A holistic approach to young people’s physical and mental health is key to overcoming the crisis, writes Dr Lee Hudson
Sir Luke Fildes, “The Doctor”, 1891
There’s a potent late Victorian painting in Tate Britain by Sir Luke Fildes titled The Doctor (1891). In it, an authoritative, bearded physician keeps pensive vigil over the pale figure of a sick female child lying across two chairs in her family home. As your eyes settle on the scene, the figures of two distraught parents emerge faintly from the shadows. We don’t know the nature of her illness, but the best guess – judging from predominant childhood illnesses of the age – is infection. We don’t know if she lived or died, but we do know Fildes used his children as models, and that his own son died young.
As a paediatrician and academic whose predominant business is to worry about child illness and any harm young people suffer, I’ve contemplated this painting many times during my career. What strikes me today is that while it’s a characteristic of the job for my paediatric colleagues and me to watch anxiously over unwell children, the nature of childhood illnesses has changed dramatically since Fildes’ time. And since we’ve all become a bit of an epidemiologist during the Covid-19 pandemic, it feels an apt time to discuss the current causes of disease and death in children.
In the 1940s, for example, a diagnosis of the blood cancer leukaemia in a child would have been a death sentence: there simply weren’t any effective treatments. Yet thanks to developments in treatment regimes, today survival is close to 90 per cent. At various points in the last century, treatment changes increased survival for many childhood conditions, such as diabetes and cystic fibrosis. Perhaps the biggest victory has been in the battle against that ancient curse, childhood infections. Vaccination, sanitation, antibiotics and better healthcare systems for treating unwell children with bacterial disease have led to an astoundingly different landscape for child health compared even to that of our grandparents’ generation.
However, nature’s a fickle mistress and among the astonishing shifts in the recent past lurks a change in what ages children and young people are most at risk of death. Mortality rates in children under five around the world have dropped steeply since the 1950s, meaning that since the mid-1990s a fifteen-year-old has had a higher risk of death than a two-year-old. Think about that. Throughout most of human history, stretching back to ancient civilisations, the youngest children in families were consistently the ones who were most at risk of dying. Indeed, the narrative of centuries of British history has arguably been driven by the twists of fortune resulting from the deaths of infant royal heirs. But we now live in an era where rates of adolescent mortality are higher, bringing with them a different set of underlying factors.
Recent data from England during the pandemic showed that around one in six children and young people in England have a mental health disorder, an increase from one in eight
The World Health Organisation estimates that the leading causes of death in fifteen to nineteen-year-olds are accidents (like road injuries, assault and drowning) and self-harm. All these causes are of course preventable, and all tied up with what has been called the “modern scourge” of mental health. Recent data from England during the pandemic showed that around one in six children and young people in England have a mental health disorder, an increase from one in eight.
I’m a scientist, so I tend to be cautious about assumptions and wait for evidence – and we don’t have lots of data on why Covid has impacted the mental health of children and young people to such a degree. That said, it isn’t difficult to make a decent hypothesis, such as the impact of lockdown restrictions on young people’s everyday lives.
Post-pandemic there’s been an increase in children and young people coming forward with mental health problems – especially in the numbers presenting with eating disorders. Thanks to vaccination, even before Covid, children and young people were more likely to get an eating disorder than a serious infection like meningitis. But across the UK right now, modern-day versions of Fildes’ doctor are holding vigil over significantly increased numbers of very unwell, distressed children and adolescents. Some of them have restricted their eating so drastically that starvation puts their lives at risk, requiring feeding tubes to rescue them. Services are struggling to manage these large numbers and specialist eating disorder centres across the UK are at capacity.
However, anyone discussing how to tackle the rise of problems in mental health must beware of creating a narrative of despair and hopelessness. The oft-used phrase “mental health crisis” is apt, but risks triggering a sense of hopelessness – or worse, ennui. While modern doctors and parents all too often sit watching over a sick young person with mental health issues, there are interventions that work for such disorders. The real tragedy is the lack of equitable access to them. The patient isn’t like Fildes’ child, fighting an infection because antibiotics haven’t been invented yet. Access Recent data from England during the pandemic showed that around one in six children and young people in England have a mental health disorder, an increase from one in eight to treatment was a vital factor in the post-war efficacy of both vaccines, and antibiotics. We know that Covid led to restrictions in access to mental health services for children and young people – but this was an area of healthcare where there had been pre-existing challenges in terms of access. As we come out of the pandemic it’s vital the increase in mental health problems doesn’t get lost in the noise of all the other demands and responses needed in our society right now.
So what are the solutions? It’s tempting to start with the obvious, which is greater funding for mental health – and yes, of course that is important – for we absolutely need more resources and more professionals to deal with the crisis. Investment in mental health, especially early on, also saves money by improving wellness and productivity. But in my mind we haven’t got the basics right yet.
Firstly, as a society we still have some way to go in an acceptance of mental health as something that affects all of us, not just as an illness but as a constant state we all carry in our daily lives (sometimes good and sometimes bad). It is still the case that as a society we view a child with a mental health problem as something conceptually worse or more sinister than a physical one, like a broken leg. As someone who looks after both physical and mental health problems in children, the idea that a mental health diagnosis is worse, more unlucky or more unfortunate, is profoundly odd. While the outlook has improved in recent years, the stigma and shame around mental health remains, and the onus for changing this starts with each of us as individuals.
Secondly, but interconnectedly, our health services are fragmented in the sense that care for mental health and physical health problems have developed quite separately – not just in terms of the language used, the access and skill sets – but also quite fundamental things like geographical location of services and communications. The phrase “integration of physical and mental health” has been used for some time now in health services, as has “parity of esteem for mental health”. But the former is the great enabler of the latter, for if we had true integration for physical and mental health, this would hopefully bring parity of esteem. Perhaps then we would achieve that ideal where services fit around children and young people, and not the other way around.
The early twentieth century generation of paediatricians found themselves, like Fildes’ doctor, too often holding vigil over sick children who didn’t need to be sick or die. Their post-war descendants managed to challenge and change this, even though they were working in the context of a world profoundly impacted by global crisis (and doesn’t that sound rather familiar). For me, that high-achieving generation left a great legacy. Fildes’ doctor would be astonished at their successes and hardly recognise child health today. But in 70 years will future doctors look back on us, and our time, in the same way?
Dr Lee Hudson is a clinical associate professor at the Great Ormond Street UCL Institute of Child Health in London, and consultant Paediatrician and Chief Officer for Mental Health at Great Ormond Street Hospital