literature review on children's mental health

• Open access
• Published: 14 September 2023

Children and youth’s perceptions of mental health—a scoping review of qualitative studies

• Linda Beckman 1 , 2 ,
• Sven Hassler 1 &
• Lisa Hellström 3  

BMC Psychiatry volume  23 , Article number:  669 ( 2023 ) Cite this article

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Recent research indicates that understanding how children and youth perceive mental health, how it is manifests, and where the line between mental health issues and everyday challenges should be drawn, is complex and varied. Consequently, it is important to investigate how children and youth perceive and communicate about mental health. With this in mind, our goal is to synthesize the literature on how children and youth (ages 10—25) perceive and conceptualize mental health.

We conducted a preliminary search to identify the keywords, employing a search strategy across electronic databases including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts and Google Scholar. The search encompassed the period from September 20, 2021, to September 30, 2021. This effort yielded 11 eligible studies. Our scoping review was conducted in accordance with the PRISMA-ScR Checklist.

As various aspects of uncertainty in understanding of mental health have emerged, the results indicate the importance of establishing a shared language concerning mental health. This is essential for clarifying the distinctions between everyday challenges and issues that require treatment.

We require a language that can direct children, parents, school personnel and professionals toward appropriate support and aid in formulating health interventions. Additionally, it holds significance to promote an understanding of the positive aspects of mental health. This emphasis should extend to the competence development of school personnel, enabling them to integrate insights about mental well-being into routine interactions with young individuals. This approach could empower children and youth to acquire the understanding that mental health is not a static condition but rather something that can be enhanced or, at the very least, maintained.

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Introduction

In Western society, the prevalence of mental health issues, such as depression and anxiety [ 1 ], as well as recurring psychosomatic health complaints [ 2 ], has increased from the 1980s and 2000s. However, whether these changes in adolescent mental health are actual trends or influenced by alterations in how adolescents perceive, talk about, and report their mental well-being remains ambiguous [ 1 ]. Despite an increase in self-reported mental health problems, levels of mental well-being have remained stable, and severe psychiatric diagnoses have not significantly risen [ 3 , 4 ]. Recent research indicates that understanding how children and youth grasp mental health, its manifestations, and the demarcation between mental health issues and everyday challenges is intricate and diverse. Wickström and Kvist Lindholm [ 5 ] show that problems such as feeling low and nervous are considered deep-seated issues among some adolescents, while others refer to them as everyday challenges. Meanwhile, adolescents in Hellström and Beckman [ 6 ] describe mental health problems as something mainstream, experienced by everyone at some point. Furthermore, Hermann et al. [ 7 ] point out that adolescents can distinguish between positive health and mental health problems. This indicates their understanding of the complexity and holistic nature of mental health and mental health issues. It is plausible that misunderstandings and devaluations of mental health and illness concepts may increase self-reported mental health problems and provide contradictory results when the understanding of mental health is studied. In a previous review on how children and young people perceive the concept of “health,” four major themes have been suggested: health practices, not being sick, feeling good, and being able to do the desired and required activities [ 8 ]. In a study involving 8–11 year olds, children framed both biomedical and holistic perspectives of health [ 9 ]. Regarding the concept of “illness,” themes such as somatic feeling states, functional and affective states [ 10 , 11 ], as well as processes of contagion and contamination, have emerged [ 9 ]. Older age strongly predicts nuances in conceptualizations of health and illness [ 10 , 11 , 12 ].

As the current definitions of mental health and mental illness do not seem to have been successful in guiding how these concepts are perceived, literature has emphasized the importance of understanding individuals’ ideas of health and illness [ 9 , 13 ]. The World Health Organization (WHO) broadly defines mental health as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, work productively and fruitfully and make a contribution to his or her community [ 14 ] capturing only positive aspects. According to The American Psychology Association [ 15 ], mental illness includes several conditions with varying severity and duration, from milder and transient disorders to long-term conditions affecting daily function. The term can thus cover everything from mild anxiety or depression to severe psychiatric conditions that should be treated by healthcare professionals. As a guide for individual experience, such a definition becomes insufficient in distinguishing mental illness from ordinary emotional expressions. According to the Swedish National Board of Health and Welfare et al. [ 16 ], mental health works as an umbrella term for both mental well-being and mental illness : Mental well-being is about being able to handle life's difficulties, feeling satisfied with life, having good social relationships, as well as being able to feel pleasure, desire, and happiness. Mental illness includes both mild to moderate mental health problems and psychiatric conditions . Mild to moderate mental health problems are common and are often reactions to events or situations in life, e.g., worry, feeling low, and sleep difficulties.

It has been argued that increased knowledge of the nature of mental illness can help individuals to cope with the situation and improve their well-being. Increased knowledge about mental illness, how to prevent mental illness and help-seeking behavior has been conceptualized as “mental health literacy” (MHL) [ 17 ], a construct that has emerged from “health literacy” [ 18 ]. Previous literature supports the idea that positive MHL is associated with mental well-being among adolescents [ 19 ]. Conversely, studies point out that low levels of MHL are associated with depression [ 20 ]. Some gender differences have been acknowledged in adolescents, with boys scoring lower than girls on MHL measures [ 20 ] and a social gradient including a positive relationship between MHL and perceived good financial position [ 19 ] or a higher socio-economic status [ 21 ].

While MHL stresses knowledge about signs and treatment of mental illness [ 22 ], the concern from a social constructivist approach would be the conceptualization of mental illness and how it is shaped by society and the thoughts, feelings, and actions of its members [ 23 ]. Studies on the social construction of anxiety and depression through media discourses have shown that language is at the heart of these processes, and that language both constructs the world as people perceive it but also forms the conditions under which an experience is likely to be construed [ 24 , 25 ]. Considering experience as linguistically inflected, the constructionist approach offers an analytical tool to understand the conceptualization of mental illness and to distinguish mental illness from everyday challenges. The essence of mental health is therefore suggested to be psychological constructions identified through how adolescents and society at large perceive, talk about, and report mental health and how that, in turn, feeds a continuous process of conceptual re-construction or adaptation [ 26 ]. Considering experience as linguistically inflected, the constructionist approach could then offer an analytical tool to understand the potential influence of everyday challenges in the conceptualization of mental health.

Research investigating how children and youth perceive and communicate mental health is essential to understand the current rise of reported mental health problems [ 5 ]. Health promotion initiatives are more likely to be successful if they take people’s understanding, beliefs, and concerns into account [ 27 , 28 ]. As far as we know, no review has mapped the literature to explore children’s and youths’ perceptions of mental health and mental illness. Based on previous literature, age, gender, and socioeconomic status seem to influence children's and youths’ knowledge and experiences of mental health [ 10 , 11 , 12 ]; therefore, we aim to analyze these perspectives too. From a social constructivist perspective, experience is linguistically inflected [ 26 ]; hence illuminating the conditions under which a perception of health is formed is of interest.

Therefore, we aim to study the literature on how children and youth (ages 10—25) perceive and conceptualize mental health, and the specific research questions are:

What aspects are most salient in children’s and youths’ perceptions of mental health?

What concepts do children and youth associate with mental health?

In what way are children's and youth’s perceptions of mental health dependent on gender, age, and socioeconomic factors?

Literature search

A scoping review is a review that aims to provide a snapshot of the research that is published within a specific subject area. The purpose is to offer an overview and, on a more comprehensive level, to distinguish central themes compared to a systematic review. We chose to conduct a scoping review since our aim was to clarify the key concepts of mental health in the literature and to identify specific characteristics and concepts surrounding mental health [ 29 , 30 ]. Our scoping review was conducted following the PRISMA-ScR Checklist [ 31 ]. Two authors (L.B and L.H) searched and screened the eligible articles. In the first step, titles and abstracts were screened. If the study included relevant data, the full article was read to determine if it met the eligibility criteria. Articles were excluded if they did not fulfill all the eligibility criteria. Any uncertainties were discussed among L.B. and L.H., and the third author, S.H., and were carefully assessed before making an inclusion or exclusion decision. The software Picoportal was employed for data management. Figure  1 illustrates a flowchart of data inclusion.

PRISMA flow diagram outlining the search process

Eligibility criteria

We incorporated studies involving children and youth aged 10 to 25 years. This age range was chosen to encompass early puberty through young adulthood, a significant developmental period for young individuals in terms of comprehending mental health. Participants were required not to have undergone interviews due to chronic illness, learning disabilities (e.g., mental health linked to a cancer diagnosis), or immigrant status.

Studies conducted in clinical settings were excluded. For the purpose of comparing results under similar conditions, we specifically opted for studies carried out in Western countries .

Given that this review adopts a moderately constructionist approach, intentionally allowing for the exploration of how both young participants and society in general perceive and discuss mental health and how this process contributes to ongoing conceptual re-construction, the emphasis was placed on identifying articles in which participants themselves defined or attributed meaning to mental health and related concepts like mental illness. The criterion of selecting studies adopting an inductive approach to capture the perspectives of the young participants resulted in the exclusion of numerous studies that more overtly applied established concepts to young respondents [ 32 ].

Information sources

We utilized electronic databases and reached out to study authors if the article was not accessible online. Peer-reviewed articles were exclusively included, thereby excluding conference abstracts due to their perceived lack of relevance in addressing the review questions. Only research in English was taken into account. Publication years across all periods were encompassed in the search.

Search strategy

Studies concerning children’s and youths’ perceptions of mental health were published across a range of scientific journals, such as those within psychiatry, psychology, social work, education, and mental health. Therefore, several databases were taken into account, including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts, and Google Scholar, spanning from inception on September 20, 2021 to September 30, 2021. We involved a university librarian from the start in the search process. The combinations of search terms are displayed in Table 1 .

Quality assessment

We employed the Quality methods for the development of National Institute for Health Care Excellence (NICE) public health guidance [ 33 ] to evaluate the quality of the studies included. The checklist is based on checklists from Spencer et al. [ 34 ], Public Health Resource Unit (PHRU) [ 26 , 35 ], and the North Thames Research Appraisal Group (NTRAG) [ 36 ] (Refer to S2 for checklist). Eight studies were assigned two plusses, and three studies received one plus. The studies with lower grades generally lacked sufficient descriptions of the researcher’s role, context reporting, and ethical reporting. No study was excluded in this stage.

Data extraction and analysis

We employed a data extraction form that encompassed several key characteristics, including author(s), year, journal, country, details about method/design, participants and socioeconomics, aim, and main results (Table 2 ). The collected data were analyzed and synthesized using the thematic synthesis approach of Thomas and Harden [ 37 ]. This approach encompassed all text categorized as 'results' or 'findings' in study reports – which sometimes included abstracts, although the presentation wasn’t always consistent throughout the text. The size of the study reports ranged from a few sentences to a single page. The synthesis occurred through three interrelated stages that partially overlapped: coding of the findings from primary studies on a line-by-line basis, organization of these 'free codes' into interconnected areas to construct 'descriptive' themes, and the formation of 'analytical' themes.

The objective of this scoping review has been to investigate the literature concerning how children and youth (ages 10—25) conceptualize and perceive mental health. Based on the established inclusion- and exclusion criteria, a total of 11 articles were included representing the United Kingdom ( n  = 6), Australia ( n  = 3), and Sweden ( n  = 2) and were published between 2002 and 2020. Among these, two studies involved university students, while nine incorporated students from compulsory schools.

Salient aspects of children and youth’ perceptions of mental health

Based on the results of the included articles, salient aspects of children’s and youths’ understandings revealed uncertainties about mental health in various ways. This uncertainty emerged as conflicting perceptions, uncertainty about the concept of mental health, and uncertainty regarding where to distinguish between mild to moderate mental health problems and everyday stressors or challenges.

One uncertainty was associated with conflicting perceptions that mental health might be interpreted differently among children and youths, depending on whether it relates to their own mental health or someone else's mental health status. Chisholm et al. [ 42 ] presented this as distinctions being made between ‘them and us’ and between ‘being born with it’. Mental health and mental illness were perceived as a continuum that rather developed’, and distinctions were drawn between ‘crazy’ and ‘diagnosed.’ Participants established strong associations between the term mental illness and derogatory terms like ‘crazy,’ linking extreme symptoms of mental illness with others. However, their attitude was less stigmatizing when it came to individual diagnoses, reflecting a more insightful and empathetic understanding of the adverse impacts of stress based on their personal realities and experiences. Despite the initial reactions reflecting negative stereotypes, further discussion revealed that this did not accurately represent a deeper comprehension of mental health and mental illness.

There was also uncertainty about the concept of mental health , as it was not always clearly understood among the participating youth. Some participants were unable to define mental health, often confusing it with mental illness [ 28 ]. Others simply stated that they did not understand the term, as in O’Reilly [ 44 ]. Additionally, uncertainty was expressed regarding whether mental health was a positive or negative concept [ 27 , 28 , 40 , 44 ], and participants associated mental health with mental illness despite being asked about mental health [ 28 ]. One quote from a grade 9 student illustrates this: “ Interviewer: Can mental health be positive as well? Informant: No, it’s mental” [ 44 ]. In Laidlaw et al. [ 46 ], with participants ranging from 18—22 years of age, most considered mental health distinctly different from and more clinical than mental well-being. However, Roose et al. [ 38 ], for example, the authors discovered a more multifaceted understanding of mental health, encompassing emotions, thoughts, and behavior. In Molenaar et al.[ 45 ], mental health was highlighted as a crucial aspect of health overall. In Chisholm et al. [ 42 ], the older age groups discussed mental health in a more positive sense when they considered themselves or people they knew, relating mental health to emotional well-being. Connected to the uncertainty in defining the concept of mental health was the uncertainty in identifying those with good or poor mental health. Due to the lack of visible proof, children and youths might doubt their peers’ reports of mental illness, wondering if they were pretending or exaggerating their symptoms [ 27 ].

A final uncertainty that emerged was difficulties in drawing the line between psychiatric conditions and mild to moderate mental health problems and everyday stressors or challenges . Perre et al. [ 43 ] described how the participants in their study were uncertain about the meaning of mental illness and mental health issues. While some linked depression to psychosis, others related it to simply ‘feeling down.’ However, most participants indicated that, in contrast to transient feelings of sadness, depression is a recurring concern. Furthermore, the duration of feeling depressed and particularly a loss of interest in socializing was seen as appropriate criteria for distinguishing between ‘feeling down’ and ‘clinical depression.’ Since feelings of anxiety, nervousness, and apprehension are common experiences among children and youth, defining anxiety as an illness as opposed to an everyday stressor was more challenging [ 43 ].

Terms used to conceptualize mental health

When children and youth were asked about mental health, they sometimes used neutral terms such as thoughts and emotions or a general ‘vibe’ [ 27 ], and some described it as ‘peace of mind’ and being able to balance your emotions [ 38 ]. The notion of mental health was also found to be closely linked with rationality and the idea of normality, although, according to the young people, Armstrong et al. [ 28 ], there was no consensus about what ‘normal’ meant. Positive aspects of mental health were described by the participants as good self-esteem, confidence [ 40 ], happiness [ 39 , 43 ], optimism, resilience, extraversion and intelligence [ 27 ], energy [ 43 ], balance, harmony [ 39 , 43 ], good brain, emotional and physical functioning and development, and a clear idea of who they are [ 27 , 41 ]. It also included a feeling of being a good person, feeling liked and loved by your parents, social support, and having people to talk with [ 27 , 39 ], as well as being able to fit in with the world socially and positive peer relationships [ 41 ], according to the children and youths, mental health includes aspects related to individuals (individual factors) as well as to people in their surroundings (relationships). Regarding mental illness, participants defined it as stress and humiliation [ 40 ], psychological distress, traumatic experiences, mental disorders, pessimism, and learning disabilities [ 27 ]. Also, in contrast to the normality concept describing mental health, mental illness was described as somehow ‘not normal’ or ‘different’ in Chisholm et al. [ 42 ].

Depression and bipolar disorder were the most often mentioned mental illnesses [ 27 ]. The inability to balance emotions was seen as negative for mental health, for example, not being able to set aside unhappiness, lying to cover up sadness, and being unable to concentrate on schoolwork [ 38 ]. The understanding of mental illness also included feelings of fear and anxiety [ 42 ]. Other participants [ 46 ] indicated that mental health is distinctly different from, and more clinical than, mental well-being. In that sense, mental health was described using reinforcing terms such as ‘serious’ and ‘clinical,’ being more closely connected to mental illness, whereas mental well-being was described as the absence of illness, feeling happy, confident, being able to function and cope with life’s demands and feeling secure. Among younger participants, a more varied and vague understanding of mental health was shown, framing it as things happening in the brain or in terms of specific conditions like schizophrenia [ 44 ].

Gender, age, socioeconomic status

Only one study had a gender theoretical perspective [ 40 ], but the focus of this perspective concerned gender differences in what influences mental health more than the conceptualization of mental health. According to Johansson et al.[ 39 ], older girls expressed deeper negative emotions (e.g., described feelings of lack of meaning and hope in various ways) than older boys and younger children.

Several of the included studies noticed differences in age, where younger participants had difficulty understanding the concept of mental health [ 39 , 44 ], while older participants used more words to explain it [ 39 ]. Furthermore, older participants seemed to view mental health and mental illness as a continuum, with mental illness at one end of the continuum and mental well-being at the other end [ 42 , 46 ].

Socioeconomic status

The role of socioeconomic status was only discussed by Armstrong et al. [ 28 ], finding that young people from schools in the most deprived and rural areas experienced more difficulties defining the term mental health compared to those from a less deprived area.

This scoping review aimed to map children's and youth’s perceptions and conceptualizations of mental health. Our main findings indicate that the concept of mental health is surrounded by uncertainty. This raises the question of where this uncertainty stems from and what it symbolizes. From our perspective, this uncertainty can be understood from two angles. Firstly, the young participants in the different studies show no clear and common understanding of mental health; they express uncertainty about the meaning of the concept and where to draw the line between life experiences and psychiatric conditions. Secondly, uncertainty exists regarding how to apply these concepts in research, making it challenging to interpret and compare research results. The shift from a positivistic understanding of mental health as an objective condition to a more subjective inner experience has left the conceptualization open ranging from a pathological phenomenon to a normal and common human experience [ 47 ]. A dilemma that results in a lack of reliability that mirrors the elusive nature of the concept of mental health from both a respondent and a scientific perspective.

“Happy” was commonly used to describe mental health, whereas "unhappy" was used to describe mental illness. The meaning of happiness for mental health has been acknowledged in the literature, and according to Layard et al. [ 48 ], mental illness is one of the main causes of unhappiness, and happiness is the ultimate goal in human life. Layard et al. [ 48 ] suggest that schools and workplaces need to raise more awareness of mental health and strive to improve happiness to promote mental health and prevent mental illness. On the other hand, being able to experience and express different emotions could also be considered a part of mental health. The notion of normality also surfaced in some studies [ 38 ], understanding mental health as being emotionally balanced or normal or that mental illness was not normal [ 42 ]. To consider mental illness in terms of social norms and behavior followed with the sociological alternative to the medical model that was introduced in the sixties portraying mental illness more as socially unacceptable behavior that is successfully labeled by others as being deviant. Although our results did not indicate any perceptions of what ‘normal’ meant [ 28 ], one crucial starting point to the understanding of mental health among adolescents should be to delineate what constitutes normal functioning [ 23 ]. Children and youths’ understanding of mental illness seems to a large extent, to be on the same continuum as a normality rather than representing a medicalization of deviant behavior and a disjuncture with normality [ 49 ].

Concerning gender, it seemed that girls had an easier time conceptualizing mental health than boys. This could be due to the fact that girls mature verbally faster than boys [ 50 ], but also that girls, to a larger extent, share feelings and problems together compared to boys [ 51 ]. However, according to Johansson et al. [ 39 ], the differences in conceptualizations of mental health seem to be more age-related than gender-related. This could be due to the fact that older children have a more complex view of mental health compared to younger children.. Not surprisingly, the older the children and youth were, the more complex the ability to conceptualize mental health becomes. Only one study reported socioeconomic differences in conceptualizations of mental health [ 28 ]. This could be linked to mental health literacy (MHL) [ 18 ], i.e., knowledge about mental illness, how to prevent mental illness, and help-seeking behavior. Research has shown that disadvantaged social and socioeconomic conditions are associated with low MHL, that is, people with low SES tends to know less about symptoms and prevalence of different mental health problems [ 19 , 21 ]. The perception and conceptualizations of mental health are, as we consider, strongly related to knowledge and beliefs about mental health, and according to von dem Knesebeck et al. [ 52 ] linked primarily to SES through level of education.

Chisholm et al. [ 42 ] found that the initial reactions from participants related to negative stereotypes, but further discussion revealed that the participants had more refined knowledge than at first glance. This illuminates the importance of talking to children and helping them verbalize their feelings, in many respects complex and diversified understanding of mental health. It is plausible that misunderstandings and devaluations of mental health and mental illness may increase self-reported mental health problems [ 5 ], as well as decrease them, preventing children and youth from seeking help. Therefore, increased knowledge of the nature of mental health can help individual cope with the situations and improve their mental well-being. Finding ways to incorporate discussions about mental well-being, mental health, and mental illness in schools could be the first step to decreasing the existing uncertainties about mental health. Experiencing feelings of sadness, anger, or upset from time to time is a natural part of life, and these emotions are not harmful and do not necessarily indicate mental illness [ 5 , 6 ]. Adolescents may have an understanding of the complexity of mental health despite using simplified language but may need guidance on how to communicate their feelings and how to manage everyday challenges and normal strains in life [ 7 ].

With the aim of gaining a better understanding of how mental health is perceived among children and youth, this study has highlighted the concept’s uncertainty. Children and youth reveal a variety of understandings, from diagnoses of serious mental illnesses such as schizophrenia to moods and different types of behaviors. Is there only one way of understanding mental health, and is it reasonable to believe that we can reach a consensus? Judging by the questions asked, researchers also seem to have different ideas on what to incorporate into the concept of mental health — the researchers behind the present study included. The difficulties in differentiating challenges being part of everyday life with mental health issues need to be paid closer attention to and seems to be symptomatic with the lack of clarity of the concepts.

A constructivist approach would argue that the language of mental health has changed over time and thus influence how adolescents, as well as society at large, perceive, talk about, and report their mental health [ 26 ]. The re-construction or adaptation of concepts could explain why children and youth re struggling with the meaning of mental health and that mental health often is used interchangeably with mental illness. Mental health, rather than being an umbrella term, then represents a continuum with a positive and a negative end, at least among older adolescents. But as mental health according to this review also incorporates subjective expressions of moods and feelings, the reconstruction seems to have shaped it into a multidimensional concept, representing a horizontal continuum of positive and negative mental health and a vertical continuum of positive and negative well-being, similar to the health cross by Tudor [ 53 ] referred to in Laidlaw et al. [ 46 ] A multidimensional understanding of mental health constructs also incorporates evidence from interventions aimed at reducing mental health stigma among adolescents, where attitudes and beliefs as well as emotional responses towards mental health are targeted [ 54 ].

The contextual understanding of mental health, whether it is perceived in positive terms or negative, started with doctors and psychiatrists viewing it as representing a deviation from the normal. A perspective that has long been challenged by health workers, academics and professionals wanting to communicate mental health as a positive concept, as a resource to be promoted and supported. In order to find a common ground for communicating all aspects and dimensions of mental health and its conceptual constituents, it is suggested that we first must understand the subjective meaning ascribed to the use of the term [ 26 ]. This line of thought follows a social-constructionist approach viewing mental health as a concept that has transitioned from representing objective mental descriptions of conditions to personal subjective experiences. Shifting from being conceptualized as a pathological phenomenon to a normal and common human experience [ 47 ]. That a common understanding of mental health can be challenged by the healthcare services tradition and regulation for using diagnosis has been shown in a study of adolescents’ perspectives on shared decision-making in mental healthcare [ 55 ]. A practice perceived as labeling by the adolescents, indicating that steps towards a common understanding of mental health needs to be taken from several directions [ 55 ]. In a constructionist investigation to distinguish everyday challenges from mental health problems, instead of asking the question, “What is mental health?” we should perhaps ask, “How is the word ‘mental health’ used, and in what context and type of mental health episode?” [ 26 ]. This is an area for future studies to explore.

Methodological considerations

The first limitation we want to acknowledge, as for any scoping review, is that the results are limited by the search terms included in the database searches. However, by conducting the searches with the help of an experienced librarian we have taken precautions to make the searches as inclusive as possible. The second limitation concerns the lack of homogeneous, or any results at all, according to different age groups, gender, socioeconomic status, and year when the study was conducted. It is well understood that age is a significant determinant in an individual’s conceptualization of more abstract phenomena such as mental health. Some of the studies approached only one age group but most included a wide age range, making it difficult to say anything specific about a particular age. Similar concerns are valid for gender. Regarding socioeconomic status, only one study reported this as a finding. However, this could be an outcome of the choice of methods we had — i.e., qualitative methods, where the aim seldom is to investigate differences between groups and the sample is often supposed to be a variety. It could also depend on the relatively small number of participants that are often used in focus groups of individual interviews- there are not enough participants to compare groups based on gender or socioeconomic status. Finally, we chose studies from countries that could be viewed as having similar development and perspective on mental health among adolescents. Despite this, cultural differences likely account for many youths’ conceptualizations of mental health. According to Meldahl et al. [ 56 ], adolescents’ perspectives on mental health are affected by a range of factors related to cultural identity, such as ethnicity, race, peer and family influence, religious and political views, for example. We would also like to add organizational cultures, such as the culture of the school and how schools work with mental health and related concepts [ 56 ].

Conclusions and implications

Based on our results, we argue that there is a need to establish a common language for discussing mental health. This common language would enable better communication between adults and children and youth, ensuring that the content of the words used to describe mental health is unambiguous and clear. In this endeavor, it is essential to actively listen to the voices of children and youth, as their perspectives will provide us with clearer understanding of the experiences of being young in today’s world. Another way to develop a common language around mental health is through mental health education. A common language based on children’s and youth’s perspectives can guide school personnel, professionals, and parents when discussing and planning health interventions and mental health education. Achieving a common understanding through mental health education of adults and youth could also help clarify the boundaries between everyday challenges and problems needing treatment. It is further important to raise awareness of the positive aspect of mental health—that is, knowledge of what makes us flourish mentally should be more clearly emphasized in teaching our children and youth about life. It should also be emphasized in competence development for school personnel so that we can incorporate knowledge about mental well-being in everyday meetings with children and youth. In that way, we could help children and youth develop knowledge that mental health could be improved or at least maintained and not a static condition.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Beckman, L., Hassler, S. & Hellström, L. Children and youth’s perceptions of mental health—a scoping review of qualitative studies. BMC Psychiatry 23 , 669 (2023). https://doi.org/10.1186/s12888-023-05169-x

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Resilience and mental health in children and adolescents: an update of the recent literature and future directions

Esther mesman, annabel vreeker, manon hillegers.

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Correspondence to Manon Hillegers, MD, PhD, Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children's Hospital, KP-2822/24, Wytemaweg 8, 3015 CN Rotterdam, the Netherlands. Tel: +31 10 703 62 13; e-mail: [email protected]

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This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Purpose of review

In order to promote optimal development of children and adolescents at risk for psychiatric disorders, a better understanding of the concept resilience is crucial. Here, we provide an overview of recent work on clinical and epidemiological correlates of resilience and mental health in children and adolescents.

Recent findings

Our systematic literature search revealed 25 studies that unanimously show that higher levels of resilience are related to fewer mental health problems, despite the heterogeneity of study populations and instruments. Correlates of resilience included multisystem factors, such as social, cultural, family and individual aspects, which is in line with the multisystem approach as described by recent resilience theories. Longitudinal studies are scarce but confirm the dynamical character of resilience and mental health. The application of longitudinal studies and innovative measurement techniques will improve our understanding on the cascade effects of stressors on resilience and mental health outcomes.

Resilience is strongly associated with mental health in children and adolescents and deserves a more prominent role in research, prevention programs and routine clinical care. Including social, cultural and family context in the evaluation of resilience is of great value, as this can identify targets for early and preventive interventions.

Keywords: children and adolescents, mental health, psychopathology, resilience

INTRODUCTION

Childhood adversity, parental psychopathology, bullying and significant threats are established risk factors for the development of psychopathology in children and adolescents [ 1 , 2 ▪ , 3 – 5 ]. However, the identification of risk factors does not necessarily lead to accurate prediction of psychopathology or adequate prevention. We argue that studies on emerging psychopathology should focus on factors that contribute to both risk and resilience. However, much less is known about factors that promote normative development or protect children and adolescents at risk for psychopathology. Insight into resilience and its modifiable clinical and epidemiological correlates in children and adolescents is important to inform clinicians and researchers on targets for preventive and early intervention strategies.

The purpose of this selected review is to provide an overview of recent work on resilience, its clinical and epidemiological correlates and mental health in children and adolescents. In part I we briefly describe the latest scientific insights regarding resilience and in part II we present a selected review of recent studies on resilience and mental health outcomes. We have conducted a systematic literature search (search period: January 2020–May 2021; for search strategy see Supplementary Material). Studies were included if they reported on resilience (measured with a resilience scale) [ 6 ▪ , 7 ]; mental health in children aged 0–18 years, clinical or epidemiological correlates of resilience and N at least 100. 

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PART I: RESILIENCE SCIENCE

Two recent reviews describe the emergence of current theories, models, methods and challenges in the field of resilience science in relation to mental health [ 8 ▪▪ ] and from a developmental perspective [ 9 ▪▪ ]. Accordingly, resilience is best defined as a multisystemic dynamic process of successful adaption or recovery in the context of risk or a threat. In essence, there are two main components of resilience: risk or threats to the person or system (e.g. maltreatment, natural disasters, mental illness in parents) and criteria by which successful adaption or recovery is evaluated (e.g. physical health or subjective wellbeing). Both authors argue that too often mental health studies on promotive or protective factors in relation to mental health and wellbeing focus on adaptive psychological systems alone, such as coping or self-regulation, without taking into account the instability of the different physical and social ecological systems, which is referred to as the multisystem approach [ 8 ▪▪ , 9 ▪▪ ]. For an example of these multiple systems in a developmental framework, we refer to Masten's shortlist of resilience in Table 1 . Additionally, apart from processes and systems of resilience at the individual, social and ecological level, also neurobiological processes, such as the hypothalamic–pituitary–adrenal axis system reflecting the biology of stress and self-regulation, are important.

Masten's shortlist of multisystem resilience factors

Reproduced with permission from Masten et al. [ 9 ▪▪ ].

Historically, assessment of resilience has been challenging. Early research focused on separate aspects of resilience, such as family support; however, an overarching concept was lacking. Current resilience measures reflect an aggregate of those aspects [ 9 ▪▪ ]; however, measures of resilience in children and adolescents are scarce [ 6 ▪ , 7 ]. Importantly, resilience is not simply the absence of psychopathology but a construct that reflects dynamic adaptation to adversity that can change over time [ 10 ]. This underscores the importance of longitudinal research. Advances in assessment methods [e.g. experience sampling methods (ESM)] and modelling (e.g. residualized approach [ 11 ], network modelling [ 12 ]) will improve our understanding of the cascade effects of a stressor in relation to resilience and mental health [ 9 ▪▪ ].

PART II: SYSTEMATIC LITERATURE SEARCH

Our systematic search resulted in 681 studies. In total, we included 25 original studies (see Table 2 ). We thematically organized studies based upon population or risk. There was heterogeneity in the assessment of resilience and study populations. Four studies had a longitudinal design. Only, two studies included children with a mean age below 12 years.

Overview of selected original studies

COVID-19, coronavirus disease 2019; NA, information not available.

General population

Five cross-sectional studies have investigated resilience in children and adolescents from the general population [ 13 ▪ , 14 ▪▪ , 15 – 17 ]. These studies showed that higher levels of resilience were related to depressive and/or anxiety symptoms. One study investigated the relationship between personality traits, resilience and depressive symptoms in 6019 high school students [ 13 ▪ ]. They found a moderating and mediating effect of resilience, and concluded that resilience may decrease the negative effect of neuroticism, and enhance the positive effect of extraversion, agreeableness and conscientiousness on depressive symptoms. Others investigated resiliency over multiple systems, such as family, school, peers [ 14 ▪▪ , 15 , 16 ]. Poorer quality in interpersonal relationships (with a parent, teacher, or peers) was related to mental health problems in children. Moreover, better interpersonal relationships were related to higher levels of resilience, which were related to fewer depressive symptoms [ 14 ▪▪ ]. Chung et al. [ 15 ] also found that living with a single parent was associated with lower resilience, which in turn was associated with higher levels of depression. Additionally, a study in 1473 high school students found that a construct of psychological capital (including hope, efficacy, resilience and optimism) buffered the influence of cumulative risk (an index of youth adjustment, family, school, peer and neighborhood aspects) on anxiety and depression symptoms but not life satisfaction [ 16 ]. Interestingly, a study in 456 high school students found that psychological capital was also positively related to flourishing. Furthermore, they found that the construct of psychological capital was a better predictor than the individual constructs, which shows the strength of combining different components that are related to resilience [ 17 ].

Adverse childhood experiences and negative life events

Nine cross-sectional studies and one longitudinal study examined resilience and psychopathology in the context of adverse childhood experiences (ACE) and negative life events [ 18 ▪ , 19 , 20 ▪ , 21 ▪ , 22 ▪ , 23 , 24 , 25 , 26 ▪ , 27 ]. Overall, these studies show that higher levels of resilience are associated with mental health.

Five studies demonstrated the importance of investigating different components of resilience – for example, individual, relationship with a caregiver and educational support – in relation to ACEs and mental health in children and adolescents [ 18 ▪ , 19 , 20 ▪ , 23 , 24 ]. A retrospective file review in 176 children referred to a Child Abuse Service [ 18 ▪ ] found that protective factors (individual items: personal skills, peer support and social skills; caregiver: physical and psychological caregiving; and context: educational support) moderated the association between adversity and trauma-related distress. Notably, children who were exposed to higher levels of adversity had fewer protective factors. Another study in 450 youth who had experienced trauma and came to a preventive care visit, observed an inverse relationship of resilience and trauma [ 19 ] and found lower levels of resilience, in particular, relationship with caregiver, to be associated with poor health outcomes (obesity, hypertension or depression). In the National Survey of Children's Health [ 20 ▪ ] in 40 302 children, absence of child emotional resilience and lack of family problem-solving skills and hopefulness in the family, were significantly associated with depression. These effects were stronger in children experiencing more ACEs. In contrast, a study among 440 adolescents focusing on trauma symptoms, adversity and a range of psychological and social strengths, found that sense of purpose was the only unique contributor to lower trauma levels [ 21 ▪ ]. Social strengths did not add to this association.

One study reported on childhood maltreatment, resilience and gender specifically [ 22 ▪ ]. They found that the moderating effect of resilience on emotional abuse and depression was stronger in girls than boys.

Two studies investigated resilience and school-related events. Zhao et al [ 21 ▪ ]. studied school-bullying in 742 adolescents, and found that interpersonal relationship risks (with parents, classmates and teachers) were associated with lower individual resilience and higher risk of being bullied and depression [ 23 ]. The second study investigated 278 drop-out students over a period of 4 years [ 25 ]. They showed a dynamic course of perceived social stigma, depression and ego-resilience levels. An increase of social stigma over time was associated with higher levels of depression and lower ego-resilience. Initial and changes over time in ego-resilience mediated the relation between social stigma and depression.

One study investigated negative life events (e.g. violence from grown-ups, catastrophes, death of someone close to you), depressive symptoms and resilience in 9546 adolescents [ 26 ▪ ]. Resilient factors – that is, goal orientation, self-confidence, social competence, social support and family cohesion – were independently of life events all negatively associated with depressive symptoms, illustrating a compensatory effect. Also, a protective effect was found for goal orientation and self-confidence by showing lower depressive symptoms in adolescents who reported more negative life events.

Last, one study investigated the relationship of resilience with coping strategies in the context of negative life evens. In 253 juveniles sent to educational centers by a family court [ 27 ], resilience significantly predicted coping strategies, in particular active coping and seeking support from others. In addition, the relationship between resilience and mental wellbeing was mediated by seeking support from others and coping through discharging negative emotions.

Although these studies on resilience after ACEs and negative life events differ greatly in instruments, study design, type of adversity and outcome measures, they demonstrate that resilience is indeed a complex multisystemic dynamic process.

Natural disasters

Five studies investigated resilience and psychopathology in children and adolescents who had experienced a natural disaster [ 28 ▪▪ , 29 ▪▪ , 30 – 32 ]. All studies showed that higher levels of resilience were related to fewer mental health problems. Two longitudinal studies will be discussed in detail [ 28 ▪▪ , 29 ▪▪ ]. In the first study, 246 adolescents were assessed 6, 9, 12 and 18 months after the Yancheng tornado [ 28 ▪▪ ]. Six to nine months after the disaster, a decline of resilience was reported, with a gradual increase after 9 months. Furthermore, individuals with lower levels of posttraumatic stress symptoms (PTSS) 6 months after the tornado reported higher levels of resilience. Individuals for whom the PTSS severity decreased more quickly in 6–12 months also reported more rapid increase in resilience in 9–18 months, which shows that resilience is dynamic and takes time. Recovery of PTSS was associated with a steeper increase of resilience. Looking at timing of recovery, changes in PTSS and resilience occurred just after restoration of schools and homes, underscoring the importance of the multisystemic approach. The second study investigated the relationship between self-esteem, resilience, social support and mental health in 1015 adolescents 2 years after the Wenchuang earthquake [ 29 ▪▪ ]. Self-esteem and common mental health problems had a mutual negative effect on each other, whilst self-esteem and resilience positively affected each other. Social support had a promoting effect on self-esteem and resilience and a buffering effect against mental health problems. Moreover the study illustrated that all these aspects fluctuated over time. Other cross-sectional studies found that maternal parenting styles were significant predictors of resilience after earthquake experiences [ 30 ]; a positive association between PTSS, creative thinking and resilience were possible manifestations of posttraumatic growth [ 31 ]. Moreover, one study found that resilience mediated the association between depression and risky substance use behavior after natural disasters [ 32 ].

Two cross-sectional studies reported on resilience in children and adolescents living in refugee camps [ 33 ▪ , 34 ]. One study illustrated that resilience among 106 children and adolescents in refugee camps was positively associated with perceived level of community support, spiritual, cultural and educational resources [ 33 ▪ ]. The authors underscore that in addition to a universal approach in resiliency programs, the context must be prioritized as well. Another study in 339 children and adolescents reported that higher levels of resilience were related to fewer symptoms of depression but that prior trauma was not associated with resilience [ 34 ], which may reflect the dynamic process of resilience.

Coronavirus disease 2019 pandemic

The coronavirus disease 2019 (COVID-19) pandemic is a global threat for public mental health. The pandemic exposes the underlying causes of insecurity, social and economic consequences, and thus challenges the multiple systems contributing to resilience [ 35 ]. Indeed, there appears a steep rise in mental health problems in youth [ 2 ▪ ]. Thus far, three cross-sectional studies have investigated resilience and mental wellbeing among children and adolescents during the pandemic [ 36 – 38 ]. An Italian study in 463 families during the first COVID-19 wave found a positive association between the child's resilience and wellbeing. Also more parental stress was related to lower levels of resilience in offspring [ 36 ]. Another study among 430 Chinese adolescents and the perceived impact of the pandemic showed both psychological distress and posttraumatic growth. Resilience and meaning in life served as protective factors for mental health [ 37 ]. Furthermore, in a study in 1488 Chinese teenagers, creative ideational behavior was positively related to intrusive rumination during the pandemic [ 38 ]. Interestingly, like Liang et al. [ 31 ], resilience and creativity were associated. In this study, the relationship between creativity and intrusive rumination was stronger in students with low levels of emotional resilience as compared with students with high levels of emotional resilience.

FUTURE DIRECTIONS

In this selected review, we discussed the recent literature on resilience, mental health and its correlates in children and adolescents up to 18 years old. Despite the heterogeneity between studies because of differences in instruments and study populations, all studies consistently show that higher levels of resilience are related to fewer mental health problems. Moreover, multiple factors, such as personal skills, social skills, peer support, school environment, contact with peers, parent–child relationship, family problem-solving, parental resilience, parental stress and goal orientation were related to resilience and demonstrate the importance of a multisystemic approach including social, cultural and family context in the study of resilience.

This review underscores that the construct of resilience is essential in the study of risk for psychopathology. However, the majority of the studies in this review were cross-sectional and did not measure resilience or psychopathology over time. As resilience is a dynamic process, longitudinal studies are essential [ 10 ]. Therefore, we argue that prospective studies on the influence of both risk and resilience in children and adolescents are needed.

The study of resilience can inform researchers and clinicians on targets for screening, intervention and preventive strategies. As higher levels of resilience are clearly associated with wellbeing in the child, and the context plays a significant role, we strongly encourage to incorporate the assessment of resilience in standard clinical care. Children and families with lower levels of resilience may be in need of other therapeutic support and more close monitoring compared with those with higher levels of resilience and a stable and supporting environment.

Over the past two decades, our research group has extensively studied intergenerational transmission of psychopathology in offspring of patients with severe mood disorders and psychotic disorders [ 1 , 3 , 39 ]. To advance our understanding of the development of psychopathology and to accommodate the growing need from clinicians and patients’ organizations for tools to promote resilience and increase wellbeing in children and adolescents, our mission has expanded from identification of risk factors of psychopathology to understanding how protective factors are related to wellbeing and daily life functioning. This has resulted in the development of new, online preventive intervention tools for children and adolescents at increased risk of psychopathology. An example of this is the Grow it! App, a gamified smartphone application, which monitors emotions, thoughts and behaviors in daily life (using ESM), and offers daily challenges using cognitive behavior therapy-based elements to promote adaptive coping. During the COVID-19 pandemic, Grow it! has been offered to individuals from the general population (aged 12–25 years) [ 40 ]. Currently, we are also studying the efficacy of this application in offspring of parents with mood disorders, and children with a chronic illness.

Resilience is a crucial aspect in the study of psychopathology in children and adolescents and should be studied in a multisystem approach, including individual, social, familial and cultural context. As resilience is a dynamic process that can change over time, there is a need for longitudinal studies that assess resilience and psychopathology in children and adolescents prospectively. An improved understanding of resilience factors might offer new targets both for clinical settings and for preventive and early intervention programs.

Acknowledgements

The authors would like to express their gratitude towards Sabrina Meertens-Gunput from the Erasmus MC Medical Library for developing the search strategy. We thank Fleur Helmink, MSc for her contributions to the manuscript.

Financial support and sponsorship

The current work was supported by the Netherlands Organization for Health Research and Development (ZonMw), project number: 606360098021 and 636320009.

Conflicts of interest

There are no conflicts of interest.

Supplementary Material

Esther Mesman and Annabel Vreeker shared first authorship.

Supplemental digital content is available for this article.

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Papers of particular interest, published within the annual period of review, have been highlighted as:

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A Systematic Review of Mental Health Literacy Measures for Children and Adolescents

• Systematic Review
• Published: 02 January 2023
• Volume 8 , pages 339–358, ( 2023 )

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• Matej Kucera   ORCID: orcid.org/0000-0003-3288-232X 1 , 3 , 4   na1 ,
• Hana Tomaskova 1 , 2 ,
• Marek Stodola 5   na1 &
• Anna Kagstrom 1  

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Mental health literacy is an essential part of preventing mental illnesses. However, the quality of mental health literacy measures remain unknown, as does its universality across various settings and populations. Few studies focus on measures aimed at assessing mental health literacy of children and adolescents that covers knowledge about mental health and mental disorders, strategies to decrease stigma, and enhancement of help-seeking efficacy. The present study aimed to conduct a systematic search to find available measures of mental health literacy of children and adolescents under the age of 19 years. The following databases were searched: Web of Science, PubMed, PsycINFO, MEDLINE, ERIC and CINAHL Plus. COSMIN checklist was applied to assess the methodological quality of each study. Twenty-one mental health literacy measures were identified in 18 studies. The quality of the studies ranged between very good and inadequate. Sixteen measures were universal, implying that they were not diagnostic specific. Two measures scored a full score of four on mental health literacy comprehensiveness. This review revealed that the overall quality of the measurement properties was mixed, that there are limited measures available to evaluate non-diagnostic-specific mental health literacy in universal populations of children and adolescents, and that measures fail to cover key mental health literacy components of knowledge of mental health, illness, stigma, and help-seeking. New measures should be developed to cover this gap in the field of child and adolescent mental health.

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This project is supported by EEA and Norway Funds Project: SUPREME Strengthening Universal Prevention, Resources, and Evaluation of Mental Health in Education, funded via the grant “Monitoring a posilování duševního zdraví dětí a adolescent,” grant number ZD-ZDOVA1-025. The funding bodies had no role whatsoever in the design of our program or study, methodology used, data collection, data analysis, data interpretation, or writing of this manuscript.

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Matej Kucera and Hana Tomaskova are first authorship.

Authors and Affiliations

National Institute of Mental Health, Topolová 748, 250 67, Klecany, Czech Republic

Matej Kucera, Hana Tomaskova & Anna Kagstrom

Department of Psychology, Charles University, Prague, Czech Republic

Hana Tomaskova

Second Faculty of Medicine, Charles University, Prague, Czech Republic

Matej Kucera

Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands

Faculty of Social Sciences, Charles University, Prague, Czech Republic

Marek Stodola

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MK participated in the design and study quality assessment, interpretation of the data, and helped draft the manuscript; HT participated in the study design, data management and extraction, and helped draft the manuscript; MS participated in data management and extraction and reviewed the manuscript; AK conceived the study, participated in its design and interpretation of the data, and helped draft the manuscript. All authors read and approved the final manuscript.

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Correspondence to Matej Kucera .

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This systematic review was registered in International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY), Registration number: INPLASY202290054, DOI number: https://doi.org/10.37766/inplasy2022.9.005 .

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Search strategy applied across the databases

Appendix II

Standards and measurement properties and its taxonomy based on COSMIN

Appendix III

Updated criteria for good measurement properties

Appendix IV

Methodological quality of each study on a measurement properties

• V very good, A   adequate, D   doubtful, I  inadequate

Rating of results in each study on measurement properties against the updated criteria for good measurement properties

• + sufficient, ? indeterminate”, – insufficient, ± inconsistent

Appendix VI

MHL comprehensiveness across the scales

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Kucera, M., Tomaskova, H., Stodola, M. et al. A Systematic Review of Mental Health Literacy Measures for Children and Adolescents. Adolescent Res Rev 8 , 339–358 (2023). https://doi.org/10.1007/s40894-022-00202-8

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Optimising child and adolescent mental health care – a scoping review of international best-practice strategies and service models

• Reinhard Jeindl 1 ,
• Viktoria Hofer 1 ,
• Christian Bachmann 2 , 3 &
• Ingrid Zechmeister-Koss 1  

Child and Adolescent Psychiatry and Mental Health volume  17 , Article number:  135 ( 2023 ) Cite this article

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Psychiatric disorders are among the most common health problems in children and adolescents, with a recent prevalence rise due to the COVID-19 pandemic. The increasing demand for service provision in this patient population, together with infrastructural, financial and staff limitations in child and adolescent mental health services, calls for an adaptation/advancement of current models of service provision. This review offers an internationally informed overview of best-practice child and adolescent mental health (CAMH) strategies and care models, with the aim of assisting decision-makers in implementing topical CAMH care models.

Using a pre-defined structured search strategy, we aimed to identify core topics within published CAMH strategies and care model documents from seven countries within the Global North, which represented a range of differing healthcare systems, geographical regions, and public health traditions. From the retrieved documents, we then systematically extracted data in an iterative process, and summarised these narratively by applying qualitative content analyses.

Our search retrieved the following key components of CAMH strategies: awareness-raising activities, prevention/promotion, detection, treatment, telemedicine, care pathways, transitional psychiatry, vulnerable patient groups, user participation, infrastructure, workforce development, implementation, digital case management tools, and data acquisition/research. Recommendations for CAMH care organisation often followed a public mental health approach, with a focus on mental health promotion, cross-sectional organisation, and funding of CAMH care services. As key principles of best-practice CAMH care models, we identified increased flexibility of care settings, early intervention, and a strengths-oriented approach, with overarching mental health services research alongside.

In order to design robust models of CAMH care and to mitigate current shortcomings, actions on the policy level (e.g., CAMH strategy development with a focus on mental health promotion, installation of cross-sectoral governance), at the organisational level (e.g., re-organisation of treatment settings and pathways of care) and at the individual level (e.g., user involvement, workforce development) are recommended. To this purpose, we strongly advocate the use of cross-sectoral and participatory approaches for CAMH care structures with accompanying health services research.

Central message

Cross-sectoral, participatory approaches, which focus on the educational sector as well as on prevention and workforce development strategies, have a great potential to improve the mental health of children and adolescents.

Mental disorders are one of the most common conditions among children and adolescents worldwide, with a prevalence between 9 and 22% [ 1 ]. The mental health of children and adolescents was further affected substantially by the COVID-19 pandemic, with a significant reduction in health-related quality of life and a greater extent of depressive symptoms, anxiety and stress reactions [ 2 ]. The increasing need for care in this group of patients, with concurrent staffing and infrastructural limitations in child and adolescent psychiatric care, leads to considerations to adapt current models of care provision and delivery.

In this study, we aim to provide an overview of international child and adolescent mental health (CAMH) care strategies and models (e.g., identifying elements of care, coordination, professional groups involved, comprehensive mental health strategy). Mental health care may include prevention, treatment, rehabilitation, diagnostic services, and other types of support. Effectiveness analyses of individual care components, or an assessment to what extent recommendations are already implemented in different countries, are not within this paper’s scope. Our results should support decision-making in the further development of CAMH care structures.

Literature search of national strategies

Between April and June 2022, we conducted a structured hand search for national strategies and models addressing CAMH care and prevention in the following online resources and databases: websites of national ministries of health, websites of national public health institutions, Google (Scholar), World Health Organization MiNDbank [ 3 ], Europe encyclopedia of National Youth Policies YouthWiki [ 4 ]. For the literature search, various keywords relating to CAMH were combined with the respective country as well as with relevant keywords such as strategy, model, care pathway, prevention.

Selection of countries and national strategies

For this scoping review, we tried to capture a broad variety of CAMH care strategies and models. We tried to achieve this by aiming for at least one country representing each European region (according to the UN Geoscheme for Europe [ 5 ]) and by representing countries with different health care systems and public health traditions. At the same time, we took into account transferability of the findings to the Austrian system (rationale: the original results were of particular interest for Austrian decision makers). This was done by restricting countries to those from the Global North and within them, selecting countries with the highest Human Development Index (HDI), 2020 report [ 6 ]. Considering this transferability, we excluded Asian countries due to the differences in health care systems and societal culture. Further, only countries who had documents available in English or German language and with a minimum population size of 5 million inhabitants were considered. This combination of criteria led to a set of six countries: Australia, Switzerland, Czechia, Spain, Norway, and the United Kingdom. In addition, Germany was included due to its proximity to Austria and high comparability of the health systems. The final set of selected countries is depicted in Fig.  1 . Regarding the selection of documents within countries, the primary sources were national documents. If no national document was available, a limited number of regional documents were included. It was not the aim of our review to present a comprehensive country overview in quantitative terms (e.g., describing frequencies of certain characteristics of CAMH care models) but rather to capture the diversity and types of concepts.

Countries selected for the analysis of child and adolescent mental health care strategies and models

Abbreviations: AU – Australia; CH – Switzerland; CZ – Czechia; DE – Germany; ES – Spain; NO – Norway; UK – United Kingdom

Document selection, data extraction and analysis of national strategies

From the literature search, we identified 128 national references. From these, we included national documents that describe a strategy or model of care specific for CAMH. In case no such specific document was available, we included a general mental health strategy or model that has a subchapter for children and adolescents. We excluded documents that were indication specific (e.g., depression, substance abuse, suicide). Further exclusion reasons were evaluation documents, surveys, situational analyses, or information campaigns.

We then prepared data extraction tables (available upon request) for each of the selected documents, deciding iteratively which information to extract. This process resulted in 14 topic areas for which we extracted information from the documents: information activities, prevention/promotion, detection, treatment, telemedicine, care pathways, transitional psychiatry, vulnerable patient groups, user participation, infrastructure, workforce development, implementation, digital tools for case management, and data acquisition/research. If available, we also extracted the documents’ key principles as well as conclusion sections. After all 14 topic areas were extracted from the documents, we reached our conclusion to the strategies by reviewing the findings and identifying patterns through qualitative content analyses.

For quality assessment of the included documents, we used an adapted version of the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument [ 7 ]. This tool was used to assess six domains: scope & purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. The process steps of quality assessment and data extraction were carried out by one researcher (RJ) and controlled by a second researcher (VH). In the process of adapting the preliminary categories for data extraction, a third researcher (IZ) was consulted for advice.

Included national strategies

We included twelve relevant documents [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ] from seven countries, published between 2013 and 2022, for our analysis of CAMH strategies and models. Table  1 gives an overview of included documents per selected countries.

Key principles

All included documents stated key principles on which CAMH services should be based. While these varied broadly across countries, most often mentioned key principles were to increase the focus on prevention, early detection/intervention (including efforts to improve mental health literacy), improved coordination and that CAMH services should be evidence-based including the need for more mental health services research. Additional key principles were to strengthen participation, to take special treatment needs into account, and to establish low-threshold services that are culturally sensitive and needs-based.

The general style of the documents differed in some regards. While some documents were rather strategic (Czechia, Germany, Spain), others were describing concrete models (Australia, Norway, United Kingdom) or a combination of both (Switzerland). Some documents explicitly provided an evidence base for each recommendation (e.g., Czechia, Norway), while others gave more jurisdictional context (Switzerland, Germany). One document in particular followed a thorough participatory approach, with the foreword of the document directed at children and adolescents in easy-to-understand language (United Kingdom).

Topic areas in included documents

The majority, but not all of the 14 topic areas were described in each of the included documents. The document from Czechia addressed the fewest number of topic areas, while Australia and Spain were the only countries addressing all topic areas. Table  2 gives an overview which topic areas were described in the included documents.

Information activities, prevention/promotion, detection

All countries recommend information and awareness raising activities to increase health literacy and reduce stigma. Several distribution channels (traditional and social media), targeting children, adolescents, carers, and less often professionals, are recommended. For strengthening mental health promotion and illness prevention, the focus is on increasing early help-seeking, and improving interpersonal relationships (e.g., reducing violence and improving respectfulness). One key target group of these activities are parents with a mental illness, as there is rising awareness of the negative impact parental mental illness can have on children. One recommendation in this area is to introduce specialised programmes aimed at developing parenting skills, especially for families under psychosocial stress, in order to reduce the risk of traumatisation of children. Another recommendation is to increase care for these affected families, to counteract the existing disadvantages. The key setting of promotion and prevention activities is within schools. Similarly, the recommended core setting for screening and early detection in the documents is the school environment, involving different professionals (e.g., school health nurses).

Treatment, telemedicine, care pathways, transitional psychiatry

Regarding treatment, the necessity to broaden the range of settings is highlighted, ranging from home-treatment, inpatient-equivalent treatment and other outreach approaches, to inpatient treatment. To allow family-focused care, alternatives to hospital care are described as important. As for medication, the need to improve safety by installing measures to reduce the wide off-label use is emphasised. Suggestions on the mode of care delivery include telehealth and face-to-face approaches in single- and/or group settings. The increased use of digital applications is mainly recommended for detection, self-care, and better system navigation. Australia has defined the expansion of telehealth tools as a priority activity, however, with funding extensive evaluation research alongside.

Suggestions on care pathways and integrated care play a prominent role aiming at integrating services across different sectors, such as health and education. A key suggestion is to establish a single point of access and to provide a coordinator for each patient/family. The pathways to access hospital care should be clearly defined and linked to quality indicators monitoring waiting times or “no shows”. The care pathways are recommended to be in line with the different developmental stages throughout child and adolescence, e.g., which service networks and interventions are required at each stage of development. For better management of transitional phases (e.g., when entering schools, or from adolescent to adult psychiatry), a shared recommendation is to move away from age thresholds to needs-based transitions depending on developmental stages, including extending ages for transition into adult mental health care up to 25 years.

Vulnerable patient groups, user participation, infrastructure

A broad number of especially vulnerable groups, at greater risk for developing a mental illness and often requiring complex care arrangements, have been identified across all documents. These include culturally and linguistically diverse groups. Measures to better and routinely detect circumstances that make a child vulnerable and installing a lead professional for case management (shifting the responsibility for coordination from the family to the professionals) are recommended. Further, an additional re-distributing of resources to better care for these vulnerable children and adolescents are suggested. These resources are recommended to cover interpreter services, additional time, personnel, and material resources, developing social and emotional wellbeing services for diverse populations, and appropriate referrals to specialist mental health services. Another topic described across most documents is strengthened user participation. The aim is to provide more tailored care and better navigation in care pathways, by involving users in both individual care planning but also in the systemic design processes of the services.

Regarding infrastructure and resources, the countries recommend infrastructure to be accessible and culturally safe. For financing, an increase in budget is required for interprofessional collaboration, psychotherapy and psychoeducational programmes, and for policies aimed at preventing inequality in youth. Examples are ring-fenced budgets jointly provided by the health, social and educational ministry. Additionally, new reimbursement mechanisms for providers are suggested to fund a combination of outpatient services for children with complex needs.

Workforce development, implementation, digital tools, data acquisition/research

The workforce qualification and professional development is another topic area described across most documents. Most countries suggest broadening the traditional health workforce with additional workers (e.g., allied health specialists, family therapists, diverse and LGBTIQ + health workers, peer support workers). A specific highlight is put on developing the competences of school teaching staff (led by mental health specialists), as well as implementing a designated wellbeing staff member in all schools. For the implementation strategy and process, some countries created inter-ministerial/cross-sectional committees, with individual responsibilities from managers of health centers, school health services and municipalities. To guide implementation, it is recommended to identify what is working in some regions and rolling it out to the whole country, with phases of implementation described as an establishment phase, an embedding phase, and a full operational phase.

Almost all countries recommend increasing data acquisition and research with the aim of monitoring changes in mental disorder prevalence and effects of interventions. A broad range of specific research topics and study designs are listed, including (cross-sectoral) mental health service research allowing benchmarking of services (e.g., waiting times and user satisfaction). Several countries are in the process of implementing national mental health services datasets for data acquisition and sharing across relevant sectors. Most countries further suggest increasing the availability of digital tools for case management (e.g., tools to facilitate clinical decision making and cross-sector video conferences) and documentation (e.g., continued development of trans-organisational electronic patient record systems).

Establishing a child and adolescent mental health strategy

Drawing inspiration from the recommendations in international CAMH strategies and models, the following Fig.  2 may serve as a starting point for health policy discussions on establishing and further adapting a stand-alone CAMH strategy. In this guiding principle, the importance of a participatory design approach is emphasised. Further, health services research plays a central role for the depicted components (current status analysis, development of a mental health strategy, operationalisation, implementation, and evaluation).

Guiding principles for a stand-alone child and adolescent mental health strategy

Quality assessment

The assessment of the overall quality of the documents ranged from 62 to 95%. Reasons for lower ratings were, among others: the views and preferences of the target population were not always included, the target users of the documents were not always clearly defined, and no application of systematic methods to search for evidence, and the recommendations were not always explicitly linked to supporting evidence (see Table  3 ).

Main findings

We found that all countries included in this report advocate a public mental health approach that is characterised by encouraging mental health promotion and prevention. For this aim, the educational sector is essential and should be supported with additional staff and mental health training for educators. In this cross-sectoral approach, in terms of professionals involved and their responsibilities, CAMH is shifting from a psychiatry-focused (more medical-oriented) model to multi-professional teams with shared responsibility and equal contributions from different professional groups.

Interpretation

Mental health policies are a logical first step in recognising need for care and prevention, and subsequent programme development. Mental health policies are guides for actions, such as programme development, financing, and access to care [ 20 ]. In this context, all the countries selected for our analysis have a general mental health strategy and, in the majority, additionally a CAMH strategy and a suicide prevention strategy exists. For adopting CAMH services, the documents suggest that prevention and care should be based on the needs of children and their families, rather than on the existing care structures. This needs-based approach increases the relevance of user participation and involvement, focusing on special support for vulnerable groups, and through creating structures within CAMH services that promote coordination of services according to individual needs (e.g., single points of access, coordinators for improved system navigation).

Based on the recommendations from the national documents, a CAMH strategy with a common vision and shared goals, integrating mental health promotion, illness prevention and mental health care across relevant sectors (health, social care, education, and criminal justice) is advisable. In particular, strengthening the outpatient area (e.g., home-treatment services) to overcome hospital bed and psychiatrist shortage, as well as informal care offers in flexible settings with improved care pathways is essential. This extension would also be more in line with the optimal mix of mental health services as recommended by the World Health Organization. A CAMH strategy needs to be linked with other existing strategies (e.g. child and adolescent health strategy). An aspect that was barely mentioned in the included documents is the role of perinatal and infant mental health. However, when designing a CAMH service, insights from perinatal and infant mental health care models and pathways can inform care models in the older ages [ 21 ]. The need for increased focus on vulnerable patient groups becomes evident when considering recent research findings, such as the multinational EU-GEI study. In this study, social vulnerability due to migration (and post-migration experiences) was associated with double the odds of psychosis in first-generation migrants [ 22 ]. An ideal CAMH service addresses the issues of culturally and linguistically diverse groups, by putting increased focus on these vulnerable patient groups. Interpretation services are important, but additional measures addressing this patient group are also required. These include promoting respect and reducing stigma towards social minority groups, and increasing adolescents’ empathy and tolerance towards what is different and diverse. For this purpose, measures are called for to reduce inequalities, such as redistribution of existing therapeutic resources towards psychosocial and/or economically challenged families.

Furthermore, the recommendations from the national documents are in accordance with the results from the ROAMER project (ROAdmap for MEntal health Research in Europe). The defined priorities regarding public mental health from an expert consensus fall in three overarching goals: to identify causes, risk and protective factors for mental health across the lifespan; to advance the implementation of effective public mental health interventions; and to reduce disparities in mental health [ 23 ].

A particular role in further improving CAMH is within the educational sector. While a comprehensive integration of mental health and mental disorder topics in the teaching content is recommended, additional school staff (e.g., well-being staff) and further development of the mental health competences for school teaching staff, guided by mental health specialists, is a key recommendation in the included documents. The school setting is essential for information activities and reduction of stigma, and to further achieve the goal of an open-minded and strengths-based (rather than deficit-oriented) approach to mental health, focusing on child’s functioning (rather than on the diagnosis). School-based interventions for CAMH can yield moderate to strong effects for a range of emotional and behavioural problems when implemented with evidence-based cognitive behavioural interventions [ 24 ]. Regarding adolescents at risk of suicide, mental health literacy programmes in the school setting (such as the Teen Mental Health First Aid) aim to increase recognition and support towards affected peers [ 25 ].

The recommendations in the documents are not always supported with evidence and implementation requirements. For example, it is unclear if there are any drawbacks to moving away from age as a transition criterion and what the training requirements of implementing the suggested approach would be. Current research projects, for example the preparation of a clinical research facility for transitional psychiatry in Austria [ 26 ], could provide the basis for implementation studies or outcome studies of such an adapted model of care.

Furthermore, the countries recommend additional health service research, implementing a national mental health dataset for coordinated data acquisition and increasing the availability of digital tools for management and documentation. In this context, indicators for planning CAMH services and monitoring CAMH can be utilised to create a better way of dealing with current shortcomings in care and prevention [ 27 , 28 ]. A report from the United Nations Children’s Fund (UNICEF) highlights that routine monitoring of mental health and mental healthcare is seriously lacking, especially for CAMH [ 29 ]. As part of our own research, a collection of internationally identified indicators covering the broad spectrum of mental health (such as risk factors, prevention and promotion factors, life satisfaction, supply and utilization of services, quality of care, and sociodemographic indicators) is publicly available [ 30 ]. It may serve as a starting point for defining core-indicator sets.

Limitations

For identifying data in our study, we used a targeted hand search (instead of a systematic literature search). We expected that CAMH care models and strategies are usually not published in scientific journals, but rather as grey literature on relevant websites (e.g., ministerial, or public health). As other authors might have identified a different set of documents for analysis, our research findings are not fully reproducible. In addition, we were only able to consider a selection of countries based on the HDI as an indicator. As the HDI combines three dimensions we considered it a better fit for our study purpose compared to other indicators, such as gross domestic product (GDP). However, other indicators could have also been used for country selection.

Further, excluding Asian countries is a limitation, as there are Asian countries with a higher HDI rank than those included in our study, with healthcare systems comparable to western systems (such as Japan or Singapore). Due to the selection strategy, and to the literature search being limited to June 2022, there is a possibility that other (or novel) CAMH policies or models exist that are not included in our study. Furthermore, we did not collect data on the extent to which the strategies have already been implemented in the selected countries.

We excluded documents addressing specific indications (e.g., medical guidelines), general health (instead of specific to mental health), or all ages (instead of specific to children and young people). These excluded documents might contain some supplementary information.

Furthermore, when extracting data from the documents, the information on the identified topic areas could not always be clearly assigned to the identified categories due to overlaps. Many aspects of mental health are intertwined, and although we have tried to match them carefully with the topic areas, there may have been alternative ways of assignment.

Based on our findings, we strongly advocate the use of cross-sectoral and participatory approaches for CAMH care structures. The involved sectors (health, education, social and youth justice) should integrate mental health promotion, prevention and care in a shared vision. For this purpose, health service research should accompany the strategic developments, aiming to create better ways of dealing with shortcomings in care in general, and for vulnerable patient groups specifically.

Data Availability

The datasets generated and/or analysed during the current study can be made available from the corresponding author upon request.

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Acknowledgements

The authors thank Smiljana Blagojevic, Dipl.-Ing. for the descriptive visualisation of all figures.

The work was conducted as part of the work program of the Austrian Institute for Health Technology Assessment, which is funded by the public payers of the Austrian health care system.

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Reinhard Jeindl, Viktoria Hofer & Ingrid Zechmeister-Koss

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RJ: conception or design of the work; acquisition, analysis, and interpretation of data for the work; drafting the work and writing the main manuscript text; preparation of figures and tables; final approval of the version to be published. VH: conception or design of the work; acquisition, analysis, and interpretation of data for the work; revising the figures and tables; final approval of the version to be published. CB: revising the text, figures and tables critically; final approval of the version to be published. IZ: conception or design of the work; analysis and interpretation of data for the work; preparation of figures and tables; revising the text, figures and tables critically; final approval of the version to be published. All authors reviewed the manuscript.

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Jeindl, R., Hofer, V., Bachmann, C. et al. Optimising child and adolescent mental health care – a scoping review of international best-practice strategies and service models. Child Adolesc Psychiatry Ment Health 17 , 135 (2023). https://doi.org/10.1186/s13034-023-00683-y

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• Child and adolescent mental health
• Child health services
• Adolescent health services
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• Prevention and care models
• Child and adolescent psychiatry
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• Child and adolescent mental health services
• School mental health services

Child and Adolescent Psychiatry and Mental Health

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Associations between ethnicity and mental health problems among children and adolescents in the United Kingdom: A systematic review and narrative synthesis

• Shengjia Guan 1 ,
• Barry Coughlan 1 ,
• Kate Evans 1 &
• Robbie Duschinsky 1  

BMC Public Health volume  24 , Article number:  3267 ( 2024 ) Cite this article

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Metrics details

The associations between ethnicity and mental health problems (MHPs) among children and adolescents in the UK have been reported in recent years. However, this is the first review to compare and synthesise these associations and provides a deep understanding of child MHPs across ethnic groups in the UK.

A comprehensive literature search across seven electronic databases and fifteen websites was conducted. The inclusion criteria focused on studies reporting quantitative associations between ethnicity and MHPs for children and adolescents aged 0–19 residing in the UK. Given the high heterogeneity of the studies, a narrative synthesis was adopted to analyse the associations.

Twelve studies met the inclusion criteria, involving a total of 48,281 participants. The review reports no significant differences in the risk of experiencing general MHPs among children from Indian, Pakistani, Bangladeshi, and Black Caribbean groups compared to their White British counterparts. However, Black African children were less likely to develop general MHPs, while children in the Pakistani, Bangladeshi, and Black Caribbean groups showed a higher risk for internalising problems. Externalising and conduct problems were similarly likely among children from Pakistani and Bangladeshi backgrounds compared to White children, with Black Caribbean children showing a higher likelihood of these issues.

The findings suggest that most ethnic minority children and adolescents in the UK have comparable risks of MHPs to their White counterparts, although specific risks vary by ethnicity and MHP types. The results underscore the need for multifaceted analyses considering socioeconomic and cultural factors, beyond simple ethnic categorisations, to inform mental health services that effectively meet the diverse needs of the UK’s child population. This review calls for more detailed and uniform categorisation in future research to understand and address the mental health disparities across different ethnic groups.

Peer Review reports

With the increasing diversity of the UK population [ 1 ], some research suggests that the mental health of children and adolescents from ethnic minority groups may be shaped by complex and multifaceted factors, leading to varied associations between ethnicity and mental health problems (MHPs). Studies by Zilanawala et al. [ 2 ] and Platt [ 3 ] suggested that children of Pakistani families are at a higher risk of experiencing mental health difficulties compared to White peers, while Amhad et al. [ 4 ] reported a lower risk. In addition, the influence of potential confounding factors on the associations appears to be complicated. Midouhas [ 5 ] reported that children of Bangladeshi communities are less likely to suffer from externalising problems when adjusted for pupil-level free school meals (FSMs), child characteristics, and family-related factors. Conversely, Karamanos et al. [ 6 ] reported a higher likelihood of experiencing these problems with increasing PM2.5 pollution levels. These intricate associations underscore the significance of understanding nuanced ethnic differences to effectively monitor mental health inequalities. Given the complex and conflicting associations presented in the studies above, this review seeks to determine whether these findings are consistently reflected across the wider body of literature.

However, efforts to synthesise the existing evidence and identify overarching patterns are made challenging due to the equivocal and fragmented nature of the evidence. Firstly, MHPs are diverse. Some studies have used broad and umbrella terms such as ‘mental illness’ and ‘mental health difficulties’ to describe general MHPs [ 7 , 8 ], while others have focused on more specific mental issues, such as externalising problems, internalising problems, self-harm, and psychosis [ 7 , 9 , 10 , 11 , 12 ]. Secondly, the categorisation of targeted ethnic groups is inconsistent across studies. Some researchers have used dichotomies to divide the general population into two ethnic groups: White British and ethnic minority groups [ 11 , 13 ]. Other research, however, has investigated child mental health across multiple ethnic groups within a single study and used varying levels of ethnic categorisation. For example, Patalay and Fitzsimons [ 7 ] used five high-level ethnic categories: White, Asian, Black, Mixed, and Other. Astell-Burt et al. [ 14 ] offered six more detailed ethnic groupings in their analysis: White British, Indian, Pakistani and Bangladeshi, Black Caribbean, Nigerian and Ghanaian, and Other African.

The fragmented state of the literature has been further highlighted by the limited scope of systematic reviews in this area. This review focuses exclusively on studies conducted in the UK due to the UK’s specific ethnic distribution [ 1 ] and its unique healthcare system [ 15 ], which differ significantly from other countries such as the US [ 16 ] and Australia [ 17 ]. As a result, extending the scope to international studies would not provide applicable evidence for this review. So far, the systematic review by Goodman et al. [ 18 ] in 2008 is the only work to date that investigates child mental health differences among ethnic groups in the UK. The review synthesised semi-structured descriptive results from relevant studies spanning 1972 to 2007. The authors concluded that children from ethnic minorities tended to show a comparable or lower prevalence of MHPs relating to internalising and externalising problems compared with White British children but a higher prevalence for certain specific disorders such as self-harm.

Over a decade has passed since Goodman et al.’s review, and with new research on the topic emerging, there is a need for a new systematic review to synthesise the current evidence and address the identified research gaps. Such a review is essential for researchers, policymakers, and practitioners to understand the complex links between ethnicity and child MHPs in the UK.

This systematic review is motivated by the following research question: what are the associations between ethnicity and MHPs among children and adolescents in the UK? If the review reveals significant associations between certain ethnic minority groups and mental health issues, it could inform targeted services and thus promote equitable mental health outcomes across ethnicities. Conversely, a finding of few or weak associations would suggest that universal, rather than ethnicity-specific, mental health services are sufficient to meet the needs of British children. Thus, the findings of this review have the potential to directly influence policy and healthcare provision strategies.

Search strategy

We conducted a comprehensive literature search in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [ 19 ]. Searches of Title/Abstract and subject index headings were run in seven electronic databases (including MEDLINE via Ovid, APA PsycINFO via ProQuest, Embase, PubMed, Web of Science, Scopus, and Applied Social Sciences Index and Abstracts (ASSIA) via ProQuest) and fifteen websites (see Additional file 1 ). Terms related to (a) population of interested age groups (e.g. “child*” and “adolescen*”), (b) population of interest by ethnicity (e.g. “ethnic*”, “race”, and “immigra*”), (c) location of interest (e.g. “UK”, “Britain”, and “England”), (d) mental health outcomes (e.g. “mental health”, “internalising problems”, and “PTSD”), and (e) mental health services (e.g. “CAMHS” and “mental services”) were combined (see Additional file 1 ). Searches were conducted in November 2022. Large epidemiological population-based studies and surveys, which might include relevant information, were also searched. Backward citation tracking (i.e. identifying studies that cited articles of interest) and forward citation tracking (i.e. scanning reference lists of included studies) were also conducted to include potentially eligible literature.

Inclusion and exclusion criteria

Studies were considered eligible for inclusion if:

they reported quantitative data on mental health outcomes (i.e. effect sizes of the associations), and results were related to participants’ mental health, either in umbrella terms (e.g. “psychological well-being” and “mental health difficulties”) or in specified diagnoses (e.g. conduct problems, behavioural disorders, psychosis, eating disorders, suicide, and self-harm);

their samples contained children and/or adolescents aged 0–19 years residing in the UK. The upper age limit aligns with the definition provided by the World Health Organization (WHO) [ 20 ] and the UK’s National Health Service (NHS) [ 21 ]. This age range is consistent with a previous systematic review focusing on children’s mental health in the UK [ 18 ];

at least two categories of ethnic groups were included, with one being White or White British. This unified approach allows for synthesising data from multiple studies to compare the outcomes of each minority ethnic group with those of the White/White British population;

mental health conditions were measured using validated tools (e.g. the Strengths and Difficulties Questionnaire [SDQ], a structured 25-item questionnaire used to screen for symptoms of childhood emotional and behavioural psychopathology [ 22 ]), clinical interviews or questionnaires, or by referrals to or admissions into child mental health services (e.g. CAMHS).

Studies were excluded if they:

exclusively targeted the adult population or did not present subgroup analysis results for participants aged 19 and under;

focused exclusively on selected at-risk groups of children and/or adolescents, such as homeless youth or those in child protective services custody, juvenile detention facilities, or foster care; this criterion is applied because the goal of the review is to provide a broader and more representative understanding of the general UK population;

Were case studies, commentaries, or editorials

involved participants with a primary diagnosis of physical illnesses – such as cystic fibrosis or cancer – other than MHPs;

targeted a population with pervasive or circumscribed developmental disorders, such as autism, language development disorders, or an intelligence disability.

Study screening

A total of 1804 citations were initially searched across the aforementioned databases and websites. Additionally, the reference lists of included articles and literature citing included articles were manually searched for additional relevant publications. Of these, 691 duplicates were removed using EndNote 20 and through manual comparisons. Two reviewers (SG and KE) screened the titles and abstracts of the first 200 articles together. The remaining 879 citations were screened independently. Disagreements regarding five articles were resolved through discussion and consultation with RD and BC. Overall, 12 records were deemed eligible for inclusion in this review (see Fig.  1 for the PRISMA flow diagram).

PRISMA 2020 flow diagram for the systematic review

Data extraction

Data extraction was performed by SG and KE using a pre-determined data extraction table (see Additional file 2 for more details). These authors collaboratively extracted data from two randomly selected studies, resolving discrepancies through conversation before independently extracting data from the rest of the studies. The information extracted involved study characteristics (e.g. study design, participants’ demographics, data collection/source, ethnicity assignment, mental health outcome(s), outcome measure(s), analysis method, and results of interest). The methodological limitations listed in the Additional file 2 were derived from a previous systematic review on a similar topic by Goodman et al. [ 18 ]. Discrepancies in data extraction were resolved through discussion with RD and BC to achieve consensus.

Quality assessment

The Critical Appraisal Skills Programme (CASP) cohort study checklist [ 23 ] was used to appraise the quality of the studies included in this review. This checklist provides 12 questions to assess study quality (see Additional file 3 for the checklist template). The first three items serve as screening questions, while the remaining nine offer a framework for assessing the study’s results, validity, and relevance. Due to this review’s primary focus on exploring the associations between ethnicity and MHPs, question 6, ‘ Was the follow-up of subjects (a) complete enough and (b) long enough? ’ was removed from the checklist. The CASP checklist does not provide a scoring system to appraise the quality of evidence. Qualitative quality rating criteria were established by SG (see Additional file 4 in appendices) based on hints provided in the checklists and the specific research question of this review. RD reviewed the criteria regarding their suitability and feasibility.

The quality assessment was independently conducted by SG and subsequently reviewed by RD; uncertainties were resolved through discussion. It is important to note that the CASP assessment was not used to exclude or weight any of the included studies; however, the assessment results (see Table 1) informed the data synthesis and the interpretation of findings.

Data synthesis

High heterogeneity was observed across the studies, including various categories of MHPs, different assignments for ethnic groups, inconsistent measures of MHPs, different age ranges of the population, different types of models (i.e. base models and adjusted models) in statistical analysis, and different confounds across models. Such heterogeneity was not intended as a quantitative measure of effect size variability but rather as a qualitative judgement of the methodological heterogeneity present in the included studies. Therefore, it was challenging to aggregate the studies’ data into a single quantitative scale for pooling and thus a narrative synthesis approach was adopted over a meta-analysis.

The synthesis steps were developed based on guidance for narrative synthesis in systematic reviews by Popay et al. [ 24 ], integrating into this review’s aim:

summarise key characteristics of each included study (including authors and years, study design, settings, targeted population with age range, MHPs, measurement tools, type of statistical analysis models, and main findings);

divide the included studies into various types of MHPs, including an umbrella term of general MHPs (GMHPs) and other specific types of mental problems; this approach helps identify patterns or differences across studies in the kind of mental health needs considered;

assess the quality of included studies through the quality assessment and other factors that might influence results, such as sample size, and potential biases during the review process;

identify patterns, trends, and contrasts between studies.

identify factors that could explain differences and contrasts in findings between studies, such as study quality differences, methodological differences, and data source (e.g. sample sizes, settings, and population and context characteristics);

assess the robustness of the synthesis by analysing the validity of measures for MHPs and ethnicity, the quality of the included studies, and any potential biases during the review process.

The effect sizes of the associations are presented in Additional file 5 (see Appendices) to provide an overview of the associations between ethnicity and MHPs in the UK. Results from both baseline and adjusted models were synthesised.

Overview of included studies

From 1,804 identified citations, 12 met the eligibility criteria for analysis, involving participants aged from 9 months to over 19 years, with the majority (k = 7/12) focusing on ages 10–16 [ 4 , 6 , 7 , 8 , 9 , 13 , 25 ]. The sample sizes varied from 2,900 to 12,376, with a grand total of 48,281 participants. To avoid duplication, only the largest participant count was included for studies using the same cohort (e.g. the Millennium Cohort Study [MCS] [ 26 ]). Among the 12 studies, 11 were population-based, and one was clinic-based, with quality assessments showing seven as high-quality (58.3%), four as moderate (33.3%), and one (8.3%) as of low quality.

All studies included White or White British groups as a reference for analysis, with 30% using high-level ethnicity categories (e.g. White, Asian, Black) and the rest focusing on specific ethnicities (e.g. Indian, Bangladeshi, Pakistani). Ethnicity assignment varied, with four studies [ 2 , 3 , 5 , 7 ] using caregiver reports based on UK census [ 27 ] categories, three utilising self-reported ethnicity [ 4 , 8 , 9 ], and two combining self-report with parental and grandparental birth countries [ 6 , 25 ].

Regarding MHPs, six studies used umbrella terms such as ‘mental health difficulties’, two [ 2 , 5 ] focused on internalising and externalising problems, two [ 6 , 9 ] on conduct problems, one [ 28 ] on psychosis-like symptoms, and one [ 12 ] on self-harm. Data collection methods also varied: one study [ 13 ] collected data directly from schools with an over-representation of children with Indian backgrounds, while the others used established datasets such as the MCS [ 26 ], the Determinants of Adolescent Social well-being and Health (DASH) study [ 29 ], and the Ethnicity and Adolescent Mental Health (REACH) study [ 30 ]. Study designs included six longitudinal, five cross-sectional, and one observational cohort study, predominantly representing populations from England, especially London (k = 4/12, 33.3%).

For the measurement of MHPs, six studies used self-reports, four used parent reports, one employed trained interviewers, and one relied on specialist assessment. The SDQ was the most common measure [ 22 ], used in 10 studies via self-reporting (k = 6/10) and parent-reporting (k = 4/10). The SDQ has been translated into more than 80 languages [ 31 ]. The average SDQ scores can calculate the estimated prevalence within sub-groups delineated by various characteristics, such as ethnicity, in the UK [ 32 ]. Other measures included the Psychosis-like Symptoms Interview (PLIKSi) [ 28 ] and a specialist psychosocial assessment for self-harm cases [ 12 ].

The number of publications on ethnic minority children’s mental health has been low over the past decade, with a slight increase in 2021, possibly related to increased attention to matters of ethnicity following the George Floyd protests in May 2020 [ 33 ].

• Narrative synthesis

The synthesis analysed effect sizes along with their 95% confidence intervals (CIs) or stand errors (SEs) from the included studies (see Additional file 5 in Appendices), categorising types of MHPs and ethnic groups for direct comparison within mental health categories. Both base and adjusted models (e.g. controlling age, gender, socioeconomic status, and deprivation index) were considered, revealing varying risks of MHPs across ethnicities. Effect sizes were reported as regression coefficients, odds ratios (ORs), risk ratios (RRs), hazard ratios, and fixed effects estimates. These metrics quantify the strength of the associations.

Most models did not find significant differences at the 5% significance level (i.e. p  ≥ 0.05 and/or having a 95% CI that includes the null value) between ethnic minority groups and the White/White British group. However, this synthesis does not rely solely on p-values. CIs have also been considered as they provide a more informative and convincing approach [ 34 ]. It also provides a more comprehensive view of the effect sizes and their direction, magnitude, and precision.

General MHPs (GMHPs)

GMHPs refer to the problems that were described using umbrella terms, such as ‘mental illness’ and ‘mental health difficulties’, rather than specific types of mental problems. The majority of included GMHPs were measured based on the total difficulties score (TDS) of the SDQ, including scores summed by emotional symptoms (five items), conduct problems (five items), hyperactivity/inattention (five items), and peer associations problems (five items) [ 22 ].

Children and young people in the Black African ethnic group were less likely to develop GMHPs in most included models (k = 4/7, corresponding to 4 out of 7 reported effect sizes from base and adjusted models shown in the Additional file 5 ), compared to their White counterparts. In Amhad et al.’s study [ 4 ], the results were stratified by sex, and only boys of Black African communities who were 14 years old were reported with a lower risk than their White British peers in base and adjusted models while controlling for social support, participation (e.g. socialising, religious attendance), and adversity. Despite this reported lower risk, the 95% CIs or standard errors (SEs) were relatively wide or large (see Additional file 5 ), indicating low precision and uncertainty over the effect sizes. Unlike the boys, no association was found among girls in the models (i.e. p-values were larger than 0.05, and the corresponding 95% CIs were wide and contained the null value of 1).

Our results also show that children in the Indian (k = 7/12), Pakistani (k = 8/11), Bangladeshi (k = 9/11), and Black Caribbean (k = 9/11) groups did not differ significantly in terms of experiencing GMHPS compared to their White counterparts (p-values in most the models were not statistically significant and the corresponding 95% CIs contained the null value of 1). Although some significant results (k = 5/12) existed for the children of Indian families, the precision of the results was relatively low. These still indicate a lack of significant results, which indicates that there might be no association between children with Indian background and GMHPs in the UK.

Other ethnic groups – such as male children of Nigerian/Ghanaian, Asian, and Black groups – reported a lower risk of suffering from GMHPs. However, conclusions cannot be drawn due to the limited number of results.

Externalising problems and conduct problems

In the four studies that examined externalising or conduct problems [ 2 , 5 , 6 , 9 ], most models did not identify statistically significant associations between children of Indian (k = 6/8), Pakistani (k = 6/8), or Bangladeshi (k = 5/8) groups and the prevalence of externalising or conduct problems.

Black Caribbean children and young people (k = 5/10, 50%) might be more likely to experience GMHPs compared to their White counterparts. Although only half of the included effect sizes reported such associations, their corresponding SEs or 95% CIs indicated the results had high precision, increasing our confidence in the findings. However, it is important to note that most significant results were from the models with fewer controlled variables [ 2 , 6 ]. The wide range of 95% CIs or large SEs of the non-significant results from the adjusted models might imply increased uncertainties because of too many confounding variables, especially if some confounds are not genuinely relevant to the outcome.

Contrasting results were found in studies with young people in the Black African ethnic group compared to those in the White ethnic group. Zilanawala et al. [ 2 ] and Midouhas [ 5 ] reported that children of Black African families were less likely to have conduct problems than White British children with relatively high precision for the effect sizes (i.e. small SEs). In contrast, Karamanos et al. [ 6 ] reported positive associations between children of Black African groups and conduct problems in an adjusted model considering air pollution (i.e. NO 2 levels) and in a model adjusting for more confounds in the context of PM2.5 exposure. The contrasting findings in these studies might be attributed to their different focuses, methodologies, and study quality. Karamanos et al.’s study (moderate quality) considered the interactive effects of air pollutants and ethnicity on child conduct problems, while Zilanawala et al. (high-quality study) examined the direct relationship between ethnicity and externalising problems and Midouhas (high-quality study) explored the impact of school poverty on behavioural trajectories, considering the role of ethnicity. These varying approaches might highlight how environmental, socio-economic, and direct ethnic factors can influence the outcomes differently.

Drawing conclusions regarding the ‘Other’ ethnic category is challenging due to the varying definitions used in the studies. It is difficult to draw definitive conclusions for certain ethnic groups, including ‘Other Whites’, ‘Any other mixed’, ‘any other Black’, ‘Latin American’, and ‘Mixed White and Black’, as only one study was conducted on each of these groups.

Internalising problems

Two studies [ 2 , 5 ] examined internalising problems. Children of Indian (k = 3/4, 75%) and Black African (k = 2/4, 50%) ethnic groups had a similar risk of internalising problems compared to White peers. However, Zilanawala et al.’s study indicated that children in the Black African ethnic group were significantly more likely to experience MHPs compared to those in the White ethnic group ( p  < 0.05), from the result of the adjusted model (coefficient = − 0.16, SE = 0.19) although the large SE relatively to the coefficient implies considerable uncertainty and might suggest no effect.

In addition, all models showed that children and young people in the Pakistani ethnic group had a higher risk of experiencing mental health disorders compared to their white peers. Similar results were also found with children in Bangladeshi and Black Caribbean ethnic groups by Zilanawala et al. [ 2 ], while Midouhas reported no association [ 5 ]. Compared to Midouhas’s study, Zilanawala et al.’s had a larger sample size, a larger effect size with higher levels of precision and less uncertainty of the results (i.e. smaller SEs), and a more direct focus on the relationships between ethnicity and internalising problems. These reduce the chance of type 1 and type 2 errors and increase the reliability and likelihood of true positive associations.

Psychosis-like symptoms

One study focused on psychosis-like symptoms. Singh et al. assessed the association between definite psychotic-like symptoms (PLIKS) and ethnicity among 1–12-year-old children [ 28 ]. Their findings indicated no statistically significant association between PLIKS and non-White children compared to their White peers, with an odds ratio (OR) of 1.50 (95% CI: 0.93–2.43) in the unadjusted model and an OR of 1.05 (95% CI: 0.56–1.97) after adjustments for urbanity, family adversity, residential and school mobility, and peer difficulties. The outcomes were measured using a valid face-to-face, semi-structured PLIKS interview (PLIKSi) derived from the Diagnostic Interview Schedule for Children, version IV (DISC-IV) [ 35 ] and the Schedules for Clinical Assessment in Neuropsychiatry version 2.0 (SCAN) [ 36 ]. Nevertheless, drawing definitive conclusions from this single study is challenging due to its solitary nature and geographical limitations (data collection was confined to Avon rather than nationwide).

Farooq et al. [ 12 ] targeted self-harm and explored its hazard ratios of repeat self-harm in children and adolescents with a complete 12-month follow-up for 10–19-year-old adolescents of ethnic minority groups compared to their White counterparts. The study suggested that Black adolescents exhibited a reduced hazard of repeated self-harm in both unadjusted and adjusted models, the latter accounting for age, sex, level of deprivation, previous self-harm incidents, and the method of self-harm. Additionally, South Asian and other non-White groups demonstrated a lower risk with narrow CIs, indicating a high level of reliability in the effect sizes reported, although the statistical significance of these findings was confined to the unadjusted models. Despite the precision of these findings and the considerable sample size (11,906 adolescents), the generalisability of the results to the broader UK context is restricted, as the data were derived from clinical settings.

Comparison with previous review

This review’s examination of the risk of MHPs across ethnicities provides the prevalence of MHPs in children and young people, which offers a different methodological approach to Goodman and colleagues’ 2008 study [ 18 ]. While the earlier review provided prevalence rates derived from age and gender-controlled models, the current analysis expands the scope by utilising both unadjusted and adjusted models. In particular, adjusted models incorporate a broader range of potential confounding variables, including socioeconomic status and maternal mental health, to accurately measure complex associations involving covariates that impact child mental health outcomes in the real world. Despite the challenges in directly comparing this review’s results with those of Goodman et al., due to their different focuses, they both identify similar patterns: ethnic minority children and adolescents in the UK generally show comparable or sometimes lower prevalence or risk of common MHPs than White British children. By integrating additional confounds, this review not only supports some of Goodman et al.’s findings but also highlights issues of intersectionality, highlighting the importance of conducting multifaceted analyses.

Overarching trends of the associations

This systematic review focuses on the relationship between ethnicity and child MHPs in the UK, incorporating data from 12 studies. Given the diverse nature of the studies, a narrative synthesis was chosen over a meta-analysis to assess the associations.

Overall, this review reveals that most ethnic minority children and adolescents have a comparable risk of experiencing MHPs as their White counterparts, although inter-ethnic and inter-study disparities do exist. Some studies, mentioned in the Background, point to striking ethnic disparities in child mental health outcomes. However, synthesising a range of studies, these results were not found consistently. A review of these studies suggests that associations between ethnicity and mental health are shaped by multiple factors, and ethnic minority status alone may not consistently result in higher or lower risks of MHPs.

Specifically, the review reveals that there were no significant differences in experiencing MHPs between children in the Indian and White ethnic groups. However, the risk of experiencing MHPs among other ethnic groups varies depending on the types of problems involved. For GMHPs, there were no significant differences between children in the Pakistani, Bangladeshi, and Black Caribbean groups compared to White peers. In contrast, Black African children were reported to be less likely to develop GMHPs. For internalising problems, the risk for children in the Black African ethnic group aligns with that of White children. However, children in the Pakistani, Bangladeshi, and Black Caribbean groups were reported to be more likely to face these issues.

In terms of externalising and conduct problems, children of Pakistani and Bangladeshi groups appear to have similar risks to those in the White ethnic group. Those in the Black Caribbean ethnic group are more likely to experience externalising and conduct problems compared to White individuals, especially in base model analyses. These findings suggest the need for consideration of additional variables, as base models may not fully capture the influence of potential confounding factors such as socioeconomic status. Goff et al. [ 37 ] also highlighted that such findings need to be interpreted cautiously and with an understanding of societal biases since Black children, particularly boys, are often perceived as less innocent and more mature than their White peers, which leads to harsher treatment and less protection [ 37 ]. Such dehumanising perceptions can result in biased reporting and interpretation of conduct problems, underscoring the need for careful consideration of how racial stereotypes impact our understanding of behavioural issues across different ethnic groups.

This review also shows that the overall likelihood of developing psychosis-like symptoms is comparable between children in White and non-White ethnic groups. Additionally, Black, South Asian, and other non-White children are less prone to self-harm than White children. Nevertheless, these differences were most apparent in basic models and no ethnic variations were reported in most adjusted models. This pattern suggests that factors beyond ethnicity, such as level of deprivation [ 12 ], may play a crucial role in understanding the true associations between ethnicity, self-harm, and psychosis. It also highlights the importance of a multifaceted approach in mental health research, where simple ethnic categorisations are insufficient to reflect complex mental health dynamics in their social and economic context.

The review also highlights challenges in using broad ethnic categories such as ‘non-White’, ‘Other’, and ‘ethnic minority groups’. The inconsistent definitions of these groups across studies lead to challenges in accurately generalising findings. This inconsistency might also cause oversimplification, potentially masking the unique risks of having MHPs within specific ethnic subgroups. Furthermore, it indicates a need for more detailed and uniform categorisation in future research.

Equivocal findings

The diverse findings across the included studies in this review and the equivocal reasons behind these variations present a complex landscape for analysis. First, ethnicity seems to have an important role in the MHPs of children and young people. The results show that children and adolescents from different ethnic minority backgrounds might be exposed to different types of mental health risks, although the underlying reasons are not fully clear. For example, children from Pakistani and Bangladeshi backgrounds showed similar risks for GMHPs and externalising problems as their White peers, yet they also had a higher risk of internalising problems. Such variation was evident despite the studies being of comparable quality and having comparable sample sizes and community-based settings. This observation suggests that such methodological factors might not fully elucidate the reasons behind the variations. A potential explanation is related to the South Asian culture, including that of the Pakistani and Bangladeshi communities, in which emotional distress might be more internalised due to cultural norms around emotional self-control (i.e. behaving appropriately rather than acting on how one is feeling) and collectivism (i.e. placing group welfare before individual welfare) [ 38 ]. Such cultural values might result in higher risks of developing internalising problems instead of externalising problems. This complexity in findings underscores the need for future research to explore cultural and contextual factors that might influence the varied mental health risk profiles within the same ethnic minority groups.

In addition, the observed inter-ethnic differences may be attributable to potential confounding factors. Factors such as socioeconomic status, maternal mental health, and experiences of racism were considered in the adjusted models, resulting in most effect sizes becoming reduced or statistically non-significant. This suggests that the ethnic disparities in MHPs reflect these external factors more than ethnicity itself. However, a limitation arises in the way most studies handle confounding variables. In their analysis, Zilanawala et al. used several statistical models to separately adjust for various factors, including cultural traditions, socioeconomic position, perceived racism, maternal psychological distress, and family environment markers, with a final model combining all covariates [ 2 ]. In contrast, most studies controlled for multiple confounds collectively in a single model, which makes it challenging to identify the specific impact of each factor on inter-ethnic risk differences. Therefore, future research might consider analysing these confounding factors separately in distinct models, allowing for a more precise assessment of the individual contributions of each factor to the ethnic differences observed in MHPs.

Robustness of the synthesis

This review raises considerations regarding the validity of mental health measures used in their populations of interest. Although the included studies predominantly utilised the SDQ as a mental health assessment tool (k = 10/12), the specific validity of this measure for certain ethnic minority groups in the UK remains unclear. Despite being one of the most widely and internally used measures of child and adolescent mental health [ 22 ], the SDQ may not account for the unique cultural contexts and perceptions of mental health across different ethnicities. For example, the stigma associated with mental illness in South Asian communities could lead to underreporting in parent-reported measures [ 39 ]. Furthermore, none of the studies that used the SDQ used the home language versions of the SDQ for populations with limited English proficiency, potentially overlooking idiomatic expressions of mental distress specific to these groups [ 40 , 41 ]. Such oversight raises questions about the SDQ’s robustness in capturing the true risk of having MHPs among diverse ethnic minority children. Additionally, the validity of other assessment methods, such as the PLIKSi used by Singh et al. [ 28 ] and the specialist assessments used by Farooq et al. [ 12 ], might be compromised by unknown racial biases or stereotypes held by the interviewers or clinicians [ 42 ]. Future research should, therefore, prioritise exploring the cultural adaptation and validity of these mental health assessment tools across different ethnicities within the same nation.

It is also crucial to consider the measurement quality and implications of how ethnicity is measured in the included studies. The measures of ethnicity in the reviewed studies were generally of high quality, typically based on validated methods such as the UK census and parent- or self-reported ethnicity. However, the use of broad ethnic categories (e.g. White, Asian, Black, and ‘Other’) may limit the internal heterogeneity within these ethnic minority groups. The inconsistent definition of some terms (e.g. ‘White’, ‘Other’, ‘non-White’, and ‘Other White’) also adversely impacts the robustness of the synthesis. These features could limit the ability to draw specific conclusions about the data.

In most included studies (k = 10/12), the proportion of ethnic minority children was over-represented to ensure a meaningful analysis of these groups. Despite this, the sample sizes of ethnic minority children were often too small compared to their White or White British counterparts, affecting the statistical power of these studies. The reduced power subsequently increases the chance of Type II (false negative) errors – where the true risk differences between ethnic minority groups might be undetected [ 43 ] – potentially limiting their ability to detect differences in mental health outcomes across groups. As a result, the observed ethnic comparisons need to be interpreted cautiously, and limitations of statistical power imposed by the small sample size of ethnic minority children should be acknowledged.

In addition to addressing the potential for Type II errors, we carefully consider the impact of Type I (false positive) errors in interpreting its findings. A standard significance level of p  < 0.05 was selected to reduce the likelihood of these errors. Despite this, there remains a 5% probability of having Type I errors even with statistically significant results [ 34 ]. Consequently, the review has adopted a cautious approach in interpreting findings with p-values. Existing research suggested that integrating p-values with CIs creates a more nuanced interpretation of statistical significance, moving beyond strict cut-off points. This is partly because CIs assess the precision of effect sizes, thus enhancing the robustness of statistical conclusions [ 34 , 43 ]. This combination of p-values and CIs in our statistical approach has helped interpret findings while acknowledging the trade-off between Type I and Type II errors.

The generalisability of the findings from this review is moderate, slightly impacting the overall robustness of the synthesis. Five of the twelve studies analysed data from the MCS, encompassing rural and urban populations across various UK regions and offering a relatively broad demographic scope. However, the remaining studies predominantly focused on specific areas, especially London. Considering that London is the UK’s most ethnically diverse region [ 44 ], these studies might not accurately represent the MHPs of children from less ethnically diverse areas. This geographical focus potentially limits the applicability of the findings across the entire UK, thus affecting the overall robustness of the synthesis.

Additionally, the findings of this review may not be generalisable to other countries due to differences in ethnic distributions and healthcare systems. For example, the UK’s ethnic minority populations are predominantly from South Asian, Black African, and Caribbean backgrounds, reflecting historical migration patterns from Commonwealth countries [ 1 ]. In contrast, in the US, the largest ethnic minority group is Hispanic and Latino, which introduces different socio-cultural factors affecting mental health outcomes [ 16 ]. These variations in ethnic group distribution result in distinct challenges and protective factors for children in each country. Thus, generalising the findings from this review to other international settings should be cautiously approached.

Overall, robustness has been evaluated by thoroughly analysing the methods used in the included studies. Concerns about the SDQ’s validity across different ethnic contexts due to cultural and linguistic factors affect its reliability. The small sample sizes for ethnic minority children increase the risk of Type II errors, which impacts the detection of actual ethnic differences. While using both significance levels and CIs strengthens credibility, the focus on urban areas – particularly London – limits the study’s generalisability across the UK. Future research should prioritise culturally adaptable psychological measurement tools and include larger, geographically diverse samples.

Strengths and limitations

This review has three main strengths. First, it synthesises findings on child mental health across ethnicities in the past ten years and is the only review conducted since 2008 [ 18 ]. Second, it considers not only base models with or without adjustment for age and gender but also models controlling for potential confounding factors. Such a method enables a better understanding of how various factors might influence associations, revealing real-world associations and potential causes of inter-ethnic differences. For instance, children of Pakistani groups had a higher risk of externalising problems than White British children in the base model adjusted for age and gender. However, the risk between the two ethnicities became similar in the model adjusted for socioeconomic position [ 2 ], indicating that the ethnic disparities initially attributed to ethnicity, age, and gender are more influenced by socioeconomic conditions. Third, the review enhances statistical interpretation by using CIs alongside p-values, thereby avoiding simplistic binary interpretations of findings as statistically significant or not.

This review also has several limitations, similar to the study by Goodman et al. [ 18 ]. First, the high heterogeneity in study designs and methodologies restricts the ability to aggregate the results. Therefore, a narrative synthesis instead of a meta-analysis was conducted to analyse the results. While narrative synthesis offers flexibility for complex data [ 24 ], it cannot quantitatively weight studies with large samples or a low SE. Second, using the White or White British ethnic category as a fixed benchmark in research can unintentionally suggest that their experiences are the standard [ 18 , 42 ], potentially reinforcing stereotypes. Moreover, treating the entire White group as homogeneous overlooks important internal variations [ 18 ], as the broad category of ‘White’ includes diverse groups such as Irish, White Other, and Gypsy or Irish Traveller, each of which has distinct mental health outcomes [ 25 ]. Third, most studies included in the review are community-based and thus lack a clinical-based sample. This kind of approach and sample may not accurately reflect the patterns of diagnosis observed in clinical practice [ 45 ]. Fourth, this review predominantly addressed MHPs as identified by the SDQ rather than the clinical diagnoses that the children received (e.g. anxiety, depression, and bipolar disorder). Such reliance on SDQ-defined MHPs may limit the breadth of represented mental health disorders, potentially resulting in an incomplete picture of the varied and clinically significant mental health challenges in children across ethnic groups. Finally, studies that meet the inclusion criteria might have been missed. Despite the adoption of multiple search approaches, ethnicity-related findings are often hidden within the main body of a publication instead of in its abstract, which can make it challenging to include all the studies meeting the inclusion criteria.

In summary, this systematic review finds that, despite facing more racism and socioeconomic disadvantage [ 14 ], ethnic minority children in the UK generally have similar, sometimes lower, mental health risks compared to White British children. The comprehensive analysis using both unadjusted and adjusted models suggests that age, gender, and income might influence mental health risks more than ethnicity. However, the focus on community samples and SDQ-defined MHPs calls for future research using clinical diagnoses and large-scale clinic-based studies for additional understanding of child mental health across ethnic groups in the UK.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

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Acknowledgements

The authors extend their sincere appreciation to Professor Paul Wilkinson and Dr. Anna Moore for their invaluable guidance regarding the selection of quality assessment tools and the interpretation of the results. We are also grateful to Dr. Yeosun Yoon for her thorough review and feedback on the manuscript draft. Additionally, we thank Prof. Anna Goodman for clarifying her methodological choice in her systematic review on child mental health and ethnicity, which helped the authors decide the appropriate analysis method.

there was no funding for this systematic review.

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SG was the main contributor to this review. She developed the research question, defined the scope and purpose of this review, designed the search strategy plan and participated in article screening, designed the quality criteria, conducted the quality assessment, designed the analysis method, synthesised the findings, interpreted the results, and drafted the manuscript. RD and BC, especially RD, provided advice and rounds of feedback on defining the scope and purpose of this review, designing the search strategy plan, and the manuscript’s draft. KE participated in independently screening articles. All authors reviewed the manuscript.

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Guan, S., Coughlan, B., Evans, K. et al. Associations between ethnicity and mental health problems among children and adolescents in the United Kingdom: A systematic review and narrative synthesis. BMC Public Health 24 , 3267 (2024). https://doi.org/10.1186/s12889-024-20695-3

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DOI : https://doi.org/10.1186/s12889-024-20695-3

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