Dr. Umar Toseeb Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Umar Toseeb, Professor of Psychology. My research focuses on special educational needs and mental health in childhood and adolescence. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances. 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. If you’re a fan of our papers podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with your friends and colleagues. Today, I’ll be speaking to Magnus Nordmo, lead author of the paper “The Diminishing Association Between Adolescent Mental Health Disorders and Educational Performance from 2006 to 2019,” published in JCPP Advances. Magnus, thank you so much for joining me. Magnus Nordmo Thank you for having me. Dr. Umar Toseeb Let’s start with an introduction, can you just introduce yourself, what you do, and your research interests? Magnus Nordmo Yes, I can. I work as a Postdoc at the Norwegian Institute of Public Health, but that Postdoc is coming to an end, and my new position is Associate Professor at the University of South-East Norway. And my research interests are quite wide, but they all tend to revolve around health and mental health and education and – but I can really – I can get interested in a lot of different things, it’s probably a weakness of mine. Dr. Umar Toseeb No, I think it’s good. I suppose it’s been really helpful to have a broad research profile on child and adolescent development, in general, ‘cause I suppose nothing happens in isolation. So, if you’re interested in lots of different things, child and adolescent development, then that would only help with your research in many different ways. Yeah, so let’s talk about the paper, so you’ve looked at the relationship between mental health disorders and educational performance, and how it’s changed over a period of time. In terms of context, have mental health difficulties increased over time in the child and adolescent population? ‘Cause I know there’s some discussion around those trends in your paper, and whether they are genuine or an artefact of measurement, so do you just want to tell us a bit about that? Magnus Nordmo Well, that’s the key question, and the key research question that we talk a lot about at the Norwegian Institute of Public Health, it’s probably the question we talk the most about, because we have a lot of very dramatic reports saying that there are big increases in mental health complaints and disorders, but it’s very difficult to interpret these data. It’s not like measuring the temperature, where you can just say, “Oh, it’s increasing or decreasing,” you have a big challenge in that people define these subjective states themselves. People I talk to often think that Researchers and Clinicians have specialised tools that allows them to look into the brain and see objectively what’s going on, but we have nothing of the sort, actually. We rely on people who interpret their problems and you don’t have to be a Philosopher or a Sociologist to understand that this interpretation has changed a lot. If you compare the grandparents who are alive now, they didn’t talk about anxiety or ADHD or depression. They had a completely different vocabulary, and more than just vocabulary, they probably understood how their mental health relates to the world in completely different ways than youth today. And that’s not controversial, that has to be true, would – the motivation for this paper was to give a perspective on this, because we feel like the more perspective we have ha – on mental health in adolescence, the better it is, and the less likely we are to go into this trap, where we just read off the data like it’s the temperature gauge, and then say – and, by the way, that’s, also, of course, you can go into the opposite trap and be all – complete relativistic and say, “Well, we don’t know anything and we can’t say anything,” so it’s a balance act, those two things. Dr. Umar Toseeb Thank you, and in the introduction, you talk about three different forms of – or measurement, as self-reporting symptoms of mental health difficulties, research-based clinical assessments of mental health disorders, and then diagnostic at the healthcare level, and labels of mental health disorders. And then you talk about how those might indicate that there’s a different trend, depending on what you – which type of data you look at. Do you just want to summarise that for us? As in, what does it look like if we look at symptoms? What does it look like if we look at clinical assessments in research environments? And what do we – what does it look like if we look at diagnostic labels? Magnus Nordmo It’s, as you say, you can group the studies into those three, roughly, but one of them is, in a sense, unique. You can ask people themselves to rate themselves on a scale of depression, or items to check off to make a diagnosis, and you can also look for diagnostic data in health registers, that’s what we have done. But the one that’s, sort of, specialist, if you get a third party, like, a specialist, to assess, you just ask questions and then the expert is supposed to give, like, the diagnostic evaluation. And there are research on all three and the one where the expert is giving the final call on what this problem is, that sort of research doesn’t really show a big increase as the other ones, but that there’s not a lot of that type of research, so it’s a lot of uncertainty. There is a trend that when you get Clinicians, experts, to assess, then you don’t see the big increase in mental health problems in Western countries. Dr. Umar Toseeb Thank you, and then if we talk about educational performance, independent of mental health conditions, what has that looked like in the last decade or so? Are children doing better at school? Are they doing worse at school? Is it staying the same? Magnus Nordmo You would probably need to go to, like, country level data and PISA examinations, but, in Norway, we see that grades are going up. But you can also – you also have to keep in mind that this has to be interpreted as well, but we can at least say for certain that there’s not, like, a trend in Norway where you see really poor grades and people are worried about it. It’s quite the contrary. It seems to go well, and the average grades are steadily increasing. People speculate that that might be a, sort of, inflation, because the grades you get become more and more important, because it’s more and more important to get a university degree, but that’s ju – that’s speculation, we don’t know that exactly. Dr. Umar Toseeb Okay, and again, you talk a bit about this in your paper. But if we have a situation where two of the three indicators of mental health difficulties suggests that mental health conditions are becoming more prevalent, and then we also – there’s some indicators to suggest that educational performance is getting better over time, you discuss a bit about the research that suggests that the increase in mental health difficulties might be driven by pressure to do well educationally. And you hypothesise, and we’ll talk about what you find later, but you hypothesise that the increase might be driven by those at the top end because they experience the most pressure. Can you tell us a bit about that? Magnus Nordmo That is one of the hypothesis or narratives that is very in vogue in, I suppose, in Norway, that desire to drive for perfectionism that’s causing the mental health problems of the youth. So, it’s not that people need to do well enough in school to get into something, but it’s that they need to do extraordinary well and be the perfect student. So, that’s – that was something we, sort of, hypothesised, but, at the same time, we were really critical of this when going into it, because what we usually see with the registers is that mental health is really related to the social gradient of society, including grades, so, high school grades. So, the people who get the most mental health problems and diagnosis, they are the ones who do the worst in school, and then that’s actually a very steep gradient. So, if you do really, really poorly in school, then you have a lot of mental health problems. So – but we wanted to assess this hypothesis with our data, and when we looked at the patterns, we saw that mental health diagnosis increased across the, like, the high school – we grouped this by high school GPA. So, you have some who do – like, the top 20% of high school GPA students and the bottom 20%, and there you have, like, this spectrum. But we see that most of the diagnosis are found in the students who perform the worst, and it gets less and less diagnosis as you go up the high school GPA quantiles. But all of them are increasing, so you see an increase in every group, however, because there’s so much more diagnosis in the bottom 20%, in terms of absolute numbers, the absolute increase is much greater for the people who get the worst grades. Dr. Umar Toseeb Let’s talk about your measures and datasets. So, which mental health conditions were you interested in? And what indicators did you use for those and what indicators of educational performance did you have? Magnus Nordmo So, this research is based on the Norwegian registers, which are this great tool for research, because we have both an educational database, where the high school GPA is – for every Norwegian student, is placed in a register and made available for Researchers. But, quite uniquely, we also have a database for primary care diagnosis, so if you visit your GP, and in Norway, the system is set up so that everyone has their own GP, and these Doctors should be consulted if you have some needs. Say, you need treatment, you first go to the GP, and he, or her, might refer you to specialised treatment, or you might get treatment or a medication from the GP. Or if the school requires some documentation that you are unfit for school because of a mental problem, you’ll also go to the GP. So, it’s actually a terrific tool for Researchers, because we believe that almost all of the problems get captured in a GP diagnosis. So, for high school GPA we have, like, this continuous measure of grades, high school grades, and for the GPs you have, like, a dichotomous variable if you get a diagnosis or not. We look at – in this paper we group depression and anxiety, and we just call it “internalising disorders,” this is fairly common practice in research. And we also looked at – look at ADHD, so ADHD is kind of special because it’s quite rare that the GP places the ADHD diagnosis, but the GP refers the adolescent to specialised assessment and if the child gets the diagnosis, then the GP is responsible for providing the medication. And if you provide medication – each time you provide medication, you also set the diagnosis, so really believe we capture most of the – if not all the adolescents who have ADHD and internalising. These diagnosis are placed following a diagnostic schema for GPs. It’s called “ICPC-2,” for those who are interested. Dr. Umar Toseeb And just so make sure I make I’ve understood this correctly, a child presenting to their GP as experiencing symptoms of depression and anxiety, does the GP do the assessment using this measure that you’ve used, or does somebody else do it, and then it’s referred back to the GP for medication? Magnus Nordmo It can happen both ways, but, especially for ADHD, that’s quite a – like, a severe diagnosis that the GP rarely places to diagnosis themselves. But in terms of depression and anxiety, it’s – if the child is severe enough that they require more treatment than the GP can provide, they will refer it, but often they will just provide treatment and place the diagnosis themselves. Dr. Umar Toseeb Okay, excellent, and just to get a sense of sample size, how big a sample are we talking about, in terms of your analytic sample? Magnus Nordmo Well, we – these registers cover the population, so we have 13-yearly cohorts of adolescents in this, so we have more than 800,000 Norwegian adolescents. So, there might be some who are left out of the registers, in special cases where they – if they immigrate to Norway and something happens and, like, timing wise, but it’s rare, like, most of the adolescents are here. Dr. Umar Toseeb And let’s get onto the findings, and let’s start with prevalence. So, we talked earlier about what you would potentially expect, in terms of the prevalence of mental health disorders over time, and also educational performance over time, what did you find for those two separate indicators? How did they change between the years that you were interested in? Magnus Nordmo Both for ADHD and for internalising, we found a more than doubling of increased prevalence from 2006 to 2019. And we would define if you have a disorder, that’s the – we – if you have the – get the diagnosis the year you turn 16, which is the last year of Norwegian High School, and that’s more than doubled for both disorders. So, there’s much more ADHD in boys, and much more internalising in girls, but the increase are seen for both boys and girls, and, also, as I said, the GPA increases in the same timepoints. Dr. Umar Toseeb So, according to your data, we’ve got increases in mental health disorders in 2006 to 19, and, also, increases in educational performance. Now, there’s a hypothesis by Lucy Foulkes, which is called the “Prevalence Inflation Hypothesis,” and she suggests that the reason why mental health conditions, or the statistics are showing they are increasing amongst the population, is because people who would previously be subclinical, as in just below the threshold, or even a lot below the threshold, are recognising everyday symptoms of depression and anxiety which aren’t clinical, and they’re just a normal part of being human, as disorder level, so then they seek support and then get a diagnosis. Now, based on that, it would suggest that amongst the group of children who now have a diagnosis for depression in 2019 versus 2006, on average, it would suggest that the group in 2006 would have higher levels of depression, because they would have been at more – at the extreme end of a normal distribution curve, compared to the 2019 kids. Based on that, I would predict that the relationship between mental health disorders and educational performance would weaken over time, just because the group that you’ve got with mental health disorders, on the whole, on average, has lower levels of mental health difficulties, compared to the group that you previously had. Is that what you found? And was that your rationale? Magnus Nordmo That was indeed our rationale and, as you said, we wanted to use this – I mean, both ADHD and internalising, they should, in theory, really impact school performance, ‘cause it should be really hard to learn stuff when you’re depressed, and – or if you’re anxious, and, of course, ADHD, and it’s been well documented that – this connection. So, it’s, sort of, a test of, like – a validity test, in a sense, that if these constructs are changing in young people’s minds, and in the systems that we deal with, then we should see this change that you see, that it gets less and less severe, the association between having a mental health problem and how well you do in school. That’s exactly our – what the goal of this paper was. And we found exactly what we would expect, if that was the case, that parallel to the increasing prevalence, there is a decreasing – a negative association with high school GPA. To say it another way, in 2006, there were not a lot of students with internalising and ADHD, but they did poorly in school. In 2019, there’s a lot more children who have these diagnosis, but they – this group does better in school. This is, sort of, evidence for this claim, but it’s – we discuss a lot about, you can’t be certain, because there are many things that change in this timepoint. And, of course, the educational system and treatment system radically changed over the time, so you could make the case that, well, actually, we’re getting better at treating mental health problems and the school is getting better at managing people. And those things can’t be ignored, but we place emphasis on this, like, threshold, kind of, a hypothesis, because when you look at this change from, like, a population point of view, it’s really hard to change the needle. It has to be a very, like, fundamental process, if the relationship between having a disorder and your school performance should change. So, we think it’s not that likely that positive treatment, because when you treat an adolescent with anxiety or ADHD, then there’s often positive benefits, but it’s – the results are often poorer than you might expect. So, we’re not that good at treating adolescent mental health problems, and we’re really not good at treating adolescent health problems if the outcome measure is school performance, so it’s not that likely, but it can’t be ruled out. Dr. Umar Toseeb And we talked – well, you talked a bit about this earlier, and I think it’d be nice to just go into a bit more detail on it, around the relationship between mental health disorders and educational performance at the extreme ends of educational performance. So, I think you hypothesise that those who are at the higher end of educational performance might be driving the increase in mental health difficulties because the increased pressure that they experience to perform well. So, what did you find with regards to that? Magnus Nordmo Basically found that the people who do well in school are not driving this phenomena. So, that the people who do well in school, they rarely get ADHD diagnosis, depression diagnosis, anxiety diagnosis, they rarely get it, compared to the other extreme end, the bottom 20% of high school performers. So, we see an increase in all levels. You can go to any level of a high school GPA, any level of society you might say, and you can say, “Is there an increase in the later years?” And then answer would be, “Yes.” But in terms of absolute numbers, how many adolescents are getting a diagnosis, then it’s definitely the bottom performers who are driving this, not the high performers. Dr. Umar Toseeb And, I suppose, for me, one of the implications of that is if we go back to this suggestion that people are recognising subthreshold symptoms as diagnoses, or seeking diagnoses for that, that should apply across the board, across the range of educational performance, and – but then if it’s more prevalent at the bottom end of the scale, it suggests that there are other factors at play. For example, you talked about social stratification, could it be also that there are other things that have changed for those people at the bottom end of the educational performance scale that’s driving this? So, for example, we had a guest a few weeks ago on wealth inequ – on the relationship between wealth inequality and children’s mental health, or poverty in general, and children’s mental health, or there could be lots of other influences on children’s mental health that are disproportionately affecting the people who tend to perform worst at school, could that be a viable explanation? Magnus Nordmo That could be. I mean, it doesn’t really – we have to speculate about that, because we know it’s, kind of, a special case where we have a really egalitarian society, and there’s not that much – so, there are very many programmes and support measures for the low end of the socioeconomic spectrum. But my take is that most of the Economists in Norway, and the people who study it, won’t say that there’s been this big divergence in Norway, that the people at the bottom have gotten it more much worse the last ten years. But it’s really – it’s somewhat out of my expertise level, but we can’t rule that out, that’s for sure. But when I say that the lower GPA performance are driving this effect, it’s actually kind of the opposite of what you said, because we see – like, in terms of percentage increase, you see this increase across the board. So, when I say that the bottom is driving it, it’s just because they have had it the worst in the beginning. There are alternative takes here. I mean, for instance, there’s a fanima – famous Danish Sociologists who say that what’s happened the last years is that instead of people blaming political system, society, like, saying that we have been unfairly treated, we are at the bottom of society, we need the more – and instead of going that way, the youth nowadays will internalise and say, “I have a problem. I have a psychological issue.” But even though their problems might be due to the, like, traditional, like, if you live in a very poor neighbourhood with a lot of crime, and your mother has then a problem with alcohol and stuff like that. But this is a difficult discussion, but I really think it’s one that we should have and it’s important. Dr. Umar Toseeb Yeah, that’s fascinating you should say that, because my understanding is that, as an Academic Researcher, is that we are moving away from purely, if one exists, purely a medical model of mental health conditions, where the problem exists within the individual, towards a social model of disability or mental health conditions, where these conditions are caused in part by societal structures and how the world is set up. And I think we are somewhere in between, as in, we understand that it’s a combination of the two. But it’s interesting that I’d never thought of it about people’s perception of what it is, ra – so we research it as we’re interested in societal structures, or we’re interested in individual cognitions, and thinking styles, etc. But, actually, people’s perceptions of whether it’s an individual or social might affect how they deal with the condition. Moving on, what are the implications for how we view the narrative around increases in adolescent mental health disorders, based on your findings? And, in your paper, you talk a bit about the paradox of health, do you just want to tell us about that? Magnus Nordmo Well, the paradox of health is related to our main finding, in the sense that it’s been fairly well documented that if you treat people’s health complaints, you will often succeed. I mean, we have a great medical system and medical science has come a really long way. But when you ask people about their subjective levels of health, will – they will often say, “Over time, it gets worse.” So, the – even though new generations have – are much more healthy, objectively, they often say that they are subjectively unhealthy, don’t feel good, don’t feel well, and this has been shown many times in Western countries. What’s usually highlighted here to explain this phenomena is that when you treat health conditions, you also set a new standard for what you expect from your body and your – like, in terms of health, you – like, when you view your life with a health lens on, you should, kind of, expect to feel good and be – for instance, with COVID, there’s been a lot of talk about “brain fog” and “fatigue” and stuff like that, and once you view your subjective health in terms of, how am I feeling? Am I feeling fatigued? And am I foggy cognitively wise? That might change something, as before, you might not have given it a lot of thought, you just, kind of, went with it, “I have pains and I have problems.” But now it’s, like, an expected – if you, for instance, seek treatment and you receive treatment for, like, post-corona symptoms, you would expect to get healthy from that, and, like, feel well again, and that’s something, the more you treat stuff, the bigger the expectation that you should feel well. And, of course, as you’ve said many times, you – it’s an inherent part of being a human being that sometimes we’re anxious, sometimes we’re depressed, it’s hard to focus on stuff, and when we put those two together, we can see that this might explain the paradox of health. Dr. Umar Toseeb So, what’s your take home message for our listeners? Magnus Nordmo And my take home message is what I would consider the main finding from the paper, is that we need to be careful when we interpret data on mental health. Either it’s interpreting subjective campaigns that are rising, or a diagnosis, you need to look at that in a broad view and keep in mind the nuances that shape these figures. Dr. Umar Toseeb Thank you so much, Magnus, that’s been a fantastic discussion. For more details on the paper, please visit the ACAMH website, that’s 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.