The changing outlook for children with psychiatric disorders

The rise in child mental health problems is well documented. NHS Digital reported that 10.8% of children aged 5 to 16 years in England had a probable mental disorder in 2017 — around one in nine. By 2020, this had risen to 16.0%, or one in six.

A new longitudinal study asks a different question: for children who already met criteria for a psychiatric disorder, have outcomes over the next three years improved or worsened across successive generations?

The answer was concerning. Among children with a psychiatric disorder in the 2017 cohort, 52.4% had worsening parent-rated mental health difficulties three years later. The corresponding figure was 34.2% in the 1999 cohort and 37.6% in 2004.

What did the study examine?

Researchers analysed three national probability surveys of children in England, undertaken in 1999, 2004 and 2017, with three-year follow-ups in 2002, 2007 and 2020. They included children aged 5 to 13 years at baseline who had information on disorder status and follow-up data: 1,824 in the 1999 cohort, 3,657 in 2004 and 2,053 in 2017.

Trained clinical raters assigned baseline diagnoses using the Development and Well-Being Assessment and standardised ICD-10 criteria. The study used the term psychiatric disorder to include mental health disorders and ADHD. At follow-up, parents — and, for older children, the children themselves — completed the Strengths and Difficulties Questionnaire (SDQ), which captures emotional and behavioural difficulties and their impact on daily life.

What changed over time?

In every survey, a psychiatric disorder at baseline was associated with greater difficulties and functional impact three years later. However, the association became progressively stronger over time.

• Parent- and self-rated difficulties were more strongly associated with baseline disorder in the 2017 cohort than in the 1999 and 2004 cohorts.

• Children in the 2017 cohort were more likely to report a greater impact of difficulties on everyday life.

• Using parent-rated SDQ scores, 52.4% of children with a disorder in 2017 had deteriorated at follow-up, compared with 34.2% in 1999 and 37.6% in 2004. The proportion who improved fell correspondingly.

The pattern was seen across ages and sexes. It is a population-level finding: it does not predict the course for an individual child.

Inequalities remained stark

Income was an important divider. In the 2017 cohort, only around one third of children with a disorder from low-income households improved or remained stable over three years. Among children from middle- or high-income households, the equivalent figure was around one half.

How should the 2020 follow-up be interpreted?

The most recent follow-up was conducted online in July and August 2020, soon after the first COVID-19 lockdown eased. The pandemic is therefore likely to have contributed to the poorer outcomes in the latest cohort. It cannot, however, explain the whole pattern: related work in the same surveys had already found greater concurrent difficulties and functional impact in 2017, before the pandemic.

Important limitations

The 2020 follow-up had a 46% response rate, compared with 73% in the 2007 follow-up. Teachers were not invited to take part in 2020, and the diagnostic interview was not repeated, so the study could not assess persistence or remission of a diagnosis. Although statistical weighting addressed measured differences in response, loss to follow-up may mean deterioration was underestimated. As an observational study, it cannot establish why outcomes have changed.

What this means for primary care

This research is not a new diagnostic or treatment pathway. It does reinforce the importance of prevention, early identification, attention to functional impact and equitable access to effective support for children and young people. Local safeguarding, paediatric and child and adolescent mental health pathways remain the appropriate routes when concerns arise.

References

1. Armitage JM, Newlove-Delgado T, Ford T, McManus S, Collishaw S. Change in the severity and impact of child psychiatric disorders over 3 years: an analysis of trends using the national child mental health surveys of England from 1999, 2004, and 2017. Journal of Child Psychology and Psychiatry. 2026. https://doi.org/10.1111/jcpp.70231

2. NHS Digital. Mental Health of Children and Young People in England, 2020: Wave 1 follow up to the 2017 survey. Official statistics.