Dr Umar Toseeb Hello, welcome to the Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I am Umar Toseeb, Professor of Psychology. My research focuses on special educational needs and mental health in childhood and adolescence. All listeners to this and indeed, any of ACAMH’s podcasts, are eligible for a free CPD certificate. Do please visit acamhlearn.org for details of this, together with information on how you can access hundreds of hours of free talks, lectures, interviews, all of which you can also get free CPD certificates for. The web address is acamhlearn.org. That’s a-c-a-m-h-l-e-a-r-n.org. Today, I’ll be speaking to Professor Dr Gonneke Stevens, author of the editorial, “Adolescent Mental Health in a Rapidly Changing World,” which was published in the JCPP. This editorial will be the focus of today’s podcast. Gonneke, thank you so much for joining me. Professor Gonneke Stevens Thank you for having me. Dr Umar Toseeb Let’s start with an introduction. Can you tell us about your professional background and your research interests and your affiliations? Professor Gonneke Stevens So, I’m Gonneke Stevens. I’m a Professor at Interdisciplinary Social Science at Utrecht University, on the topic of adolescent health and wellbeing. So, I focus a lot on adolescents and their health, particularly their mental health, but also, how all kinds of different contexts influence the mental health of adolescents. And then, my focus is, for instance, on families, but also on neighbourhoods, schools, different countries, but also, the specific times in which adolescents grow up in. Also, related to that, I would say my research is on social inequalities in adolescent health and mental health, so that means differences in mental health across socioeconomic groups and migrant and non-migrant groups. And perhaps it’s also good to mention that I’m involved in the HBSC study, the Health Behaviour in School-aged Children study, which is an internationally comparative study on the health and wellbeing of adolescents. We do that every four years in 40 to 50 countries. We have been doing that for 20 years or more now, so that means that you really can get a good insight into what changes, or what doesn’t change, in the health and wellbeing of adolescents and all kinds of related stuff, so their social relations, how they feel at school, their substance use, for instance. Dr Umar Toseeb Thank you. Let’s start with some context. So, when I was reading the editorial, I think there was a quote quite early on that I liked, and I think it helps to explain the importance of adolescent mental health. And so, the quote was, “It’s no exaggeration to say young people and their mental health act as early warning signs for contemporary society.” Let’s discuss that. Why is that important and why does that give us the sense of why adolescent mental health is important? Professor Gonneke Stevens Perhaps it’s good to first mention that it’s a quote from McGorry and from a paper in The Lancet, and I think several other Scholars also, kind of, said similar things. So, the idea is that there are all kinds of new developments and societal phenomena going on and adolescents pick up these new developments very early on, and I think the best example is, of course, internet, social media use. And because they do this, we also see the consequences for their mental health very early on, you could say. So, that means that what we see in adolescents, we may also see later on in different groups in our society. So, in that sense, we use this idea of early warning system for contemporary society. And I think other than that, of course, adolescents are the adults of the future, so if they are not feeling well, if they are not doing well, that has consequences for all our societies. So, focusing on adolescents is very important. Dr Umar Toseeb Excellent, and I think the premise and the starting point for the paper is that adolescent mental health is worsening as time goes on, and mental health difficulties are on… Professor Gonneke Stevens Yeah. Dr Umar Toseeb …the rise with adolescents. And I think for the most part, the Researchers in the field would agree with that, but there’s some people who would say that there isn’t really a rise in adolescent mental health difficulties. So, just to start with, some evidence. What evidence is there that mental health difficulties are on the rise in adolescents? Professor Gonneke Stevens Yeah, we think there is a lot of evidence. Yeah, basing that on the HBSC research, we really saw in a lot of countries, and actually in almost all of our countries, we saw that there’s an increase in mental health problems and this increase is the strongest, actually, in the last couple of years, so between 2018 and 2022. So, in almost all countries, we see that and especially among girls. So, if we look at some numbers, in 2014, 39% of the adolescent girls were experiencing psychosomatic complaints and in 2022, that was 56%. So, there is a strong increase, and psychosomatic symptoms, then, are symptoms like feeling unhappy, feeling nervous. So, we see that across Europe and we also see that if you look at other types of data. So, for instance, in the Netherlands, there’s data on deliberate self-poisoning and we see that there are huge increases there. And also in the same period of time, and in other countries, like in Norway, there’s data on the amount of adolescents that got a mental health diagnosis and that also gone up. So, we think there’s really strong evidence and that evidence really shows that it’s – the strongest increase has been there in the last couple of years. Dr Umar Toseeb Thank you, and then, in the editorial, you talk about some of the societal changes that might help to explain some of these increases in adolescent mental health difficulties, and there’s five that you speak about. So, social media, academic pressure, COVID-19, prevalence inflation and then worries about the future. And let’s start with ‘social media’, because I think that’s what you’ve started with in the paper. So, what does the evidence actually show? Professor Gonneke Stevens Yeah, that there’s a lot of research on this topic and there’s a huge debate, the importance of social media for these trends in adolescent mental health. But I think if we take all the evidence together, the most evidence I would say, that’s especially problematic social media use and not so much the intensity of social media use, that is associated with more mental health problems. And then problematic use are, kind of, signs of addiction, so things like not feeling okay anymore when you cannot be on social media, or getting into fights about it, or losing interest for hobbies because of social media. So, if adolescents have several signs of addiction, we see that that is associated with more mental health problems. And with the intensity of use, what we see there is that for some adolescents, intensity of social media use can be very positive, because it stimulates social relations, for instance, but for others, it can be negative. So, if you use it to compare yourself with the ideal worlds, or lives, I should say, of others, then intensity of social media use can lead to more mental health problems. So, that means, if you look at the average picture, what we do if we think about the trends in mental health, we feel that looking at problematic social media use is the most important indicator. And we do see, especially in the last few years, that there’s an increase in this problematic social media use, again, especially among the girls. So, if you look at the average we have within HBSC, there’s been an increase from eight to 13% between 2018 and 2022. So, that’s an increase, and we know, as I said, it’s associated with mental health problems. So, we think that social media is important, but still, you could say, these percentages are not so high, they’re still pretty low, so that does give us the idea that there are other factors, as well. So, there are some scholars who tend to say social media is the cause for problematic trends in mental health, but we say it’s only one of the causes and we should also look at potential other causes and address these. Dr Umar Toseeb Thank you, and I think it’s – you’ve made an important point there around not – it just not being social media as a whole. It also being more nuanced than that, and what people do on social media, is sometimes there’s a misconception that social media on the whole is bad. I mean, I think that that’s not what it shows. The potential negative effects is about the problematic use, which is what you’re describing there. So – and then the next thing that you talk about is ‘academic pressure’. So, what evidence is there that the – there are – there have been changes in academic pressure over recent years, and those changes are then associated with the increase in mental health difficulty? Professor Gonneke Stevens Yeah, yeah, we think that this an important point, as well. So, we know that there are increases in academic pressure, so the – this pressure that adolescents perceive because of their schoolwork. That’s what we ask in HBSC, and there have been increases there. So, we know, among girls, there has been an increase from 35% to 50% of girls receiving schoolwork pressure, and in some countries, this increase is even bigger. So, we know in the Netherlands there has been a huge increase. Adolescents in the Netherlands were the group that were the lowest on schoolwork pressure in 2001 and now we are somewhere in the middle, so we really changed in the Netherlands. So – but you also see that throughout Europe, this increase, again, especially in the girls, and we know that it is associated with mental health problems. And there are also a couple of studies that try to connect the trends in mental health with the trends in schoolwork pressure and there really seems to be a relation addressing schoolwork pressure and why there are increases there and how to tackle that is also very important. Dr Umar Toseeb And in your editorial, you talk about the difference between “individual level” and “country level effects.” Why is it necessary to look at both individual and country level effects? And I suppose maybe just start by telling us what the difference is between individual level effects and country level effects. Professor Gonneke Stevens Yeah, so what we found is that in countries that had a stronger increase in schoolwork pressure, there were stronger increases in mental health problems. And on the one hand, you could say, okay, so that means that the countries that have a stronger increase in schoolwork pressure, they now have more adolescents that perceive the schoolwork pressure and that is stressful for them and that may lead to mental health problems. So, that will be saying something about the individual effect. But when we controlled for the fact that in these countries, there are more adolescents that perceive that individually, we still found an effect and that suggests, although we need more research on that, that growing up in a country with more academic pressure, yeah, that the country context may change. There may be more competition or the relevance of being excellent or being the best goes up and that may also have negative impacts on a society as a whole. So, that’s why we think it’s important to distinguish between that and we need to think about what it means if, on a country level, there is more competition, there’s more academic pressure. What does it do to our countries? And of course, it can be good, but it can also have downsides, of course. Dr Umar Toseeb Thank you, and the third thing that you talk about in the editorial is the ‘COVID-19 pandemic’ and the potential impacts of that on young people’s mental health. Again, what does the evidence say about what impact the COVID-19 pandemic had on adolescent mental health? Professor Gonneke Stevens Yeah, yeah, I think there are many studies, thousands of studies, I would say, that show that mental health problems have gone up, if you compare before COVID to during or after COVID. Although I should also say that the research is not always consistent, of course. But taking the example of HBSC again, where we have long-term trends, we already saw, kind of, a slight increase in mental health problems between 2000 – 2010 and 2018, and then between 2018 and 2022, we saw a much steeper increase. So, that mean – that indicates that there’s a change in trends in this last four years and yeah, and what happened? COVID, of course. So, it’s likely that COVID plays a role, but of course, we’re not 100% sure about that, because well, we would have needed an experiment, kind of, with countries that wouldn’t have had COVID and then see what the trends would be in these countries, of course. But yeah, considering the fact that these trends between 2018 and 2022 are so different than the period before, it’s very likely that COVID played a role and there’s also evidence that all kinds of risk factors for mental health problems also increased during these times. And I think one important example is the social relations that we see, that’s comparing the before and during/after COVID periods, social relations decrease. So, adolescents were less positive about their relations with friends and with their family. Well, it’s likely that all kinds of COVID restrictions played a role there. If you’re not able to see your friends or meet your friends, the level of support may decrease. Dr Umar Toseeb And then, that was going to be my next question, so you’ve mostly answered that, as well. So, I suppose that’s one of the reasons why the COVID-19 pandemic might have increased adolescent mental health difficulties, that lack of in-person social interaction. Are there other… Professor Gonneke Stevens Yeah. Dr Umar Toseeb …explanations, other pathways through which the pandemic might have made worse adolescent mental health? Professor Gonneke Stevens It could be that COVID also has been, kind of, a catalyst, you could say, of the increase of the schoolwork pressure. So, considering the fact that performing at school is becoming more and more important and then COVID hit in and adolescents were trying to work from home, well, depending a little bit on the context, of course, and they got motivation problems, but still, for them, performing is very important. So, it could be that this combination has led to an increase in schoolwork pressure that is bigger than we would have had without COVID-19. Dr Umar Toseeb Thank you, and I think the next one that we’re going to speak about, which is ‘prevalence inflation’, is slightly different to the previous three. What is prevalence inflation and why might that explain the increase in adolescent mental health difficulties? Professor Gonneke Stevens Yeah, I think there’s more and more interest in this idea about the prevalence inflation, and I think the concept has been coined by Foulkes and Andrews. And the central idea is that the increase in awareness about mental health, mental health problems, may have led to increased recognition, and that means that, kind of, more rightfully thinking that you have a mental health problem, so that’s a good thing. But it may also have led to overinterpretation and that means that just not feeling well, feeling like, hmmm, that may be interpreted more easily as, “Oh, I feel depressed,” or “I am anxious,” and that that, in turn, may lead to more mental health problems. Dr Umar Toseeb So, part of my understanding of prevalence inflation is that if young people, or anybody really, is perceiving everyday mental health difficulties, which are just a typical part of being human, you sometimes feel low, perhaps sometimes anxiety is an adaptive response and is needed. Professor Gonneke Stevens Yeah. Dr Umar Toseeb If those are perceived as psychopathology or mental health difficulties, then people might then – more likely to report them as mental health difficulties. But the interesting thing that I saw, I think it was in Lucy Foulkes’ papers and And – Jack Andrews, was if we take something like anxiety, if adolescents or young people experience adaptive anxiety, which is quite typical – and there are certain situations in school environments, for example, like doing presentations or feeling anxious before an exam, or all of those kinds of things, which are expected, you would expect to be anxious before those things, if those times of anxiety are perceived as pathological and then avoided, what might have previously… Professor Gonneke Stevens Yes. Dr Umar Toseeb …been – not been an anxiety disorder, might develop into an anxiety… Professor Gonneke Stevens Yeah. Yeah, yeah, yeah. So, the prevalence inflation hypothesis has two parts. So, the first part is that adolescents are more likely to interpret just mild symptoms of not feeling well as really mental health problems, and then you get – then, there’s a self-fulfilling prophecy. So, if you think I might – may be anxious, then you may start avoiding things and you may focus more on your physical reactions and then, you may really develop anxiety. So, that’s the basic idea. So, if that’s going on, it could be that the trends in mental health problems are partly explained about this idea, and I think even more importantly, that means that all kinds of a mental health awareness programme may actually have effects that we don’t want. So, the idea is that they help people and that it helps reducing mental health problems, but it may be the case that it may increase mental health problems, and obviously, we don’t want that. So, it’s very important to do further research on this, because it’s a hypothesis and there’s hardly any evidence on it, and we need to think about ways to test this. Because it’s – you need to distinguish this idea of okay, good recognition versus overinterpretation, and that is quite hard. But I think more and more people and more and more scholars are thinking about that and developing research and we are also thinking about research using HBSC data, for instance. So, if we can identify countries where awareness has increased more than in other countries, we could try to relate that to the trends, and it is at least, kind of, evidence for or against this hypothesis. Dr Umar Toseeb Thank you, and the next explanation is “worries about the future,” and I think in my view, this seems to be – I mean, other than prevalence inflation hypothesis, the other three, I think this is the least researched and the least talked about, who recognise that it’s now gaining traction. So, tell us about that. Professor Gonneke Stevens Yes, yes, I totally agree that there’s not a lot of research on that, but I think there is increasing concern about the topic. So, we know a lot of things are going on throughout the world. There are a lot of global challenges, you could say, thinking about climate change, about wars throughout the world, and the idea is that adolescents are worrying about that. They are worried about that, and that that, in turn, may lead to mental health problems. So, that’s the basic idea, but we need to know much more about it, because we assume that a lot of adolescents worry about it, or think about it, but actually, we do not really know. There are just a couple of studies, I think in quite selective groups, so we don’t know if this is something a lot of adolescents worry about, and has it changed over time? We don’t know that either. To what extent is it related to mental health problems, or is it the case that adolescents with more mental health problems also were – worry more about these types of phenomena? So, a lot of research to be done, I would say. Dr Umar Toseeb Thank you, and I think it’s great that within one editorial, you’ve talked about multiple different things. So, like, you’ve talked about five things that might be contributing to the increases in adolescent mental health difficulties, and that’s interesting because it seems that the same manifestation of difficulties, whatever those symptoms are, might have different underlying causes. So, you can get to the same difficulty by lots of different ways and actually, it might be more than one of those things that’s contributing. And I suppose when I used to – hmmm, I still teach this, and one of the things that I start with on my module is, “There is no one cause of adolescent mental health difficulties.” Professor Gonneke Stevens Yes. Dr Umar Toseeb Because if there was, we might be much closer to trying to solve the issue. Problem is that there are so many different causes that work together and work differently in different people. Professor Gonneke Stevens Yes. Dr Umar Toseeb And I think… Professor Gonneke Stevens Yeah. Dr Umar Toseeb …the great thing about the editorial is that you’ve highlighted lots of them, which is great. Professor Gonneke Stevens Yeah, thank you. Yeah, I totally agree. I think it’s several factors that also interact, that influence the mental health and the mental health trends among adolescents. I’m really looking forward to doing more research on this, together with all my colleagues, internationally. So, there are so many things that we could do, so we really want to get our heads around this idea of the prevalence hy – inflation hypothesis. So, how can we test it? What kind of data can we use? We are thinking about, or working, actually, on studies that more closely focus on the trends between 2018 and 2022 in mental health and investigating whether these trends are associated with the trends in social – in schoolwork pressure and social media and in social relations, to see if we can, perhaps, find out which factors may be more important than the other factors. But we’re also very curious about the development in problematic social media use. You know, is it – will that be increasing more? Because we also know that because – probably because of the increase in TikTok use, the intensity of social media use has increased and perhaps in time, problematic social media may increase, as well. And perhaps if COVID is really behind us, then mental health problems may go down, just naturally, as well. So, there are so many questions to be answered. Dr Umar Toseeb And it gives a great insight of lots of things to look out for, from you and your colleagues, and finally, what’s your take home message for our listeners? Professor Gonneke Stevens I think that we, yeah, we should take care of ad – our adolescents and we should take these numbers on the increase of mental health problems among adolescents very seriously. And we need to think, and that’s also related to what you said, that there are many, many interrelated phenomena that explain that, so there’s not one cause. We need to do many more things to help them and to help our societies in effect. Dr Umar Toseeb Thank you, that was fantastic. Thank you so much for that fantastic and wide-ranging discussion. For more details, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with your friends and colleagues.