/school or places of worship, and, finally, the outer circle (macrosystem) which represents the resources within wider society that help children to develop good mental health. Around each of the systems is the passage of time, suggesting that situations and circumstances evolve over time and will change as a matter of course in response to external events. The child themselves will also continue to grow and move across the systems as they move further into the world and away from their family networks.

Earlier in this session you saw how, at different points in history, wider social issues such as war have had a significant impact on how families function and the extent to which children thrive in more challenging environments.

You will find it helpful to return to these different systems as you examine how various practices and policies might affect children’s wellbeing, and the ways that the different ‘layered systems’ might work together to promote more positive mental health in young children and their families, as well as the communities in which they live.

It is worth bearing in mind that even if children have many of the resources available to them, some children will still develop a mental health condition. And the opposite is also the case: children who have experienced a great deal of adversity and are missing many of the positive factors in the systems around them do not necessarily develop poor mental health.

Bio-medical terms can be like a different language and, as with any language, learning it can help us to understand what is happening. This section gives definitions and explanations about some of the language associated with children’s mental health. There are many definitions for some of these terms.

Mental health: We all have mental health and, in a similar way to physical health, it can fluctuate in response to a range of factors. The World Health Organization defines mental health as:

If we are not able to cope with the stresses of life and can’t do the things that make us feel we are achieving something positive, we can start to lack confidence and motivation. This is the same for children as it is for adults. Imagine being a child who is overwhelmed by events that are beyond their control, but must still attend school and be tested, or participate in activities that they have no motivation for.

Mental illness or a mental health condition: A disorder of the mind, which seriously affects a child’s functioning as well as their behaviour or thinking over an extended period of time. There are a number of mental health conditions, the most common in children being depression, anxiety and trauma-related problems as well as issues to do with poor conduct. There will be more about these conditions later in the course.

Wellbeing: A concept that has many definitions, but is usually associated with being ‘comfortable’, happy, well-adjusted and healthy. Other definitions make reference to the quality of an individual’s life. In relation to children, their level of wellbeing can often be judged in relation to their behaviour. A child who is experiencing a poor sense of wellbeing is more likely to be unhappy, have difficulty in concentrating and be unable to engage adequately with everyday activities.

Figure 9 Children’s wellbeing is to do with the quality of their lives

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This is a photograph of a child chasing a bubble.

Figure 9 Children’s wellbeing is to do with the quality of their lives

Diagnosis: The identification of the nature of an illness or other problem by examination of the symptoms. Medical doctors are the professionals that usually diagnose mental health conditions, including among children. A diagnosis is helpful to enable a person to access appropriate and evidence-informed treatments, as well as for advocacy purposes (e.g. where parents who have a child with the same mental health condition can support each other). However, a diagnosis is not always welcome, as unfortunately mental health conditions, even in children, can be stigmatised.

Developmental norms: A sound knowledge about developmental norms is essential in terms of ‘making sense’ of children and mental health conditions. For example, a young child that has an imaginary friend that they speak to in primary school is perfectly normal (and is thought to be associated with being intelligent), whereas talking to an imaginary friend for older teens is seen as unusual and often problematic. Hence, children with a mental health condition will present in ways that are outside of the norm, but determining what is within the ‘normal range’ is vital in terms of establishing if a problem is really a problem.

Risk factors: A risk factor in terms of child mental health is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a condition. In relation to younger children, salient risk factors that can impact on their mental health include a clear lack of routine, not having their physical and emotional needs met, or living in a family where there is domestic violence.

Adverse Childhood Experiences (ACE): Stressful events that can occur in childhood including, but not limited to, the following:

• domestic violence
• parental abandonment (e.g. through an acrimonious separation or divorce)
• having a parent with a mental health condition where this is poorly supported
• abuse (physical, sexual and/or emotional)
• neglect (physical and/or emotional)
• growing up in a household in which there are adults experiencing alcohol and drug use problems.

Protective factors: Conditions or attributes in individuals, families, communities or wider society that mitigate or eliminate risk in families and communities, thereby increasing the health and wellbeing of children and families. For example, communities that have plenty of green open spaces and well-equipped schools are associated with enhanced health and wellbeing for children.

Nature and nurture: In the ‘nature versus nurture’ debate, ‘nurture’ refers to personal experiences ‘growing up’ and the impact of a person’s context or environment. Nurture is therefore directly related to a person’s childhood or upbringing. However, nature is to do with a person’s biology, including their genes. A person’s physical ‘make up’ (e.g. their potential to grow to a certain height) and aspects to do with their personality traits are determined by their genes. The person has little control over certain aspects or features of themselves, irrespective of where they were born or how they were raised. It is now generally accepted that children grow and develop as a result of a complex interplay between both nature and nurture.

Child and Adolescent Mental Health Services (CAMHS): CAMHS are a form of specialist mental health services, primarily delivered by the National Health Service in the UK. CAMHS provide a range of services for children and young people who have difficulties with their emotional or behavioural wellbeing. CAMHS vary depending on the catchment area they serve – with many having waiting lists, and struggling to meet the demands for their services.

At the end of each session, you should take some time to reflect on the learning you have just completed and how it has helped you to understand more about children’s mental health. The following questions may help your reflection process each time.

Well done – you have reached the end of Session 1. You can now check what you’ve learned this session by taking the end-of-session quiz.

Session 1 practice quiz

Open the quiz in a new tab or window and come back here when you have finished.

Now that you have completed this first session, you will hopefully have gained an overview of the history of children and mental health. You have also explored some of the reasons why there is an increase in awareness of children’s mental health. Some of the language associated with mental health has been defined and you have started to identify factors that can impact children’s mental health and wellbeing.

You should now be able to:

• describe an overview of the history of children and mental health
• outline reasons why there is an increase in awareness of children’s mental health
• identify selected factors that can impact children’s mental health and wellbeing.

In the next session, you will delve further into some of the causes of mental health conditions in children. You will also examine the possible impact of compromised mental health on children’s development and education and explore some of the likely ‘triggers’ of anxiety in children.

You can now go to Session 2.