ON MY MIND — Promoting, protecting and caring for children’s mental health
Unicef
THE STATE OF THE WORLD ’S CHILDREN 2021
October 2021.
The COVID-19 pandemic has raised huge concerns for the mental health of an entire generation of children and young people and parents and caregivers. But the pandemic may represent only the tip of a mental health iceberg — an iceberg we have ignored for far too long.
For the first time in its history, The State of the World’s Children examines mental health, with a special focus on how risk and protective factors in the home, school and community shape mental health outcomes. Against a backdrop of rising awareness of mental health issues, and growing demand for action, the report argues that we now have a unique opportunity to promote good mental health for every child, protect vulnerable children and care for children facing the greatest challenges.
The report demands urgent investment in child and adolescent mental health across sectors, not just in health. It argues for proven interventions in areas like health, education and social protection, such as parenting and whole-school programmes. And it calls for societies to break the silence surrounding mental health, by addressing stigma, promoting understanding, and taking seriously the experiences of children and young people.
KEY MESSAGES
Around the world, mental disorders are a significant and often ignored cause of suffering that interfere with children’s and young people’s health and education and their ability to reach their full potential.
· It is estimated that more than 13 per cent of adolescents aged 10–19 live with a diagnosed mental disorder as defined by the World Health Organization.
· This represents 86 million adolescents aged 15–19 and 80 million adolescents aged 10–14.
· 89 million adolescent boys aged 10–19 and 77 million adolescent girls aged 10–19 live with a mental disorder.
· Prevalence rates of diagnosed disorders are highest in the Middle East and North Africa, North America and Western Europe regions.
· Anxiety and depression make up about 40 per cent of these diagnosed mental disorders; the others include attention deficit/hyperactivity disorder, conduct disorder, intellectual disability, bipolar disorder, eating disorders, autism, schizophrenia and a group of personality disorders.
· Children and young people also report psychosocial distress that does not rise to the level of epidemiological disorder but disrupts their lives, health and prospects for the future.
· According to research carried out by Gallup for UNICEF’s upcoming Changing Childhood report, a median of 19 per cent of 15- to 24-year-olds in 21 countries self-reported in the first half of 2021 that they often feel depressed or have little interest in doing things.
The cost of inaction is great — in terms of the toll it takes in human lives and on families and communities and financially.
· An estimated 45,800 adolescents die from suicide each year, or more than 1 person every 11 minutes.
· Suicide is the fifth most prevalent cause of death for adolescents aged 10–19; for adolescent boys and girls aged 15–19, it is the fourth most common cause of death, after road injury, tuberculosis and interpersonal violence. For girls aged 15–19, it is the third most common cause of death, and the fourth for boys in this age group.
· New analysis for this report indicates that the annual loss in human capital arising from mental health conditions in children aged 0–19 is US$387.2 billion (purchasing power parity dollars). Of this, US$340.2 billion reflects disorders that include anxiety and depression, and US$47 billion reflects the loss due to suicide.
· Of the US$340.2 billion, anxiety disorders account for 26.93 per cent; behavioural disorders 22.63 per cent; and depression 21.87 per cent.
Despite widespread demand for responses that promote, protect and care for children’s mental health, investment remains negligible.
· Research carried out by Gallup for UNICEF’s upcoming Changing Childhood report indicates strong demand for action. A median of 83 per cent of young people aged 15–24 in 21 countries believe it is better to address mental health issues by sharing experiences with other people and seeking support than by going it alone.
· Despite demand for support, median government expenditure on mental health globally is a mere 2.1 per cent of the median government expenditure on health in general.
· In some of the world’s poorest countries, governments spend less than US$1 a person treating mental health conditions.
· The number of psychiatrists who specialize in treating children and adolescents was fewer than 0.1 per 100,000 in all but high-income countries, where the figure was 5.5 per 100,000.
· Investment in promoting and protecting mental health — as distinct from caring for children facing the greatest challenges — is extremely low.
· Lack of investment means workforces — including community-based workers — are not equipped to address mental health issues across multiple sectors, including primary health care, education, social protection and others.
Mental health is widely stigmatized and misunderstood: It is, in fact, a positive state of well-being and a foundation that allows children and young people to build their futures.
· Despite growing awareness of the impact of mental health conditions, stigma remains a powerful force. Stigma — whether purposeful or not — blocks children and young people from seeking treatment and limits their opportunities to grow, learn and thrive.
· Like physical health, mental health should be thought of as a positive: It underlies the human capacity to think, feel, learn, work, build meaningful relationships and contribute to communities and the world. It is an intrinsic part of individual health and a foundation for healthy communities and nations.
· Mental health exists on a continuum that can include periods of well-being and periods of distress, most of which will never evolve into a diagnosable disorder.
· Mental health is a basic right and essential for achieving global objectives, including the Sustainable Development Goals.
Risks and protective factors influence mental health at critical developmental moments.
· At critical moments of child development, factors based on experience and environment can represent a risk to mental health or can help to protect it. Policy approaches should aim to minimize risk and maximize protective factors.
· Risk and protective factors can be organized into three spheres of influence: The world of the child focuses on home and caregiving settings; the world around the child involves safety and security and healthy attachments in preschools, schools and communities; and the world at large includes large-scale social determinants — such as poverty, disaster, conflict and discrimination.
· Mental health is tied to critical moments of brain development, which can be affected by factors such as toxic stress triggered by adverse childhood experiences (ACEs), such as physical and emotional abuse, chronic neglect and violence.
· Research has shown that exposure to at least four ACEs is strongly associated with sexual risk taking, mental health conditions and alcohol abuse; it is even more strongly associated with problematic drug use and interpersonal and self-directed violence.
Parenting is crucial to laying strong foundations for children’s mental health, but many parents need more support.
· Parenting is foundational to children’s mental health. However, for many caregivers, fulfilling this critical role requires support from parenting programmes, which can include information, guidance, and financial and psychosocial support.
· Many caregivers also need support for their own mental health.
· Before conception and in early childhood, risk factors for the child’s mental health include low birthweight, maternal malnutrition, maternal mental health and adolescent parenthood. Globally, 15 per cent of children are born at a low birthweight, while about 15 per cent of girls become mothers before age 18.
· In childhood, risk factors include poor nutrition and violent discipline. Globally, around 29 per cent of children do not have minimum dietary diversity.
· In the world’s least developed countries, 83 per cent of children experience violent discipline from caregivers and 22 per cent are in a form of child labour.
· In adolescence, nurturing and supportive parenting remains one of the strongest protectors of mental health.
Schools and learning environments can provide opportunities to support mental health, but can also expose children to risks, including bullying and excessive exam pressure.
· Schools can be healthy and inclusive environments where children learn critical skills to bolster their well-being, but also places where children experience bullying, racism, discrimination, peer pressure and stress about academic performance.
· Despite links between early learning opportunities and child development, about 81 per cent of children in the least developed countries do not attend early childhood education.
· Among older children, absence from school or dropping out before finishing is linked to social isolation, which in turn can lead to mental health conditions, including self-harm, suicidal ideation, depression, anxiety and substance use.
· An analysis by RTI International for this report indicates that school-based interventions that address anxiety, depression and suicide provide a return on investment of US$21.5 for every US$1 invested over 80 years.
Socioeconomic and cultural factors in the wider world, as well as humanitarian crises and events like the COVID-19 pandemic, can all harm mental health.
· The relationship between poverty and mental health is a two-way street. Poverty can lead to mental health conditions, and mental health conditions can lead to poverty. Globally, nearly 20 per cent of children younger than 5 live in extreme poverty.
· Gender norms can impact the mental health of both girls and boys. Girls may face restrictive stereotypes about work, education and family as well as the risk of intimate partner violence; boys may experience pressure to suppress emotions and to experiment with substance use.
· Children are far too often on the front lines in humanitarian crises — 415 million in 2018, each exposed to stress and trauma. The impact of such crises can differ from child to child, with some showing resilience and others experiencing extreme and lasting distress.
· There are multiple reports of abuse of children in institutions, a high proportion of whom have disabilities, including developmental or mental health disabilities. There is also extensive evidence of the continued use of shackling of children and young people with serious mental health conditions, and of the use of coercion and restraint in mental health services.
· There is wide concern about the impact of the COVID-19 pandemic on mental health. Research indicates some increases in stress and anxiety among children and adolescents. The mental health of caregivers, especially young mothers, is also a concern.
Interventions across a range of systems and sectors — including in families, communities and schools, and through social protection — can help to promote and protect mental health.
· Evaluations of parenting programmes indicate that they help deepen attachments between caregiver and child, reduce harsh parenting practices and improve children’s cognitive development.
· In schools, social and emotional learning approaches that include whole-school interventions and specific interventions for at-risk children and young people have proven effective.
· Cash transfer programmes can indirectly influence children’s and adolescents’ mental health by increasing school participation, food security and access to health care and social services.
· In humanitarian settings, the careful implementation of brief, structured interventions that provide immediate responses to depression, anxiety and post-traumatic stress disorder can bolster children’s and young people’s mental health.
Recommendations
The State of the World’s Children 2021 concludes by calling for commitment, communication and action to promote good mental health for every child, protect vulnerable children and care for children facing the greatest challenges.
COMMITMENT means strengthening leadership to set the sights of a diverse range of partners and stakeholders on clear goals and ensuring investment in solutions and people across a range of sectors.
COMMUNICATION means breaking the silence surrounding mental health, addressing stigmas, improving mental health literacy, and ensuring children, young people and people with lived experience have a voice.
ACTION means working to minimize risk factors and maximize protective factors for mental health in key areas of children’s lives, as well as investment and workforce development to:
· Support families, parents and caregivers
· Ensure schools support mental health
· Strengthen and equip multiple systems and workforces to meet complex challenges
· Improve data, research and evidence
Foreword (from the beginning of the report)
Children around the world have been locked out of classrooms, sequestered in their homes and robbed of the everyday joy of playing with friends — all consequences of the COVID-19 pandemic. Millions more families have been pushed into poverty, unable to make ends meet. Child labour, abuse and gender-based violence are on the rise.
Many children are filled with sadness, hurt or anxiety. Some are wondering where this world is headed and what their place is in it.
Indeed, these are very challenging times for children and young people, and this is the state of their world in 2021.
But even absent a pandemic, psychosocial distress and poor mental health afflict far too many children — including millions who, each year, are forced from their homes, scarred by conflict and serious adversity, and deprived of access to schooling, protection and support.
In fact, the COVID-19 pandemic represents merely the tip of the iceberg when it comes to poor mental health outcomes.
It is an iceberg we have been ignoring for far too long, and unless we act, it will continue to have disastrous results for children and societies long after the pandemic is over. When we ignore the mental health of children, we undercut their capacity to learn, work, build meaningful relationships and contribute to the world.
When we ignore the mental health of parents and caregivers, we fail to support them to nurture and care for their children to the best of their ability. And when we ignore mental health issues in our societies, we close off conversation, reinforce stigma and prevent children and caregivers from seeking the help they need.
In the face of this reality, we are too often silent, too often unwilling to embrace the full complexity of what it is to be human. Or, as human rights advocate Lea Labaki, a contributor to this project, puts it: We fail to acknowledge that “psychological distress is not deviant behaviour to be repressed and hidden away, but just a normal aspect of human experience.”
We must be silent no longer.
We must listen to the young people all around the world who are increasingly raising their voices and demanding action.
And we must act.
With this edition of The State of the World’s Children, the first ever to focus on mental health, UNICEF is signalling our determination to listen — and to act.
In recent years, we have worked to help safeguard the mental health and psychosocial wellbeing of children, adolescents, parents and caregivers in some of the world’s most challenging settings. We have worked, too, to address the sweeping impact of the pandemic on mental health. In 2020, we reached 47.2 million children, adolescents and caregivers with community-based mental health and psychosocial support, including targeted community awareness campaigns in 116 countries — or almost twice as many countries as in 2019. This engagement will only grow in the years to come, as will our efforts to secure investment for mental health and to tackle the scourges of neglect, abuse and childhood trauma that undermine the mental health of far too many children.
Because we know we all must do more.
Now, with key partners like the World Health Organization, governments, academics and many others, we all must show commitment to leadership and investment to better support mental health.
We all must work to help break the silence around mental health — challenge stigmas, raise mental health literacy and ensure the voices of young people are heard, and especially those with lived experience of mental health challenges.
And we all must commit to action in key areas, like better supporting parents, ensuring schools are kinder and safer places, and — through investment and workforce development — addressing the mental health needs of families in areas like social protection and community care.
Crucially, we all must work to improve data collection, routine monitoring, and research — a key challenge for all of us in the United Nations system. The picture we have of children’s mental health is a partial one, and it is one that is skewed heavily towards the world’s wealthiest countries. That means we know too little of how children and young people in most parts of the world experience mental health. It also means we know too little of the potential strengths and support that diverse communities and cultures may be able to offer children and families.
The challenge we face is immense. It is one that — despite the best efforts of so many, especially the young people who have shared their stories, ideas and passion for change — our global community has barely begun to address. When it comes to mental health, every country is developing.
But if the challenge is great, the rewards of meeting it can be greater still — for every child, for every family and for every community.
We can wait no longer. We cannot fail another generation. The time to act is now.
Henrietta H. Fore
UNICEF Executive Director
Suggested citation:
United Nations Children’s Fund, The State of the World’s Children 2021: On My Mind — Promoting, protecting and caring for children’s mental health, UNICEF, New York, October 2021.
Report team
Brian Keeley, Editor in Chief; Juliano Diniz de Oliveira, Research and Policy Specialist; Tara Dooley, Deputy Editor; Natalie Rykiel, Researcher; Dennis Gayanelo, Programme Associate; John McIlwaine, Photo Writer and Editor; and Amanda Marlin, Chief, Editorial Unit, Office of Global Insight and Policy.
Health, data and analytics Liliana Carvajal, Lauren Francis, Nicolas Gasquet, Jennifer Requejo.
Mental health lead Zeinab Hijazi, Senior Mental Health Technical Advisor, Programme Group.
Editorial and production Samantha Wauchope, Production Specialist; Ahmed Al Izzi Alnaqshbandi, Arabic Editor; Maud CombierPerben, French Editor; Carlos Perellon, Spanish Editor; Yasmine Hage and Baishalee Nayak, Fact Checkers; Upasana Young, Programme Associate; Charlotte Kuo-Benitez (Green Ink), Copy Editor.
Media and communications Kurtis Albert Cooper, Helen Wylie, Tess Ingram.
Advocacy Benjamin Perks, Emma Ferguson.
Design Blossom.it
Photography and reporting VII Photo Agency The State of the World’s Children is produced by the Office of Global Insights and Policy; Laurence Chandy, Director.
