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García-Carrión, R., Villarejo-Carballido, B., & Villardón-Gallego, L. (2019, April 24). Children and adolescents mental health: A systematic review of interaction-based interventions in schools and communities. PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC6491840/

This systematic review examines the effectiveness of interaction-based interventions in schools and communities to improve mental health in children and adolescents. The study focuses on interventions that involve supportive interactions among peers, teachers, families, and professionals. Out of 384 studies, 11 were selected for review, showing that these interventions led to reduced symptoms of mental disorders, such as anxiety and depression, and improved social skills and personal well-being. The review highlights the importance of collective interactions and suggests that further research is needed to better understand the impact of these interventions.  This will help further explain in my project that schools addressing mental health plays a large part in in helping end the stigma.

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Children and Adolescents Mental Health: A Systematic Review of Interaction-Based Interventions in Schools and Communities

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Background: There is growing evidence and awareness regarding the magnitude of mental health issues across the globe, starting half of those before the age of 14 and have lifelong effects on individuals and society. Despite the multidimensional…

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Beckman, L., Hassler, S., & Hellstrom, L. (2023, September 14). Children and youth’s perceptions of mental health-A scoping review of qualitative studies - BMC Psychiatry. BioMed Central. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-023-05169-x

This study investigates how children and youth (ages 10–25) perceive and conceptualize mental health, recognizing the complexity of understanding mental health issues versus everyday challenges. The literature review, based on 11 studies, emphasizes the need for a shared language to clarify these distinctions, particularly among children, parents, and professionals. The findings highlight the importance of promoting mental well-being and integrating these insights into educational systems. Additionally, the study acknowledges that age, gender, and socioeconomic status influence youths' understanding of mental health, suggesting that tailored interventions should consider these factors for effective support.This study will help support my research question and will help me point out the vulnerabilities depending on age and gender.

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Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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].

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?

Methods

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

Population

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.

Context

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.

Concepts

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

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.

Table 2 Summary of included studies studying child and youth's perceptions of mental health

Results

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].

Gender, age, socioeconomic status

Gender

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.

Age

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.

Discussion

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.

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].

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].

References

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Funding

Open access funding provided by Karlstad University. The authors report no funding source.

Author information

Authors and Affiliations

1. Department of Health Service, Management and Policy, University of Florida, 1125, Central Dr. 32610, Gainesville, FL, USA

Linda Beckman & Sven Hassler

2. Department of Public Health Science, Karlstad University, Universitetsgatan 2, 651 88, Karlstad, Sweden

Linda Beckman

3. Department of School Development and Leadership, Malmö University, 211 19, Malmö, Sweden

Lisa Hellström

Contributions

L.B and L.H conducted the literature search and scanned the abstracts. L.B drafted the manuscript, figures, and tables. All (L.B, L.H., S.H.) authors discussed and wrote the results, as well as the discussion. All authors reviewed the manuscript.

Corresponding author

Correspondence to Sven Hassler.

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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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# data[].attributes.attachment_link.title
Children and youth's perceptions of mental health-a scoping review of qualitative studies - BMC Psychiatry

# data[].attributes.attachment_link.description
Background 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.

# data[].attributes.body
Mukolo, A., Heflinger, C. A., & Wallston, K. A. (2010). The stigma of childhood mental disorders: a conceptual framework. Journal of the American Academy of Child and Adolescent Psychiatry, 49(2), 92–103; quiz 198. https://pmc.ncbi.nlm.nih.gov/articles/PMC2904965/

The article The Stigma of Childhood Mental Disorders: A Conceptual Framework explores the stigma faced by children with mental health issues and its impact on access to care. It discusses how this stigma affects both children and their caregivers, leading to underutilization of mental health services, especially among minority groups, and calls for improved models to address stigma in child mental health. This journal is important to my project because it discusses how it can be hard to access help for mental health.

# data[].attributes.attachment_link.title
The stigma of childhood mental disorders: A conceptual framework

# data[].attributes.attachment_link.description
To describe the state of the literature on stigma associated with children’s mental disorders and highlight gaps in empirical work. We reviewed child mental illness stigma articles in (English only) peer-reviewed journals available through Medline…

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Kaushik, A., Kostaki, E., & Kyriakopoulos, M. (2016). The Stigma of Mental Illness in Children and adolescents: a Systematic Review. Psychiatry Research https://www.sciencedirect.com/science/article/abs/pii/S0165178116306400?via%3Dihub

The article reviews the stigmatization of children and adolescents with mental health difficulties (YP-MHD), revealing that it is a widespread and disabling issue. The study highlights how stigma, both from peers and adults, can prevent young people from seeking treatment, exacerbating their mental health struggles. The review identified that self-stigmatization often leads to secrecy and avoidance of intervention, ultimately worsening outcomes. The findings suggest that better understanding and addressing the specific stigmatizing processes affecting this group could improve early intervention efforts and long-term mental health outcomes. Using this source for my project will be important so I can explain the importance of mental health and the struggles that go along with it.

# data[].attributes.attachment_link.title
The stigma of mental illness in children and adolescents: A systematic review - PubMed

# data[].attributes.attachment_link.description
One in ten children and adolescents suffer with mental health difficulties at any given time, yet less than one third seek treatment. Untreated mental illness predisposes to longstanding individual difficulties and presents a great public health burden. Large scale initiatives to reduce stigmatizati …

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Sheikhan, N. Y., Henderson, J. L., Halsall, T., Daley, M., Brownell, S., Shah, J., Iyer, S. N., & Hawke, L. D. (2023, January 26). Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: A qualitative study - BMC health services research. BioMed Central. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-023-09075-6

The study explores how stigma acts as a barrier to early mental health intervention for youth in Ontario, Canada. It reveals that stigma causes youth to delay seeking help, with many feeling caught between being "sick enough" or "not sick enough" to deserve services. Participants described how stigma influenced both their access to services and how their challenges were perceived, either being trivialized or overly medicalized. The study calls for changes in service models to reduce stigma, particularly through offering services across a spectrum of challenges, and increasing awareness about the invisibility of mental health issues. This article by BioMed Central explains delay of getting help in adolescents and shows a study surrounding this issue and will be crucial for my project.

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Abstract

Background

Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction.

Objective

This study aims to understand how stigma influences service seeking among youth with mental health challenges.

Methods

Qualitative inquiry was taken using youth engagement, underpinned by pragmatism. Data were collected via 4 virtual focus groups with 22 purposively selected youth participants with lived experience of mental health challenges in Ontario, Canada. Focus group guides were developed collaboratively among research team members, including youth co-researchers. Data were analyzed inductively using reflexive thematic analysis.

Results

Three main themes were constructed from the data: point of entry into the system, being biomedicalized or trivialized, and paving the way for non-stigmatizing services. Initial contact with the mental healthcare system was seen to be affected by stigma, causing participants to delay contact or be refused services if they do not fit with an expected profile. Participants described a constant negotiation between feeling 'sick enough' and 'not sick enough' to receive services. Once participants accessed services, they perceived the biomedicalization or trivialization of their challenges to be driven by stigma. Lastly, participants reflected on changes needed to reduce stigma's effects on seeking and obtaining services.

Conclusion

A constant negotiation between being 'sick enough' or 'not sick enough' is a key component of stigma from the perspectives of youth. This tension influences youth decisions about whether to seek services, but also service provider decisions about whether to offer services. Building awareness around the invisibility of mental health challenges and the continuum of wellness to illness may help to break down stigma's impact as a barrier to service seeking. Early intervention models of care that propose services across the spectrum of challenges may prevent the sense of stigma that deters youth from accessing and continuing to access services.

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Introduction

The stigma toward mental illness includes a variety of harmful stereotypical attitudes and behaviors enacted against people who have been labeled as mentally ill [ 1]. Common stigmatizing beliefs include the notion that mental illness signals personal deficits, weakness, difference, and a lack of self-control, and that people with mental illness cannot recover and are dangerous and violent [ 2]. Stigma intersects with culture and is found throughout all levels of society [ 3]-in the general public, within families and social circles, in the media and social media, among healthcare professionals, and among affected individuals themselves [ 4].

Stigma can be understood at three intersecting levels: structural, social, and self-stigma [ 5]. Structural stigma refers to the policies and practices of institutions that systematically restrict the rights and opportunities for people living with mental health disorders. Social stigma refers to the process whereby social groups endorse stereotypes about people with a stigmatized condition and act against them. Self-stigma occurs when individuals with mental health disorders internalize societal attitudes and discriminatory practices.

In 2018, some 10% of Canadian youth aged 12-24 years considered their mental health to be no better than "fair" or "poor" [ 6]. This proportion more than tripled in 2020, in the midst of the COVID-19 pandemic [ 7]. Youth are a critically important population in terms of mental health promotion, prevention, and treatment from a developmental perspective. About half of all mental health disorders first arise by about mid-adolescence [ 8]. Suicidal ideation and attempts are particularly high among youth [ 9]. The negative impacts of mental health challenges on developmental trajectories make adolescence an optimal time to intervene, both for full threshold mental disorders and subthreshold mental health challenges. There is also a need for greater investment in mental health promotion and prevention efforts [ 10]. Early intervention approaches, in particular, can connect youth with services before a full-threshold disorder develops. Although much work remains to be done in terms of developing effective, evidence-based early interventions for at-risk youth [ 11], such interventions have the potential to prevent medium- and long-term deterioration.

Despite the potential for intervening early, youth are highly impacted by stigma, and stigma can in turn constitute a major barrier to service seeking [ 12, 13]. In a systematic review, perceived stigma was found to be one of the main reasons youth choose not to seek mental health services [ 14]. Service seeking is fostered by factors such as parental support and social support, positive past service experiences, and the youth's motivation to develop coping skills and address negative impacts of mental health challenges [ 13, 14]. A variety of mental health promotion and service design strategies have been recommended to foster service seeking among youth with mental health challenges, such as increasing health literacy [ 14], developing youth-friendly service settings that address a wide range of challenges [ 15, 16], and reducing stigma [ 17].

A range of stigma reduction approaches have also been examined [ 18]. For instance, intergroup contact theory proposes that direct contact with individuals impacted by stigma is key to reducing prejudice [ 19]. Although social contact has become a key ingredient of anti-stigma interventions, for providers, professional contact may not have the same stigma reduction effects [ 20]. Other approaches, including internet-based interventions [ 21], arts-based interventions [ 22], mass-media approaches [ 23], and peer support [ 24] also have potential. Among youth, classroom-based contact approaches have been used with some success [ 25]. If such interventions can reduce stigma, they may increase the willingness of youth to seek services when needed. However, the effect sizes of anti-stigma interventions are consistently small and stigma remains a considerable societal problem [ 18].

Researchers have been continually calling for more research on youth mental health stigma and stigma-reduction interventions to better understand the phenomena in various populations and reduce its negative impacts [ 26, 27, 28]. Since youth are embedded in families, schools, and societies, there are many potential sources of stigma and targets for stigma-reduction interventions. Identifying the mechanisms of how stigma influences decision-making may help guide those designing anti-stigma interventions on how to best break down stigma's impact as a barrier to service seeking. The present study aims to understand how stigma influences service seeking decisions among youth with mental health challenges in Ontario, Canada.

Method

Design and setting

An experiential approach to qualitative inquiry was used to understand youth experiences and meanings [ 29]. Virtual focus group interviews were conducted in Ontario, Canada to elicit a rich understanding of the phenomena. The research team consisted of mental health researchers from the health and social sciences, clinicians, and youth co-researchers connected to a mental health and substance use clinical research setting. The present manuscript followed the Consolidated Criteria for Reporting Qualitative Research checklist [ 30].

Epistemological stance

The present study was underpinned by a pragmatic worldview. As youth engagement occurred at all stages of this study, pragmatism was well suited to guide the study given the orientation towards real world practice and social change [ 31]. Pragmatism aligns with youth-oriented research as it is underpinned by democratic values, collaborative and action-oriented approaches, and social justice [ 31].

Youth engagement

In accordance with the McCain Model of Youth Engagement [ 32], youth team members with lived experience contributed to all aspects of the project. Many youth members of the Centre for Addiction and Mental Health (CAMH) Youth Engagement Initiative have consistently identified stigma as an important research topic to pursue, guiding the initial project idea. Over the course of the project, five youth supported the research process through various roles, including three youth who were highly engaged in the project (one youth research analyst, one youth engagement specialist, and one youth data analyst), as well as two youth consultants who contributed on an advisory basis. Youth contributions included discussing the development of the grant application, co-developing study and recruitment materials, recruiting and consenting participants, co-facilitating the focus groups, analyzing and interpreting the data, and writing the manuscript. The three youth who contributed substantially to the project are co-authors (NYS, MD, SB).

Participants

Participants included 22 youth with lived experience of mental health challenges. To be eligible, youth had to be aged 14-25 years, reside in Ontario, and self-describe as having experienced mental health challenges. Some participants had a pre-existing relationship with the research team as they had previously participated in research by the team and expressed interest in participating in future research.

Procedures

Participants were purposively selected to increase sample diversity and breadth of data. In an initial open recruitment call, we sent a study flyer through the team's networks of youth engagement entities and youth-serving organizations. We then examined several sociodemographic factors (age, gender, ethnicity) in the initial sample to identify gaps in diversity; accordingly, we used selective recruitment based on demographic characteristics to invite participants from a database of previous study participants in Ontario who consented to be contacted about future research. Potential participants contacted a research staff member by phone, email, or text, as per the study flyer, to learn more about the study. They were then invited to a screening and informed consent process, using the institutionally approved teleconferencing platform. Informed consent was collected electronically via REDCap software [ 33], after which participants provided demographic information on an unlinked REDCap survey. Participant numbers were assigned sequentially as participants were screened. Participants received a $50 honorarium. CAMH Research Ethics Board approval was obtained.

Data collection

The research team conducted 4 semi-structured virtual focus groups from August to December 2021. A virtual platform was chosen for pragmatic reasons, given pandemic-related restrictions during the data collection period. The focus group discussions were approximately 120 min long, included 4 to 7 participants, and were held sequentially as participants were consented into the study.

The interview guide was developed collaboratively with the research team, including youth co-researchers. The guide included questions about the impact that various types of stigma have on service seeking, with a focus on attitudes, language, acceptance, discrimination, knowledge, and self-stigma. For instance, the guide included questions such as "When you're struggling with mental health challenges, how does stigma affect the way you see your challenges?", "Once you've made the decision to seek services, does mental health stigma make it harder to get those services?", and "Once you've actually gotten into services, does mental health stigma affect how much you get involved or invested in the treatment?" The intersection of gender and other diversity factors with stigma was directly embedded in the interview guide, for example, "Do you think gender influences stigma? How does it influence your experience of stigma? How does it affect the way people feel or show stigma?" and "What other aspects of a person's identity influence stigma?".

Focus groups were co-facilitated by two youth with lived experience, one in a research analyst position and one as a youth engagement specialist. At the start of each focus group, they led a discussion about participants' perspectives on stigma to help participants come to a common understanding of the topic. Discussions were recorded and transcribed verbatim. As focus groups were conducted virtually, participants had the option of using the chat function. To ensure that the chat content stimulated discussion among participants and was captured in the transcripts, facilitators read the content of the chat aloud as it occurred. A trained support worker was available if any participants needed extra support; this service was not used for any of the focus group discussions.

Data analysis

Data were analyzed inductively using reflexive thematic analysis (TA) as outlined by Braun and Clarke [ 34]. Reflexive TA was chosen as it is a flexible approach to identify patterns and themes across the data. Reflexive TA is a recursive process and includes the following 6 phases: (1) data familiarization; (2) systematic coding; (3) generating the initial themes; (4) developing and reviewing the themes; (5) refining and defining the themes; and (6) writing the results. Within reflexive TA, themes are developed from codes and conceptualized as patterns of shared meaning. The analytic process was inductive and grounded in the data.

The coding process was conducted on NVivo 12 by a single analyst with lived experience (NYS). This process was organic and involved prolonged engagement with the data [ 35]. Throughout the analysis, ongoing meetings with NYS, LDH, MD, and SB were held to foster a rich nuanced interpretation of the data and enhance reflexivity [ 35]. For instance, the analyst (NYS) and lead (LDH) brought the tentative themes back to the youth co-authors (MD, SB) with representative quotes; through this discussion, they refined the themes, confirmed their relevance, and gained new interpretive insights. To aid quality practice, the analyst kept a reflexive journal throughout the research process. The written reflections were used to enhance self-awareness and reflect on researcher positionality.

Results

Participants had a variety of backgrounds and characteristics (Table 1). Most participants had spoken to a professional about mental health or substance use. The analysis below discusses three main themes related to the influence of stigma on service seeking that were constructed from the data: (a) point of entry into the system (b) being biomedicalized or trivialized; and (c) paving the way for non-stigmatizing services.

Table 1 Demographic characteristics of participants

Theme 1: Point of entry into the system

The first theme relates to how stigma shaped participants' initial first contact with services. There are two subthemes: (a) delaying first contact; and (b) 'am I sick enough?'. This includes reasons for delaying first contact with services, and subsequently, having to be labeled as 'sick enough' to receive treatment.

Delaying first contact

Youth participants discussed various reasons for delaying first contact with mental health services. Their reasons related to limited literacy, shame, negative stereotypes, a fear of shifted identity, and label avoidance.

As participants reflected on why they delayed first contact, many believed they lacked appropriate knowledge and information about mental illness as it was not generally discussed. They recalled being unaware that their symptoms were related to mental illness. One youth noted how the shame associated with mental illness intersected with a lack of knowledge regarding their symptoms:

Youth participants also reported that they delayed seeking services as they were afraid service seeking would shift how they perceived themselves and how others might perceive them. One youth noted a dissonance between their ideal self and their self-image if they accessed services:

Similarly, a few participants reported delaying seeking services because they felt that the negative stereotypes associated with mental illness would shift their professional identity, especially if they had to disclose. For example, one youth recalled feeling that a mental health diagnosis would jeopardize their career prospects:

Am I sick enough?

After the initial barriers that delayed service seeking, youth reported feeling self-doubt about whether they were 'sick enough' for treatment. They explained that they were subsequently labeled by themselves and others as either 'sick enough' or 'not sick enough' to be treated. They expressed that 'sick enough' was often equated with being in crisis. Providers were seen as gatekeepers, holding the power to label youth as 'sick enough' for treatment.

Youth discussed self-doubt as a form of 'imposter's syndrome' regarding whether they felt they were 'sick enough' to be using services. Imposter's syndrome, as described by the participants, was when they felt they did not warrant the treatment and were taking away resources from. One youth noted:

As participants attempted to access services, they felt labeled as either 'sick enough' or 'not sick enough' by providers. The 'not sick enough' label represented a liminal space between sick and healthy, when youth did not fit into either category. Many described being denied treatment for not fitting into the stereotypical depiction of a mental health patient-this was a major barrier to early treatment. One stated that, "there's only one 'look' of people who can get that treatment early and it's because they look like that stereotype - and if they don't fit into that, you don't get help" [Focus Group 4]. Another described this process as humiliating:

Theme 2: Being biomedicalized or trivialized

The second theme captures participant experiences in clinical settings and how they felt that their experiences were either trivialized or biomedicalized according to their perception of the application of the 'medical model'. It contains two subthemes: (a) ignoring the gray; and (b) symptoms are trivialized by providers. According to the participants, being biomedicalized included having to fit into reductive treatment approaches that included unnecessary labels, finite and structured options, and quick fix solutions. They perceived these approaches to be due to the valorization of the medical model by clinicians. Similar to the label 'not sick enough', being trivialized pertained to being ignored or dismissed by providers during their care.

Ignoring the gray

Participants strongly criticized certain approaches to the care they received, citing them as a reflection of the medical model. Youth described a paternalistic and oversimplified approach that they considered to be inherent to the system. Several discussed feeling the gray areas of mental health were ignored by the service system: "It's like, you're kind of given these black and white options and they don't talk about gray areas." [Focus Group 4] The gray areas that participants felt were ignored pertained to treatment options and outcomes, both of which they felt were bound by the 'medical model' due to its perceived reductionist nature. Similarly, youth described services as being finite and oversimplified:

Some discussed feelings of guilt, shame, and judgment for not feeling better after a set course of treatment. For example, one participant felt worried about the negative label they may receive if they did not get better:

Another youth shared feeling shame and having to hide that they did not feeling better after six weeks of cognitive-behavioral therapy, stating that, "I'm going to be seen as I wasn't trying hard enough." [Focus Group 2].

Symptoms are trivialized by providers

When youth did access services-despite the initial barriers-many felt their symptoms were trivialized by providers. Several described feeling dismissed and ignored. This was worsened when it intersected with stereotypes related to specific diagnoses, gender, and race.

A few participants indicated that trivialization and stigma differ by diagnosis. For instance, youth felt that the stigmatizing attitudes and stereotypes regarding schizophrenia were more severe and harmful compared to those about depression. Youth felt they were treated differently-and ultimately, trivialized-based on these attitudes. One participant referred to opioid use disorder as an example, stating that, from their experience, providers will dismiss any other symptoms they might have as due to opioid use, even if it is unrelated. Another felt that providers dismissed personality disorders as 'unfixable'. In varying ways, then, the youth felt that the stigmatizing attitudes they experienced from providers ultimately deterred youth from accessing services.

Trivialization also manifested through microaggressions for some racialized youth. For instance:

Many participants indicated that trivialization contributed to the formation of negative perceptions regarding treatment. Ultimately, their difficult encounters discouraged them from accessing services again because they anticipated future experiences would be similar. In fitting with the previous sub-theme, youth tied their experience of feeling dismissed to stigma and 'paternalistic attitudes' in health care.

Paving the way for non-stigmatizing services

To address the barriers to service seeking, the final theme captures several priorities for reducing stigma toward mental health services. This theme contains three subthemes: (a) shifting attitudes; (b) increasing awareness and dialogue; and (c) increasing service accessibility.

Shifting attitudes

Participants indicated the need to shift attitudes regarding mental health. This included valuing mental health like physical health, breaking down the dichotomy of mental illness versus wellness, and reducing stigmatizing forms of care. Many felt that treating and valuing mental health like physical health could reduce stigma. This was seen as an issue within and beyond the clinical setting:

Viewing a diagnosis of mental illness in the same context that you would see a diagnosis of a physical one. So, in the same way that you wouldn't blame someone with cancer for being, like, tired, or moody, you're not going to blame someone with a mental illness for being tired and moody. [Focus Group 4]

One thing that can be done on kind of institutional level is to treat mental health the same way we treat other health. For example, when an employer provides benefits for health care or whatever... It's always health and dental that's covered or have good coverage, or whatever. And mental health kind of is like an afterthought. [...] Just acting, I guess, or showing that you accept mental health as an important part of health. [Focus Group 2]

Reflecting similar frustrations with labeling in previous themes, a few participants discussed the need to shift attitudes regarding how mental health is traditionally approached. This includes transitioning from labels such as 'sick' versus 'healthy', to viewing mental health on a continuum:

Lastly, a few participants mentioned the need to change certain aspects of care that perpetuate stigma. For instance, one youth stated that a starting point to reducing stigma includes "changing the language we use, especially in a medical context, you know. Like, not phrasing things in ways that make people feel singled out or demonized." [Focus Group 4] This appeared to be a necessary change given that many participants had previously avoided services as a consequence of care that they experienced as stigmatizing.

Increasing awareness and dialogue

A desire for greater awareness and dialogue around mental health was widely expressed by participants. Many identified wanting greater open dialogue around mental health within their families and within institutions. For example, one youth discussed the need for open dialogue in schools to prevent instances where professionals may dismiss their mental health concerns:

Participants further discussed the need for increased mental health awareness in schools as early as possible. Some described education as a solution for combating stigmatizing attitudes, while others challenged this sentiment and indicated that education alone was not sufficient.

Increasing accessibility of services and accommodations

Participants discussed increasing access to mental health services and improving accommodations at school or work as solutions to mitigating stigma. Some described that addressing issues with the health system could in turn reduce stigma. For instance:

Lastly, a few participants suggested the need for greater accommodations in educational institutions or employers as one facet to reducing stigma. Reflecting prior discussions around treating mental health like physical health, one participant described 'mental health days' as a solution to reducing stigma:

Discussion

Previous research shows that stigma delays access to mental health services [ 28, 36, 37]. Consistent with existing literature on stigma among service-seeking youth [ 36, 38, 39], many youth in the present study delayed seeking services due to negative stereotypes that they encounter in the media, limited mental health literacy, label avoidance, and fear of shifted self-image. Moreover, disclosure-related concerns can also delay access to services [ 36]. In our study, disclosure concerns were raised by participants who felt that seeking services would shift their professional identity or jeopardize their career prospects. As most of the stigma research is carried out with adults [ 40], further research is needed on youth identity and mental health stigma as identity and career development contexts may differ for youth.

In clinical settings, it has previously been reported that people seeking mental health services often feel patronized, dismissed, and humiliated by their providers [ 41, 42]. Youth have reported that even providers minimize and belittle their mental health concerns, and that they are denied access to services if they are not considered sick enough [ 43]. Therapeutic pessimism-when providers hold pessimistic views regarding the likelihood of recovery-is also a source of stigma in clinical settings [ 42]. In the present study, participants referred to therapeutic pessimism as their challenges are considered 'unfixable' or they are quickly labeled as 'treatment resistant'. Similar to our findings, Barney et al. [ 44] found that negative beliefs regarding symptom severity can shift the blame to individuals when they do not recover fully and quickly. In short, individuals would come to stigmatize themselves for their mental illness if they did not recover quickly and doubly if clinicians labeled them 'unfixable'. However, most stigma research focuses on initial access to care [ 28]. Our findings highlight how clinical encounters that are experienced as stigmatizing also deter youth from accessing services at later points.

Stigma manifests across the spectrum of mental health challenges, negatively impacting life opportunities, quality of life, and self-esteem [ 45]. For milder mental health challenges, illness invalidation and controllability stigma emerge [ 45, 46, 47]. Illness invalidation stigma occurs when certain symptoms are viewed as trivial, while controllability stigma involves beliefs that individuals are responsible for resolving their symptoms on their own [ 47]. For example, in a recent study [ 48], youth reported invalidating experiences such as not feeling heard or seen by providers, being turned away from services, and non-recognition of the severity of their symptoms. Wrongful depathologization, such as when the severity of mental health problems is trivialized by providers, can increase stigma as it reinforces stereotypes that service users exaggerate their symptoms [ 49].

Many of our findings align with a conceptual model by Henshaw et al. [ 47] on treatment and illness stigma. Although the model is specific to depression, the components relate to the experiences of youth in our study. For instance, the model suggests that when people seek services soon after symptom onset, they are met with the stigma of being 'not sick enough' [ 47]. If they seek services too late, they are faced with the stigma of being 'too sick'. Given the established value of early intervention [ 50], mitigating the stigma that prevents youth from accessing effective early interventions is a critical step to improving youth mental health.

Youth consider labels to be a double-edged sword. On the one hand, labels can facilitate help seeking for youth by enabling access to services, validating their experiences, and providing them with a greater understanding of their diagnosis [ 37]. On the other hand, labels place youth in a distinct illness category that can further exacerbate stigma. Although much of the literature focuses on the consequences of labelling as it relates to stigma [ 51], there are also consequences of withholding diagnostic labelling, for instance, placing youth in a 'not sick enough' category that disqualifies them from vital services. Moreover, oversimplified labels largely ignore the dimensionality aspect of mental illness. Lane [ 51] discusses the implications of taking a categorical understanding of diagnosis-similar to 'sick enough' vs. 'not sick enough'-in terms of reducing access to services and resources. This is also shown in finite prognoses and treatment options as mental health problems are seen as acute, with a distinct endpoint [ 52]. Reflecting epistemic shifts in psychiatry, providers might consider moving away from categorical approach, towards a dimensional and transdiagnostic approach that cuts across traditional diagnostic boundaries and treatments [ 53]. This is especially needed for youth, as the complexities with emerging and early illnesses are difficult to capture with traditional taxonomies [ 54].

Early intervention models of care, such as transdiagnostic staging models that propose services for subthreshold symptoms [ 54], hold the potential to prevent negative mental health impacts by addressing symptoms earlier. Our findings suggest that such models might have the added advantage of reducing stigma and encouraging service-seeking behaviors, as they open their doors to youth who might elsewhere be deemed as 'not sick enough'. With a focus on early symptom reduction and resilience building, wellness-based models have the potential to bring mental health out of a medical model that excludes them based on symptomatic thresholds-which, according to youth, drives stigma and poses a barrier to care. From this perspective, addressing youth mental health at the societal level requires a wellness focus that prioritizes health equity, strengthens protective factors, and supports positive youth development [ 55, 56, 57].

Despite increases in anti-stigma campaigns, stigmatizing attitudes held by providers remain [ 58]. In light of our findings, reducing stigmatizing forms of care should be prioritized in systems change. There is a need for patient-oriented research and service development co-designed with youth [ 16], in addition to anti-stigma training for providers early on in their careers [ 38, 39, 59]. Moreover, as a few participants reported their care being influenced by stereotypes related to gender, race, and transphobia, anti-oppressive pedagogies should be integrated into training programs. Racialized groups often face 'double stigma', with mental health stigma being an additional burden to prejudice, maltreatment, and discrimination as it relates to racism [ 60]. Future research should further explore youth experiences with 'double stigma', which remains largely unexplored for youth [ 36, 37].

Strengths & limitations

This research demonstrates both strengths and limitations. A notable strength is the extent of youth engagement; engaging youth in all stages of the study enhanced the validity of the data and increased the relevance of the findings to the community. The remote nature of the focus groups enabled us to reach a more diverse sample and provided participants with an added means of contributing to the discussion, such as through the chat function; however, the virtual approach also excluded individuals without online access and prevented in-person group dynamics from occurring. Moreover, individual interviews may have evoked greater depth and clarity in the data compared to focus groups [ 61]. It is also important to note that these findings provide a snapshot of perspectives on stigma at a unique time in the history of global public health, given that the COVID-19 pandemic has had considerable repercussions for both youth mental health and associated services [ 62, 63]. Lastly, it is possible that the experiences reported are largely negative given that the interview guide did not include questions on positive experience with care. As suggested by MacDonald et al., future research on positive youth experiences with mental health services is needed to support best practices [ 39], in addition to exploring service provider views to gain a more fulsome picture.

Conclusion

Stigma shapes the experiences of youth seeking mental health services, from delaying first contact with services to deterring youth from recurrent service use. Certain practices that place youth into 'sick enough' or 'not sick enough' categories warrant reconsideration-youth consider them an oversimplification of their lived experiences, which precludes many from accessing vital services and acts as a barrier to early intervention. Mitigating the stigma that prevents youth from accessing effective early interventions is a critical step to improving youth mental health. Stigma reduction initiatives would benefit from a dimensional approach that is inclusive of the mental health continuum, and targets both service users and providers.

Availability of data and materials

Data are available upon reasonable request to the corresponding author (lisa.hawke@camh.ca), with Research Ethics Board approval.

Abbreviations

CAMH:

Centre for Addiction and Mental Health

TA:

Thematic Analysis

References

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Acknowledgements

The authors thank the youth members of the CAMH Youth Advisory

Initiative for their contributions to the study.

Funding

This study was funded by the Canadian Institutes of Health Research. The authors have no conflicts of interest to declare.

Author information

Authors and Affiliations

1. Centre for Addiction and Mental Health, 80 Workman Way, Toronto, ON, M6J 1H4, Canada

Natasha Y. Sheikhan, Jo L. Henderson, Mardi Daley, Samantha Brownell & Lisa D. Hawke

2. University of Ottawa Institute of Mental Health Research, 1145 Carling Avenue, Ottawa, ON, K1Z 7K4, Canada

Tanya Halsall

3. Department of Psychiatry, McGill University, 1033 Pine Avenue West, Montreal, QC, H3A 1A1, Canada

Jai Shah & Srividya N. Iyer

Contributions

LDH conceived, contributed to the design, interpreted the data, and supervised the study. NYS analyzed and interpreted the data. Both LDH and NYS drafted the manuscript. MD and SB facilitated the focus groups, interpreted the data, and critically reviewed the manuscript. JH, TH, JS, and SI contributed to the design of the study and critically reviewed the manuscript. All authors approved the final version.

Corresponding author

Correspondence to Lisa D. Hawke.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Centre for Addiction and Mental Health Research Ethics Board in Toronto, Canada. Informed consent was obtained electronically from all participants. All methods were performed in accordance with the relevant guidelines and regulations.

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Not applicable.

Competing interests

The authors have no competing interests to declare.

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Sheikhan, N.Y., Henderson, J.L., Halsall, T. et al. Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: a qualitative study. BMC Health Serv Res 23, 86 (2023). https://doi.org/10.1186/s12913-023-09075-6
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DOI: https://doi.org/10.1186/s12913-023-09075-6

Keywords

# data[].attributes.attachment_link.title
Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: a qualitative study - BMC Health Services Research

# data[].attributes.attachment_link.description
Background Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction. Objective This study aims to understand how stigma influences service seeking among youth with mental health challenges.

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Gale, F. (2007). Tackling the stigma of mental health in vulnerable children and young people. In P. Vostanis (Ed.), Mental health interventions and services for vulnerable children and young people (pp. 58–79). Jessica Kingsley Publishers. Tackling the stigma of mental health in vulnerable children and young people.

This chapter explores the impact of mental health stigma on vulnerable children and young people, focusing on how stigma leads to shame, social exclusion, and reluctance to seek help. It highlights that certain groups, particularly those at greater risk of mental health issues, face additional health inequalities and discrimination. While literature on stigma in this population is limited, the chapter applies broader research to understand how stigma affects these children and suggests strategies for cross-agency service improvements and interventions to address the issue. This chapter explains the stigma of mental health and goes into how it's not understood enough in younger kids and talks about improvements that could be made to help address this issue which will help me answer my research question.

# data[].attributes.attachment_link.title
Tackling the stigma of mental health in vulnerable children and young people.

# data[].attributes.attachment_link.description
The severe and pervasive effects of the stigma of mental health are known to affect individuals and families, and can result in intense feelings of shame, social exclusion, and a reluctance to seek help. There is an increasing body of knowledge which explores the impact of stigma in children and young people who may have mental health needs. Certain vulnerable groups of children and young people are known to be at greater risk of mental health problems, especially those groups discussed within this book. These children are also known to experience greater health inequalities than the rest of the population and be subject to discrimination because of their status, and because of the perception that they are ‘at-risk’. This chapter will examine the origins and experiences of the stigma surrounding mental health in relation to vulnerable children and young people with emerging mental health needs. There is a paucity of literature on the effects of stigma in this population; however, this chapter will explore literature that focuses on the context and impact of stigma on children and young people from the general population and will apply it to children from vulnerable groups. It will also determine factors that could contribute to cross-agency service improvements and interventions to tackle stigma. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

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Lomax, T., Butler, J., Cipriani, A., & Singh, I. (2024, August 5). Effect of nature on the mental health and well-being of children and adolescents: Meta-review. Cambridge Core. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/effect-of-nature-on-the-mental-health-and-wellbeing-of-children-and-adolescents-metareview/CDFA53EA8BEFFDA0613B80632F3FB18B

His meta-review examines how nature impacts the mental health and well-being of children and adolescents, finding that nature appears to have a beneficial effect, though the evidence is not conclusive. The studies suggest positive outcomes, but more research is needed, especially in clinical, ethnically diverse, and low- and middle-income populations. Using this article I can show how the adolescents crisis line receives a large amount of calls and shows readers how extreme the mental health crisis is right now in younger kids.

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Method

This review is built around four key questions:

1. (a) How does the literature define 'nature'?

2. (b) What are the characteristics of the nature intervention?

3. (c) What are the mental health and well-being outcomes being measured?

4. (d) What does the evidence show with regard to how nature affects the mental health and well-being of children and adolescents?

The study protocol was registered on Open Science Framework ( https://osf.io/ehyc8/). As this is a meta-review of existing published literature, ethical approval was not required.

Search strategy

The full search strategy can be found in the Supplementary material available online at https://doi.org/10.1192/bjp.2024.109. The search included terms relating to nature, mental health and well-being, and children and adolescents. Search terms used relating to nature include (but are not limited to): Natural environment, natural world, nature, forests, grasslands, wetlands, wilderness, wilderness experience, horticulture therapy, gardens, gardening, parks, green space, blue space, outdoor*, ecotherap* and nature-based. Mental health and well-being outcomes used include (but are not limited to): mental health, mental disease, mental wellbeing, psychological well-being, well-being, cognitive development, infant development, depression, anxiety, child psychiatry, adolescent psychiatry. The following databases were searched: MEDLINE, Embase and PsycINFO. Searches were limited to the English language and from 2010 until 31 October 2022. The search was from 2010 onwards, as an initial search using the MEDLINE search strategy found little evidence on nature published before then (Supplementary Figs 2 and 3).

Inclusion criteria

Studies with children and/or adolescents up to the age of 18 were included, as well as studies using a sample population up to 25 years of age that had a mean age below 18. Studies also including adults were included if there was a subgroup analysis on our population of interest (<18 years). The exposure/intervention of interest was 'nature'. We took a broad inclusive view of the definition of 'nature' (thus including studies looking at surrounding green space to those looking at wilderness therapy). Outcomes included any measure of mental health and well-being (e.g. developmental, cognitive and behavioural outcomes), using validated mental health and well-being scales as well as less well-defined measures, such as self-perceived stress.

Study type and source of evidence selection

Both primary (observational or experimental) and secondary (reviews with or without quantitative synthesis) studies were included. Unpublished studies, such as dissertations, were excluded. Two reviewers independently undertook title and abstract screening, then full-text examination. Any disagreements were settled between the two reviewers, seeking advice from a third reviewer in case of discrepancies. After identifying all systematic and scoping reviews, the reviews were examined to ascertain whether any individual studies were not included in the retrieved evidence base (i.e. primary studies that were published after the date of the last identified review). Review authors were contacted for missing information, as appropriate.

Certainty of evidence

Included studies were critically appraised according to their study type, using the following validated tools: the AMSTAR 2 tool for systematic reviews; RoB 2 (version 2 of the Cochrane risk-of-bias tool) for randomised controlled trials; ROBINS-I (Risk Of Bias In Non-randomised Studies - of Intervention) for experimental non-randomised studies; and the Newcastle-Ottawa Scale (NOS) for observational studies. The NOS tool was adapted for cross-sectional and cohort studies respectively to align with our study aims, considering the following specific confounders relevant to the literature base: pollution, noise, social contact/engagement and exercise (Supplementary material). All information about the assessment tools can be found in our protocol ( https://osf.io/ehyc8/).

Data extraction

Two independent reviewers extracted data on: author, year of publication, journal (impact factor); country of origin; aims/purpose; population characteristics; methodology; how nature is defined; nature intervention characteristics; mental health and well-being outcome measures; key findings; any mechanisms. Data extraction was first performed on 15 November 2022.

Analysis of the evidence

Data were analysed using a descriptive content analysis, broken down into the four questions that reflect the meta-review's aims (see above).

Results

Study selection

We retrieved 1657 articles in total, after removal of duplicates. After title, abstract and full-text screening, 162 studies were eligible for inclusion (the PRISMA flowchart appears in Supplementary Fig. 1). From these, we identified the evidence with the highest degree of certainty - 16 systematic and 2 scoping reviews, as well as 5 cohort studies (published after the date of the last identified review). The Supplementary material lists the 139 studies that were potentially eligible but not included in this meta-review owing to selection for inclusion only of the highest quality evidence to answer the study aims, as per protocol.

Study characteristics

See Supplementary Table 1 for the study characteristics of included studies and key findings.

All reviews were from institutions in high- and middle-income countries. Two reviews did not give information on included studies' country or continent of origin. Five reviews reported some detail on continent or country of origin of included studies but did not provide detail on country of origin for all studies. Of the 441 primary studies where country of origin was reported (identified from reviews and the 5 cohort studies), studies were almost exclusively from high-income countries (HICs) ( n = 431), with only 9 studies coming from upper middle-income countries (South Africa, n = 5; Turkey, n = 2; Bulgaria, n = 1; Jamaica and St Vincent, n = 1) and one study from a low-income country (Iran). Of the primary studies where country of origin was reported, the majority ( n = 418) came from HICs, most likely examining majority White populations.

In general, ethnicity was poorly explored, with seven reviewsReference McCormick10,Reference Tillmann, Tobin, Avison and Gilliland11,Reference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24,Reference Fang, Lu, Gill, Liu, Chyi and Chen32-Reference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35 not reporting on whether included studies adjusted or collected data on ethnicity. Of the reviews that did report this, ethnicity was rarely adjusted for in included studies (Supplementary Table 1). Only oneReference Naya, Yi, Chu, Dunton and Mason36 out of the five cohort studies included in this meta-review adjusted for ethnicity and this was in a limited way (Hispanic versus non-Hispanic). Socioeconomic status (SES) was more routinely collected and adjusted for in primary studies compared with ethnicity, but reporting on SES in reviews was generally poor, with eight reviews not reporting on whether included studies collected data on and adjusted for SES (Supplementary Table 1).Reference McCormick10,Reference Tillmann, Tobin, Avison and Gilliland11,Reference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24,Reference Reece, Bray, Sinnett, Hayward and Martin27,Reference Dankiw, Tsiros, Baldock and Kumar29,Reference Fang, Lu, Gill, Liu, Chyi and Chen32,Reference Mann, Gray, Truong, Brymer, Passy and Ho34,Reference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35

Certainty of evidence

Only five primary studies (all cohort studies) published after the date of the last identified review were found to be of good quality and are included in this review (Supplementary material). In two of these five studies, out of eight risk-of-bias domains, high risk of bias was identified only in the selection domain (demonstrating that the outcome of interest was not present at the start of the study) and in the outcome domain (relating to adequacy of follow-up). In the remaining three studies high risk of bias was only identified in the selection domain (demonstrating that the outcome of interest was not present at the start of the study). These five primary studies were identified after reviewing all cross-sectional, cohort and experimental studies after the date of the last systematic review and examining their quality. There was cause for concern about the risk of bias in all systematic and scoping reviews in various domains, with high risk of bias identified in more than half of reviews in the following domains: reporting a priori protocol (with justifications of deviations from the protocol); using a comprehensive literature search strategy (although the majority of reviews were marked down for giving no justification of the English-language limitation); data extraction performed in duplicate; providing a list of excluded studies with justifications for exclusions; and reporting on the source of funding of the included studies (see Supplementary material).

How does the literature define 'nature'?

Results from the descriptive content analysis reveal that 'nature' appears to be defined or conceptualised along a continuum into three broad categories: a human-designed environment with natural elements (e.g. outdoor tarmacked playground with surrounding trees); a human-designed natural environment (e.g. garden); or a natural environment (e.g. woodland). Some studies found in this review can be categorised using this framework, but many articles did not clearly define what they meant by 'nature'Reference Zhang, Mavoa, Zhao, Raphael and Smith13,Reference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24,Reference Luque-Garcia, Corrales, Lertxundi, Diaz and Ibarluzea26,Reference de Keijzer, Gascon, Nieuwenhuijsen and Dadvand33,Reference Alderton, Villanueva, O'Connor, Boulange and Badland38-Reference Ahmed, Knibbs, Moss, Mouly, Yang and Mishra40 or included heterogeneous studies where nature appeared to be conceptualised in different waysReference Tillmann, Tobin, Avison and Gilliland11,Reference Zare Sakhvidi, Knobel, Bauwelinck, de Keijzer, Boll and Spano28-Reference Sprague, Bancalari, Karim and Siddiq31,Reference Mann, Gray, Truong, Brymer, Passy and Ho34,Reference Anabitarte, Ibarluzea, Garcia-Baquero, Santa Marina, Fernandez-Somoano and Tardon37,Reference Bikomeye, Balza and Beyer41 (Supplementary Table 2). Many studies referred to more general concepts, such as 'green space' or 'greenness'.Reference Vanaken and Danckaerts12,Reference Fleckney and Bentley25,Reference Reece, Bray, Sinnett, Hayward and Martin27,Reference Naya, Yi, Chu, Dunton and Mason36,Reference Bloemsma, Wijga, Klompmaker, Hoek, Janssen and Lebret39,Reference Almeida, Barros and Ribeiro42 Such cases could not be categorised without making unfounded assumptions.

What are the characteristics of the nature intervention?

Results from the descriptive content analysis show that the nature 'intervention' falls into three key areas: access to nature, exposure to nature or engagement with nature; the quantity and quality of nature are relevant to all three areas ( Fig. 1). Tillman et al's frameworkReference Tillmann, Tobin, Avison and Gilliland11 also included the three areas (access, exposure or engagement), but it did not include quantity and quality of nature. Research studies examined access, exposure or engagement with nature (or a mixture of these). All five cohort studies reported that they were looking at green space exposure, but they were actually using proxy measures of exposure (i.e. presence of 'surrounding green space' near the home ( n = 5) or school ( n = 1)) and in two cohort studies they also examined accessibility to green space. Five reviewsReference Vanaken and Danckaerts12,Reference Luque-Garcia, Corrales, Lertxundi, Diaz and Ibarluzea26-Reference Zare Sakhvidi, Knobel, Bauwelinck, de Keijzer, Boll and Spano28,Reference de Keijzer, Gascon, Nieuwenhuijsen and Dadvand33 reported that they were examining green space or 'greenness' exposure, but they all included studies in their review that looked at proxy measures of exposure (surrounding green space) and/or studies that looked at other things, such as access to green spaceReference Luque-Garcia, Corrales, Lertxundi, Diaz and Ibarluzea26 or activities in green space.Reference de Keijzer, Gascon, Nieuwenhuijsen and Dadvand33 Some studies made explicit the quantity (e.g. 1 day a week in a forest school); however, very few considered the 'quality' of the nature intervention. Fig. 1 gives examples of how studies may fit this framework.

What are the mental health and well-being outcomes being measured?

Mental health and well-being outcomes fit along a continuum, with 'disorder' at one end and 'well-being' at the other. Fig. 2 shows the range of mental health and well-being outcomes found in the meta-review.

The majority of studies examined symptoms or behaviours relating to mental health and well-being; a few looked at mental disorders, namely anxiety, depression and ADHD.Reference Tillmann, Tobin, Avison and Gilliland11,Reference Fleckney and Bentley25-Reference Reece, Bray, Sinnett, Hayward and Martin27,Reference Naya, Yi, Chu, Dunton and Mason36 No studies looked at bipolar affective disorder, psychosis, autism spectrum disorder (ASD) or eating disorders. Cognitive and developmental outcomes were examined frequently,Reference McCormick10,Reference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24,Reference Luque-Garcia, Corrales, Lertxundi, Diaz and Ibarluzea26,Reference Dankiw, Tsiros, Baldock and Kumar29-Reference Sprague, Bancalari, Karim and Siddiq31,Reference de Keijzer, Gascon, Nieuwenhuijsen and Dadvand33-Reference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35,Reference Anabitarte, Ibarluzea, Garcia-Baquero, Santa Marina, Fernandez-Somoano and Tardon37,Reference Ahmed, Knibbs, Moss, Mouly, Yang and Mishra40,Reference Almeida, Barros and Ribeiro42 perhaps because childhood and adolescence is a key period of brain development. Studies focused on younger child populations tended to focus more on development and cognitive outcomes, whereas studies focused on older populations (adolescents) tended to focus more on traditional mental health outcomes.

What does the evidence show?

Nature appears to have a beneficial effect on mental health and well-being, with largely significant positive results (indicating a beneficial effect) or positive results with unknown significance. Supplementary Table 2 presents summary results, highlighting studies supporting nature's beneficial effect, studies where the evidence was unclear and studies indicating that nature had a negative effect. It also details how authors defined and examined 'nature' and how this may fit the proposed frameworks. Outcomes rated as unclear in Supplementary Table 2 are further described in the table, giving context. There were no studies/reviews indicating that nature had a negative effect.

Children only

In general, the evidence was in support of nature's beneficial effects on children's mental health-related outcomes; however, no review or cohort study focused on well-being outcomes in children. All reviews were in support of nature's beneficial effect on mental health; however, the three cohort studies were more mixed, with one indicating benefit, one having a mixture of beneficial and unclear resultsReference Anabitarte, Ibarluzea, Garcia-Baquero, Santa Marina, Fernandez-Somoano and Tardon37 and the third having unclear resultsReference Naya, Yi, Chu, Dunton and Mason36 (Supplementary Table 2). Some reviews examined only observational evidence, assessing the association between green space exposure and mental health outcomes, and one focused on 'nature play', an experimental nature intervention.Reference Dankiw, Tsiros, Baldock and Kumar29 Some reviews examined cognitive or neuropsychological developmental outcomes and others mental health difficulties and emotional outcomes.Reference Dankiw, Tsiros, Baldock and Kumar29,Reference Alderton, Villanueva, O'Connor, Boulange and Badland38

Adolescents only

All four reviewsReference Zhang, Mavoa, Zhao, Raphael and Smith13,Reference Fleckney and Bentley25,Reference Reece, Bray, Sinnett, Hayward and Martin27,Reference Fang, Lu, Gill, Liu, Chyi and Chen32 found support for nature's beneficial effect, except for the reviews by Reece et alReference Reece, Bray, Sinnett, Hayward and Martin27 (where the evidence was uncertain) and Fleckney & BentleyReference Fleckney and Bentley25 (when examining longitudinal evidence) (Supplementary Table 2). All four reviews assessed a measure of mental health and/or mental well-being. Zhang et alReference Zhang, Mavoa, Zhao, Raphael and Smith13 assessed mental well-being outcomes; Fleckney & BentleyReference Fleckney and Bentley25 assessed mental health and well-being outcomes; Reece et alReference Reece, Bray, Sinnett, Hayward and Martin27 focused on anxiety and depression; and Fang et alReference Fang, Lu, Gill, Liu, Chyi and Chen32 looked at self-efficacy. Similar to reviews assessing the child population, reviews involving adolescents focused primarily on assessing observational evidence of green space/nature ( n = 3). Only one reviewReference Fang, Lu, Gill, Liu, Chyi and Chen32 focused on a form of nature engagement (outdoor education programmes).

Both children and adolescents (under-18s)

All ten reviews that focused on both child and adolescent populations (under-18s) supported nature's beneficial effects on mental health and well-being. However, evidence was less clear for some outcomes in two reviews (Supplementary Table 2), i.e. self-concept, problem-solving and moodReference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35 and emotional well-being, self-esteem and depression.Reference Tillmann, Tobin, Avison and Gilliland11 Of the two cohort studies, oneReference Bloemsma, Wijga, Klompmaker, Hoek, Janssen and Lebret39 supported nature's beneficial effects in improving mental well-being; in the other,Reference Ahmed, Knibbs, Moss, Mouly, Yang and Mishra40 the evidence for beneficial effects of nature on childhood development and academic outcomes was less clear, as even though the direction of change was in support of nature's beneficial effects, results did not reach significance.

A subset of reviews assessed both observational and experimental evidence;Reference Tillmann, Tobin, Avison and Gilliland11,Reference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24 another subset focused on experimental evidence, looking at the following forms of nature engagement: 'immersive nature experience';Reference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35 'family-based outdoor treatment';Reference Stea, Jong, Fegran, Sejersted, Jong and Wahlgren30 'nature-specific outdoor learning';Reference Mann, Gray, Truong, Brymer, Passy and Ho34 or 'school yard greening'.Reference Bikomeye, Balza and Beyer41 The remaining four reviews focused on observational evidence assessing green space exposure.Reference McCormick10,Reference Vanaken and Danckaerts12,Reference Zare Sakhvidi, Knobel, Bauwelinck, de Keijzer, Boll and Spano28,Reference Sprague, Bancalari, Karim and Siddiq31 One reviewReference Stea, Jong, Fegran, Sejersted, Jong and Wahlgren30 focused on clinical populations, whereas the remainder focused largely on non-clinical general populations. Seven reviewsReference McCormick10-Reference Vanaken and Danckaerts12,Reference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24,Reference Mann, Gray, Truong, Brymer, Passy and Ho34,Reference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35,Reference Bikomeye, Balza and Beyer41 assessed for mental health and well-being outcomes; oneReference Stea, Jong, Fegran, Sejersted, Jong and Wahlgren30 assessed for mental health problems; three reviews assessed for developmental outcomes, two assessed for behavioural outcomesReference Fyfe-Johnson, Hazlehurst, Perrins, Bratman, Thomas and Garrett24,Reference Zare Sakhvidi, Knobel, Bauwelinck, de Keijzer, Boll and Spano28 and one assessed for academic outcomes.Reference Mann, Gray, Truong, Brymer, Passy and Ho34

Discussion

In this meta-review we found that 'nature' is conceptualised along a continuum into three broad categories: a human-designed environment with natural elements; a human-designed natural environment; and a natural environment. We call this continuum the 'nature research framework'. Nature 'interventions' fall into three key areas - access, exposure, or engagement with nature - with quantity and quality of nature being relevant to all three areas ( Fig. 1). We call this the 'nature intervention framework'. Mental health and well-being outcomes fit along a continuum, with 'disorder' at one end and 'well-being' at the other. Following the use of validated critical appraisal tools, we found medium certainty of evidence with medium to high risk of bias in reviews and recent cross-sectional and non-randomised interventional studies, and lower risk of bias in recent cohort studies (Supplementary material).

We judge that in general (i.e. non-clinical) child and adolescent populations, there is sufficient indication of benefit to motivate more high-quality research into the relationship between nature and mental health and well-being (including cognitive and academic outcomes). The evidence is more uncertain in child and adolescent clinical mental health populations owing to the small number of studies. ADHD has received the most research attention, although the majority of studies examining ADHD symptomatology, such as inattention and hyperactivity, were conducted in non-clinical populations. This research focus on ADHD and inattention may be partly driven by having a well-established underpinning mechanistic theory - attention restoration theory. More high-quality studies in different clinical groups with different diagnoses are needed to understand whether nature interventions have benefits for such groups. There is a binary approach when diagnosing mental disorder verses mental health; however, we know that in fact mental health and mental disorder sit along on a continuum.Reference Patel, Saxena, Lund, Thornicroft, Baingana and Bolton43 Therefore, it is likely that, for a subset of clinically diagnosed children and adolescents, there will be benefits similar to those found in non-clinical groups.

Sociodemographic characteristics

The lack of data on other sociodemographic factors, particularly race/ethnicity, severely limits the generalisability of the findings and undermines research commitments to equality, diversity and inclusion (EDI). Despite the majority of studies including a measure of SES, there needs to be a better exploration of how SES mediates nature's effect through more detailed comparison across socioeconomic groups and more consistent data collection on both household and neighbourhood socioeconomic measures. Alderton et alReference Alderton, Villanueva, O'Connor, Boulange and Badland38 found only three studies comparing findings across socioeconomic groups, with two of these finding greater benefits in those from poorer socioeconomic backgrounds (also supported by Zhang et alReference Zhang, Mavoa, Zhao, Raphael and Smith13), suggesting that those from poorer socioeconomic groups may benefit more.

Defining nature

Our nature research framework enables better testing of two prominent hypotheses regarding the mechanisms driving the relationships between nature interventions and mental health and well-being benefits. Attention restoration theory posits that the natural environment is particularly restorative to our attention. Stress reduction theory hypothesises that the natural environment reduces stress and promotes parasympathetic activity.Reference Ulrich, Simons, Losito, Fiorito, Miles and Zelson20 However, there is little disaggregation of what 'natural environment' means operationally; how natural the environment must be; or how much of it (dose) one needs to gain benefit. It is pressing that we understand these things, as with global urbanisation, people's 'nature' will most likely come from 'human-designed environments with natural elements' rather than wholly natural environments. It is important to know whether we can still see beneficial effects of nature using our urban parks, or whether more natural environments within urban settings are required to harvest nature's protective effects.

Some evidence is emerging, mostly from the adult literature, highlighting how the type and dose of nature may affect outcomes, such as nature connectedness (how connected people feel to nature) and psychological restoration.Reference Wyles, White, Hattam, Pahl, King and Austen47 Some evidence suggests that more natural environments (e.g. natural protected parks with increased biodiversity versus less biodiverse urban parks) and increased time in natureReference Hatty, Mavondo, Goodwin and Smith46 have greater effects on nature connectedness and psychological restoration.Reference Wyles, White, Hattam, Pahl, King and Austen47 In a recent study, this relationship was more confused, with significant increases in nature connectedness seen also in urban parks as well as more natural environments.Reference Hatty, Mavondo, Goodwin and Smith46 There is a clear need for more research in this area, understanding how the type, quality and dose of nature, especially in the child and adolescent population, affects health.Reference Jimenez, DeVille, Elliott, Schiff, Wilt and Hart49 It is important to not simply extrapolate adult findings to the child and adolescent population, as childhood and adolescence may be a particularly sensitive and unique period, whereby nature may have long-lasting effects on mental health across the life-course. For example, one European study found that adults with low levels of childhood exposure to nature had significantly worse mental health outcomesReference Preuß, Nieuwenhuijsen, Marquez, Cirach, Dadvand and Triguero-Mas50 and another large study (of 1 million people) with a 28-year follow-up period, found that high levels of the presence of continuous green space during childhood was associated with a lower risk of a multitude of psychiatric disorders later in life.Reference Engemann, Pedersen, Arge, Tsirogiannis, Mortensen and Svenning51 These findings are alarming, in light of the pattern of urbanisation and children spending less time in nature.Reference Oswald, Rumbold, Kedzior and Moore6 Finally, it is important to understand what the minimal effective dose of nature may be, to inform practice and policy-making. Recommendations from a Canadian national nature prescribing programme (PaRx) suggests a minimum of 2 h in nature per week; however, it is unclear what this recommendation is based on. Coventry et al,Reference Coventry, Brown, Pervin, Brabyn, Pateman and Breedvelt53 in a systematic review and meta-analysis examining nature-based interventions in community-based adults, put forward that the most effective nature-based interventions were offered for between 8 and 12 weeks, with an optimal 'dose' ranging from 20 to 90 min. Current nature prescriptions take place in diverse settings,Reference Nguyen, Astell-Burt, Rahimi-Ardabili and Feng54 and it would be helpful to know which settings or type of nature is most beneficial.

Confounders will differ along the continuum of the nature research framework, and air pollution becomes particularly salient in human-designed environments with natural elements (e.g. urban parks) and less so in purely natural settings. Some of these confounders are seen as mechanisms driving nature's beneficial effect. Finally, using the biophilia hypothesis, which draws on our evolutional bond with nature, one may postulate that we may expect greater benefits of nature further up the nature research framework towards purely natural environments.

The nature intervention

The nature 'intervention' falls into three key areas: access, exposure, and engagement with nature, with quantity and quality of nature being relevant to all three areas. We call this the nature intervention framework. Six out of eighteen reviews and three out of five cohort studies aimed to examine what they defined as 'exposure' to nature. However, five of these six reviews included studies that were not directly measuring exposure, but rather using measures of surrounding green space as a proxy,Reference Vanaken and Danckaerts12,Reference Luque-Garcia, Corrales, Lertxundi, Diaz and Ibarluzea26,Reference de Keijzer, Gascon, Nieuwenhuijsen and Dadvand33,Reference Anabitarte, Ibarluzea, Garcia-Baquero, Santa Marina, Fernandez-Somoano and Tardon37 with the Normalized Difference Vegetation Index (NDVI) being one of the most common metrics used (Supplementary Table 1). Perhaps this is not surprising, as surrounding green space measured using the NDVI has been put forward as the most standardised metric of nature exposure.Reference Marviera, Kareiva, Desiree Felix, Ferrantec and Billington55 NDVI measures vegetation density. An argument against this method is that it may not accurately capture someone's exposure, as the NDVI also includes measurements of non-accessible agricultural land. Some measures of surrounding nature, such as 'school greenness', may be more accurate measures of true exposure, if children play outside in their school breaks. Fewer studies measure direct exposure to nature, relying on subjective reported time in green space or on objective measures such as real-time Global Positioning System (GPS) technology to provide participants' daily locations and movement patterns. One studyReference Mennis, Mason and Ambrus57 used geographic ecological momentary assessment (GEMA) technology (providing an objective measure of green space exposure) to assess whether being in urban green space is associated with reduced momentary psychological stress. Few reviews looked at exposure to nature in terms of views of nature or having contact/touching materials from nature. Some reviews used the word 'exposure' loosely (Supplementary Table 2) and included studies measuring surrounding nature as well as access to nature in the neighbourhood. Studies that looked at access to nature from the home or school did this in a variety of ways (Supplementary Table 1), for example measuring the time taken or distance from home to the nearest park or 'park density' in buffer areas around the home. Studies that examined a form of nature engagement (i.e. not merely being exposed to it but rather engaging or using it in some way) included, for example, studies looking at 'nature play',Reference Dankiw, Tsiros, Baldock and Kumar29 'nature-specific learning outside the classroom',Reference Mann, Gray, Truong, Brymer, Passy and Ho34 'outdoor education programmes',Reference Fang, Lu, Gill, Liu, Chyi and Chen32 'greening interventions'Reference Bikomeye, Balza and Beyer41 and the Scandinavian tradition friluftsliv (an immersive nature experience with an emphasis on the experience of closeness to nature during activities).Reference Mygind, Kjeldsted, Hartmeyer, Mygind, Bolling and Bentsen35 Very few studies reported the quantity and quality of nature.Reference Zhang, Mavoa, Zhao, Raphael and Smith13 Ensuring future studies clearly report on the quantity and quality of nature will also help us to understand the 'dose' required to reap its beneficial effects and what aspects of nature may be particularly beneficial or important to people's experience.

Outcome measures

Mental health and well-being outcomes appear to fit along a continuum, with 'disorder' at one end and 'well-being' at the other. Examining outcome measures in this way has highlighted the need for a greater focus on examining nature's effects on mental disorders, including depression and anxiety. Future studies should also focus on unexamined disorders, including eating disorders, ASD, bipolar affective disorder and psychosis in children and adolescents.

This meta-review has highlighted how the current literature has often merged mental health and well-being outcomes, not fully recognising that they are related but distinct entities with a separate literature base. Zhang et alReference Zhang, Mavoa, Zhao, Raphael and Smith13 defined mental well-being as positive mental health and outcomes could include mood, stress, anxiety, depression, happiness, pleasure, emotional health, psychological health and mental health. In Fleckney & Bentley's review,Reference Fleckney and Bentley25 even though mental health and well-being outcomes were recognised as two different entities, they found that some studies used scales/tools to measure both, thereby blurring this distinction. Bloemsma et alReference Bloemsma, Wijga, Klompmaker, Hoek, Janssen and Lebret39 used a validated tool to measure mental well-being - the Mental Health Inventory-5. Future research should better recognise the distinction between mental health and mental well-being, acknowledging them conceptually and operationally as different entities, as our understanding of them has evolved.

Nature's effect

The evidence base is large, with the majority of studies finding significant positive results in support of nature's beneficial effect or positive results with unknown significance. Some studies found null results (not meeting significance); however, these have generally all been associated with a direction in support of a beneficial effect of nature. Only a small number of studies/findings suggested a potential negative effect, although the significance of these results is not clear. Despite the evidence base being large (in number of studies), it comes almost exclusively from HICs and there is medium to high risk of bias in the majority of studies, with few considering all potentially important confounders, such as air and noise pollution, social engagement and exercise. The mediating and moderating role of sociodemographic factors, such as ethnicity and SES, are not known or are poorly understood.

Implications

Despite the evidence base having its limitations, we are already seeing the widespread uptake of 'green social prescribing' within the UK's National Health Service (NHS) as part of the government's Green Social Prescribing Programme (launched April 2021). Green social prescribing has been defined as 'the practice of supporting people to engage in nature-based interventions and activities to improve their mental and physical health'. This could involve a health professional prescribing a community garden project to a patient with the aim of improving their mental health. Green social prescribing could therefore be thought of as a mechanism by which to implement the evidence base (on nature's effects on mental health and well-being) in practice. Despite the evidence base being larger for adults, with an attempt by Coventry et alReference Coventry, Brown, Pervin, Brabyn, Pateman and Breedvelt53 at ascertaining the optimal 'dose' of nature one needs for nature-based interventions in adults, we must be mindful of the evidence base if or when we implement green prescribing to children and adolescents, understanding that even though current evidence suggests nature's beneficial effects, certainty is lacking. This is especially true for clinical populations. Intuitively, we may feel nature is good for us; however, it could be harmful (given the lack of and uncertainty in the evidence) to promote green prescribing to child and adolescent clinical populations as a form of 'treatment', especially if it is promoted as a stand-alone treatment and not as an adjunct to 'treatment as usual'. However, if further down the line, more certain evidence does support its benefits, then 'green prescribing' could work not only for us humans (e.g. reducing the need for possible medications and unwanted side-effects) but also for the planet, in promoting nature's flourishing in our neighbourhoods and reducing the burden on mental health services (with associated carbon costs).

Limitations

The research field examining nature and its effects on mental health and well-being in children and adolescents is a rapidly developing, interdisciplinary and heterogeneous field, mostly made up of observational studies looking at surrounding green space as a proxy for exposure in general child and adolescent population samples or non-randomised poorly controlled experimental studies in more unwell/clinical child and adolescent populations. There are few studies examining mental disorders and no studies examining disorders such as ASD, eating disorders, bipolar affective disorder or psychosis in children and adolescents. Data are lacking examining the role of ethnicity and SES in children and aolescents; however, current evidence suggests that nature may be most beneficial to those from lower socioeconomic groups or marginalised groups.

Unfortunately, not all reviews gave details of their included studies (despite our attempts to contact the corresponding authors) and therefore we were unable to identify whether reviews had missed key primary studies. However, we felt this unlikely, owing to the large number of reviews. Therefore, we did not include primary studies published before the last identified review, to avoid the risk of double counting. We limited our search to the English language, which resulted in two study exclusions. We purposefully kept the scope of this meta-review broad in order to answer our study aims; however, this made summarising the heterogeneous evidence more challenging.

It was not in our scope to formally review and report mechanistic pathways, although this could have proved useful in supporting the evidence base more formally. Data were collected on this as detailed in the protocol. Studies often framed their results in the context of current mechanistic thinking; however, few studies examined mechanistic pathways in depth or contextualised them in the context of their specific results.

Strengths

This meta-review has synthesised a large multidisciplinary literature base that uses varying concepts and definitions and has produced two clear frameworks to guide future rigorous interdisciplinary research. Definitions and concepts of nature were broad to allow for the development of these frameworks, to ensure their relevance to this diverse field of research. This is a clear strength, as previous reviews have had a narrower focus of enquiry, which would inhibit the development of such frameworks relevant to the field at large. Studies were rigorously examined for their certainty of evidence, using validated assessment tools. A protocol was developed and made publicly available a priori.

Recommendations

To date, it is difficult to judge the strength of the evidence for nature interventions for mental health and well-being in children and adolescents. Our proposed nature research and nature intervention frameworks promote the design of future studies that will bring more certainty to the evidence base, by encouraging a clearer and more consistent approach to scientifically examining nature interventions. Accumulation of more certain evidence relies on clarity and consistency of measurement, as well as the use of validated measurement tools. These factors, in turn, enable replication, which informs evaluation of the strength of evidence. If we take 'green prescribing' through the NHS to be a formal reflection of an evidence-based clinical intervention, then it is not acceptable or ethical for prescribing to be conducted in the absence of standard evidence to inform dosing. 'Dose' requires knowledge of: intervention type, how much of it and for how long, with accompanying information about expected outcomes and side-effects. In this sense, we also need to be mindful of the 'indication' - appreciating the difference in examining mental health and mental well-being, which are separate but connected entities, and the difference in prescribing for clinical and non-clinical child and adolescent populations, in light of the evidence base. It is also important to be aware of mediating and moderating factors that can affect intervention outcomes, including sociodemographic factors such as access to green space and sociopolitical factors such as air pollution exposure.

To increase the amount of evidence about underserved groups in mental health research, future clinical trials should focus on more ethnically diverse child and adolescent populations and children and adolescents from low- and middle-income countries. We should also expand to a wider range of diagnoses. Of the clinical child and adolescent populations, current limited research has focused on ADHD, anxiety and depression, with no research focusing on children and adolescents with ASD, eating disorders, bipolar affective disorder or psychosis.

Conclusion

Nature appears to have a beneficial effect on the mental health and well-being of children and adolescents. However, we cannot be certain of its benefit, owing to the limitations of the evidence base coming from available studies. Even in more recent studies, not all potentially important confounders are considered (such as pollution, exercise and social engagement). To reach a global potential, more data are needed about ethnically diverse populations and populations from low- and middle-income countries.

Data availability

Data availability is not applicable to this article as no new data were created or analysed in this study.

Acknowledgements

Search strategies were developed in conjunction with Carolyn Smith, a research librarian at the Bodleian Health Care Libraries, Oxford, UK.

Author contributions

T.L.: protocol development and methodology, screening and article selection, quality assessment, data extraction and analysis, manuscript writing. J.B.: screening and article selection, data extraction, quality assessment, manuscript revisions. A.C.: protocol development and methodology, manuscript revisions. I.S.: protocol development and methodology, manuscript revisions.

Funding

T.L. has been funded to undertake this research by the National Institute for Health and Care Research (NIHR) (NIHR Award number: ACF-2021-13-010). I.S. has been supported by the NIHR Oxford Health Biomedical Research Centre (NIHR203316) and Wellcome Trust (Wellcome Centre for Ethics and Humanities 203132/Z/16/Z). A.C. is supported by the NIHR Oxford Cognitive Health Clinical Research Facility, by an NIHR Research Professorship (grant RP-2017-08-ST2-006), by the NIHR Oxford and Thames Valley Applied Research Collaboration, by the NIHR Oxford Health Biomedical Research Centre (grant NIHR203316) and by the Wellcome Trust (GALENOS Project). The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR or the UK Department of Health and Social Care.

Declaration of interest

None.

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Effect of nature on the mental health and well-being of children and adolescents: meta-review | The British Journal of Psychiatry | Cambridge Core

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Effect of nature on the mental health and well-being of children and adolescents: meta-review - Volume 225 Issue 3

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Batchelor, S. (2021, April 12). Use of kids helpline by children and young people in Australia during the COVID-19 pandemic. PubMed. https://pubmed.ncbi.nlm.nih.gov/33858763/

The study examines the use of Kids Helpline during the COVID-19 pandemic in Australia. It found an initial increase in demand for the service when the pandemic was declared, followed by fluctuations, including a second rise during a wave of infections. The increase in demand was mainly through WebChat, with a significant number of contacts coming from girls aged 13-18. Common reasons for reaching out included mental health issues, suicide/self-harm, family relationships, and COVID-19-related concerns. The findings highlight the challenges of responding to rapidly changing demand and the importance of understanding different communication modalities' effectiveness. Using this article I can explain how the Kids Helpline helped children receive help during covid and how much the number helped in my project.

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Use of Kids Helpline by Children and Young People in Australia During the COVID-19 Pandemic - PubMed

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In Australia, the COVID-19 pandemic saw a rapid increase in demand for Kids Helpline, mainly by WebChat, with the virus itself, mental health, suicide/self-harm, and relationships common reasons for contact. Responding to rapid changes in demand for particular modalities is challenging and understan …

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The article titled "The effectiveness of school-based mental health services for elementary-aged children: A systematic review" reviews studies on the effectiveness of mental health services provided in schools for elementary-aged children. The authors found that school-based interventions can be effective in improving mental health outcomes for children, particularly in reducing symptoms of anxiety and depression. However, the effectiveness varies depending on factors like the type of intervention, the quality of implementation, and the characteristics of the children involved. The study emphasizes the need for well-designed and consistent mental health programs in schools to support children's mental well-being. Using this article it shows how services for mental health have an increasing impact on anxiety and depression in school aged kids and is important for my research question.

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Villatoro, A. P., DuPont-Reyes, M. J., Phelan, J. C., & Link, B. G. (2022a, June 6). “me” vs. “them”: How mental illness stigma influences adolescent help-seeking behaviors for oneself and recommendations for peers. PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC9910848/

This study examines how stigma influences adolescents' help-seeking behaviors, both for themselves and when recommending help for peers. It found that adolescents are more likely to suggest help for peers with mental health issues than to seek help for their own problems. The stigma dimensions of labeling, stereotypes, and separation/discrimination were key factors in these behaviors, with labeling being a strong predictor of both self-reported help-seeking and peer recommendations. Mental health literacy and positive stigma awareness were also linked to increased help-seeking in formal and informal settings. This article go into depth about how people often search for help for others more than themselves and how the stigma influences this behavior and will be important to discuss in my work.

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‘Me’ vs. ‘Them’: How Mental Illness Stigma Influences Adolescent Help-Seeking Behaviors for Oneself and Recommendations for Peers

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Mental illness stigma is a significant barrier to utilizing mental health services for young populations. Few studies have evaluated how specific stigma dimensions relate to help-seeking and recommendations among adolescents. We examined how the…