Inside the teen mind: what’s happening to mental health? Episode 8 of the Health Foundation podcast

Jennifer Dixon: One of my guests today has described adolescence as, ‘The central drama of life,’ but we've all seen some trends. Increasing depression, self-harm, anxiety, eating disorders, and other mental health issues. We know about wider economic trends which have piled pressure on kids to make it to college and social trends which might help or hinder teens as they negotiate adulthood. For example, less drinking, less smoking, less sex and pregnancy, and huge use of social media, as well as different attitudes to gender identity and religion, for example. That's already a heady and complex mix. On top of that, we've had the pandemic too. What's going to be the longer-term impact of that?

Today, we're going to be looking at what's happening inside the lives of teens. I'll be joining all the dots to get a more complete picture. Are there warning signs? Might we be facing a tidal wave of mental ill-health or diminished well-being in the future? And three-quarters of lifetime mental illnesses are first experienced before age 20. What more might we do to prevent it earlier? I'm really delighted to welcome two people who know a lot about these issues. Jean Twenge is a Professor of Psychology at San Diego State University. Jean has focused much of her research on generational differences, including work values, life goals, and speed of development.

She's also known for her books, including the very interesting iGen and Generation Me. I can highly recommend iGen in which Jean argued that smartphones were the most likely cause behind the sudden increases in mental health problems among teens after 2012. Yvonne Kelly is Professor of Lifecourse Epidemiology in the Department of Epidemiology and Public Health at University College, London. Yvonne is Director of the International Centre for Lifecourse Studies and leads work on health and development during childhood and adolescence on which she has written extensively. Her research makes use of the unique assets of the longitudinal data sets tracing trends and associations over time in Britain.

Welcome to you both.

Jean Twenge: Thanks very much.

Yvonne Kelly: Thank you.

Jennifer: Let's kick-off. Let's have some broad constructs to some of what we're talking about today. I want to just ask about some broad health trends. What is the picture of mental health among young people pre-pandemic? What are the key trends that we should know about?

Yvonne: We've seen deteriorations in mental health broadly over the last couple of decades, certainly. We've seen an upward shift in depression, anxiety, self-harm in terms of recorded statistics, diagnoses, self-reported problems which is, of course, worrying. Along with that, along with those self-reporting diagnoses, in the UK, at least, we know that there is increasing levels of unmet need. Children and young people are falling through the cracks in terms of service provision.

Jennifer: Thank you. Jean, are we seeing similar trends in the United States that Yvonne paints the picture of?

Jean: Yes. The picture for the mental health of teens in the US started to become significantly more negative around 2012 across the board in this really, really pervasive trend. You see more depression, more anxiety. Not in terms of diagnoses even, just in terms of the symptoms that people are having. I think it's always important to make that point because it's tempting to say, ‘Well, maybe more people are seeking help,’ or ‘Maybe doctors are more willing to diagnose depression,’ but that's not what we're seeing here. We're seeing it in these screening studies where they get a cross-section of the population and look at the symptoms the people are experiencing.

For more teens, those symptoms fit the criteria for clinical-level depression. It's not a small change either. Between 2011 and 2019, the rate of clinical-level depression among 12 to 17-year-olds in the US doubled. Big changes. It also shows up in behaviours. Emergency room visits for self-harm behaviours like cutting or taking too many pills have gone up. The suicide rate in this age group has doubled or nearly doubled over such a short period of time. Things were relatively stable or even getting better, say between 2000 and about 2011 or 2012, then things started to deteriorate.

Jennifer: Are we seeing the same kind of pivot point around 2011 in the figures in the UK? Also, are these trends affecting boys and girls equally?

Yvonne: Well, we don't see the same pivot point when we look at population-level data interestingly. We've seen a gradual decline over the last 20 years in terms of deterioration in young people's mental health. That the shape of the graph looks a little bit different, but we do see this steady deterioration and interesting work where we compare the mental health of young people who are born in 2000 with those born in 1990, so 10 years earlier, decade apart. We do see striking upswings, and we see it for across gender. As many countries, I think, we see that much higher rates of depressive symptoms of self-harm, for example, in girls compared with boys. For boys, we're seeing higher levels of hyperactivity and conduct problems.

Jennifer: Jean, presumably this gender differences also true in the US, why might that be?

Jean: We do that for depression, definitely among girls where you see that it's a much larger increase in, for example, clinical-level depression among teen girls compared to teen boys. Although just in the last couple of years, that increases among boys have started to catch up, but the overall change is still larger among girls. Then you're right, the next interesting question is why might that be? To answer that, I think we have to start with we have an increasing level of depression among teens overall in the first place, but particularly among girls.

I do think you can make a pretty strong case for the rise of the popularity of social media because 2012 was the time when the ownership of smartphones became common. That was around the time when it shifted to the majority of people owned a smartphone. It's also around the time that social media use moved from optional to mandatory. Because just a few years before, about 50% of teens were using social media every day. After 2012, it reached this inflexion point where it became more like 70%, then 80%. In other words, if you're not using social media, you're left out.

Jennifer: Let's think about lower down in the pyramid, which is trends and wider behaviours and attitudes amongst teams in particular. What is going on, what's happening in their lives that might then poke through to be the precedent of mental ill-health or self-harm. Jean, in your very interesting book, iGen, you have so many line graphs, which document a really interesting picture about some wider trends in attitudes and behaviours. I wonder if you might just chart those out for us, and then I'll turn to Yvonne for the picture in the UK.

Jean: One big set of trends, what you might call adult activities, things that adults do, and children do not do. With iGen, we see that they are taking longer to do these adult things. For example, 17 and 18-year-olds are less likely to have tried alcohol. They're less likely to have had sex. They are less likely to have had a paid job, to have a driver's license. All of these things show that they are just, they're taking longer to grow to adulthood. It's a really interesting shift because for a while, we have, of course, seen these trends during young adulthood of young adults taking longer to settle into careers, to get married, to own a house for probably both cultural and economic reasons.

For a while, that wasn't really true for adolescents. Adolescents were, if anything, growing up faster and then taking longer to grow to full adulthood as young adults. But what's happened in the last especially 15 years has been this slowdown in adolescence, that instead of adolescents getting expanded, which is the way it was for Gen X-ers like me who were growing up in the 1980s, what we have now is that childhood is extended. I mentioned 18-year-olds, you see the same trends for 13 and 14-year-olds in eighth grade that they are much less likely to have a paid job or have tried to alcohol or to go out on dates. All these things that used to be fairly common by the age of 14 are now much less common.

Jennifer: How much of this is not indulging in actual risky behaviour in reality, but doing more of this virtually? I'm thinking delayed sex, but I'm thinking about all the access to porn online. How much of the risk is just transferred to a different sphere, do you think?

Jean: That is definitely part of it. I think there's a couple of things that argue against online activities being the whole explanation. They have been going on since before the smartphone, if not before the internet. You could say, they're going to watch a lot of porn, and then they're going to want to have more sex in the real world, or they're going to have more access to information about sexuality and birth control online, and then have more sex in the real world. I think you can make the argument either way. For going out, I think that's a much clearer argument. They're not getting together as much in person and going out, probably because they're interacting online.

Having internet access certainly doesn't prevent you from getting a job. I'm not sure why it would prevent you from dating or getting a driver's license. I think there is definitely some influence there, but I think it is not as comprehensive in explanation as the speed of development slowing down.

Jennifer: Yvonne, do we see similar trends in the UK of what Jean is describing?

Yvonne: Yes, certainly in terms of substance use or drinking, smoking, having sex. Teenage pregnancy rates have dropped off the scale hugely in the last 20 years. Echoing Jean's observation about Generation X, these things were certainly happening a lot earlier in this part of the life course.

Jennifer: In some areas, I think, Yvonne, you've written quite a bit about this, is that there is a delay to, for example, trying alcohol, but then there's also the bingeing afterwards. What is that about? Maybe in the US is there an equivalent with drugs? I don't know, maybe starting drugs later, but then actually, as we know, there's this huge exposure in the US to drugs.

Yvonne: Yes. I think there's something about that polarization. They are on average, the proportions of young people doing these things are coming down, but you get those extremes of behaviour. There was a phrase that was used in the UK a few years ago, ‘The young fogies’ because you had all of these supposedly clean-living young people. Then they go to university, for the 50% in the UK who go to university. Well, I've got direct experience through my own children going to university, being absolutely, this avalanche of fliers coming through.

They've just passed the public examinations to get into university, or they've chosen the first choice they've got in. All of a sudden, they're just getting flyers after flyers after flyers for, ‘Sign up for this pub crawl. Pay your money here. Your t-shirt will be delivered to you before you get to university.’ Day 1, it's this pub crawl, Day 2 it's this, Day 3, it's ... and all based around alcohol.

Jennifer: There's another really interesting theme in the iGen book, which I found particularly interesting, which is this whole idea of emphasis, on psychological safety, that obviously has huge ramifications for what happens once the teens enter college, for those who'd go on to college.

Jean: It is really interesting. We're talking about a group where a lot of them are teens and young adults. That's an age group that usually you would associate with risk-taking. Then in terms of behaviours, at least in the US data, what we see is a pretty big decline in binge drinking. One of my favourite graphs, as you mentioned, I love line graphs, is one where you look at their perception of the safety of binge drinking, and then how many actually do it.

Up until iGen, you had what you'd expect to be a pretty normal pattern for 18-year-olds, which is more of them were binge drinking and thought it was safe because they're like, ‘I know it's not safe, but hey, I'm living on the edge of 18. That's what 18-year-olds often do. I'm going to binge-drink.’ That that line was higher than the number who said, ‘Yes, we know it's safe.’ They're like, ‘Yes, I'm going to do it, but I know it's not safe. Then, as the generation shifts from millennials over to iGen, around 2012 or so, those lines cross. Suddenly you get fewer binge drinking than think it's safe, and you see the same thing for marijuana use. That gets to this general idea of them placing a lot of emphasis on safety.

That's physical safety, and then that has expanded to also include what iGen-ers call emotional safety, that they don't just want to be physically safe. Many of them believe that emotional safety is just as important as physical safety. Say not being upset, not having bad experiences, and so on. It's a very interesting concept because, on the one hand, it is a very positive thing. On the other hand, it might also be at the root of some of the more controversial beliefs, attitudes, and behaviours among this group, such as the idea that I don't ever want to talk to someone I might disagree with, because then I wouldn't feel emotionally safe.

Jennifer: There's a fabulous book called The coddling of the American mind by Jonathan Haidt and Greg Lukianoff where they take some of these ideas and develop them and show how, in university settings, how some of this is playing out with, which is fascinating. We'll put that in the show notes. Yvonne, I wonder whether you might talk to us a little bit about what might be some of the predictors here of mental ill health from your working with the cohort studies.

Yvonne: Well, there's such a wide-ranging number of factors which could have an impact or bearing on young people's mental health. From very broad or real concerns around climate emergency, about the path forward. The pressures around education, pressures to succeed, the perception of doing well at school, well in education. The staggering levels of student debt, the inability to get onto the housing market, question marks around ... family formation, partnerships and family formation, long-term relationships, all of those things. Being able to leave home, boomerang generation.

Then within that, of course, we've got individual socioeconomic differences and family context and so on. Digital technology use, social media use might be a part of this if it is. If there is a causal association going on here between uses of digital technology and social media, then we have to take that seriously. There certainly has been a deterioration in mental health alongside an increase in access to these technologies and the use of smartphones and social media platforms. The key is trying to get those together to make stronger causal arguments, I think is important.

Jennifer: Thank you. You paint an interesting picture, Yvonne, of why there are societal changes, and then proximal home environment, poverty, other factors that's all critical in a young person's life, then other factors such as social media into which the person enters. Can you unpack the social media ingredients here a little bit about what's been going on and what the link is with mental ill-health?

Jean: This is always a difficulty that, when you're looking at trends over time, and trying to explain what the cause is, you're limited because you can't do a random assignment experiment. You cannot randomly assign people to be born at different times and then see what happens. Social media is social, it does not happen in a vacuum. It's not just one person using social media because even people who do not use social media are influenced by social media because other people use it. That's especially true for teens, I think it's especially true for teen girls that if you have a teen girl who chooses not to use social media or use it in a limited way, then she can still feel excluded.

You're left out whether you use it or you do use it, it's like a no-win situation. You just look at the impact that it's had on social life. Let's take somebody, a teen girl who says, ‘Communicating online isn't really my thing. Hey, friends, let's go out.’ They're like, ‘No, we're not going out. We're all at home on Instagram. We're content with that.’ This is the problem. This is something that's happening at the level of the group, not just at the level of the individual. That's important to keep in mind as well when we're talking about what causes what.

At the individual level, yes, some of it could certainly be that the kids who are depressed are spending more time on social media rather than social media causing depression, probably some of both. The level of the trend and the generation and the group is a different picture because you're going to say it's reverse causation, it's depression causing social media use. You would have to make this argument. You would have to say, ‘Teen depression rose for a completely unknown reason. that nobody can figure out. Then that's why smartphones became popular, and that's why social media became popular. It's because more people were depressed.’ Given that, at that level, at the level of the group, I think, you cannot improve it, but I think you can make a stronger argument that the position is much more likely to go in the direction of these technologies becoming popular and then the depression going up. Also, that if you're spending a lot of time, an increasing the amount of time online, that you may not be sleeping as much, and sure enough that's why see. The percentage of teens not getting enough sleep started to increase again right around 2012. That if teens are communicating with each other online, maybe they're not spending as much time with each other face to face.

Again, sure enough, that's what we see in the big surveys across the board. In-person social interaction started to... The trend in that, the downward trend in that really accelerated again right around 2012.

Jennifer: Can you then lead us onto why girls might be experiencing things very differently to boys?

Jean: I think there's a number of things. First is if you look at digital media time, girls spend more of their time on social media, boys spend more of that time on gaming. Now, social media is more strongly linked to depression in terms of time spent than gaming is. Also, the way girls' social relationships impact their mental health is a little different than the way for boys. Social media really exacerbates a lot of the already existing issues for adolescent girls and the way they relate to each other. It makes popularity a number, makes exclusion even easier, it makes bullying a 24/7 event. There's still a lot of things in there that are… socially, it's a perfect storm for girls and their mental health in a lot of ways.

Jennifer: Body image is the other, isn’t it?

Jean: Yes. Thank you for mentioning that. That's another great example that social media, say, especially image-based social media like say Instagram, it really raises the bar on a lot of these body image issues, which were already there.

Jennifer: Yvonne, is that a very similar picture in the UK?

Yvonne: We do see these different pathways through sleep, through upwards surge of comparisons, body image, cyberbullying. That's all very real, all of those things impact directly on young people's mental health. It just happens that, for girls in particular, who spend more of their time online, that they're more likely to encounter all of these things. It's absolutely that. Just as we see in the US, young people, particularly girls who don't spend time online, have more mental ill-health on average than those who do because of those things around exclusion and thinking about the group.

You're not in the group, ‘We want to be here, we want to be chatting online. We don't want to be out gaming into the park and things like that or meeting up. We want to do that.’ Young people who wish to spend so much time online can get excluded for all sorts of reasons.

Jennifer: Sprinkling on all this, the pandemic, if we can just turn to that for a minute.

Jean: We don't know yet is the short answer. We did really well-matching demographics with some of the previous national data. Found very much to our surprise that mental health among teens was actually relatively stable, and in some cases, even a little bit better than it had been. Possibly because they were sleeping more and possibly because they were spending more time with family. However, I had to get a big caveat on that, which is we were, of course, not able to collect the data at schools, like the previous data collections. It had to be done online and it had to be done with the permission of a parent.

Even though we did very well-matching demographics, we probably didn't get the kids who maybe didn't have a good relationship with their parents, and, of course, those are going to be kids who are depressed and lonely. They would have been captured by the schools' surveys in a way that we couldn't do just given the challenges of data collection during the pandemic. I'm really waiting for that more comparable data because until we get it, I think we don't really know what happened with teen mental health during the pandemic, even though we tried.

Jennifer: Yvonne, we have the NHS Mental Health in Children and Young People Survey that was carried out in July and October last year. Do you want to say a little bit about the findings?

Yvonne: It looks like there's been an uptick. Similar to the US, other data sources don't suggest such wide variations over that first part of the pandemic, so it's a complex picture. Then we're thinking about young people at different stages at that part of the life course, and what's happening to them, and the different things that are occurring. Young people studying at home, online. Socialising perhaps more over social media platforms has been a lifesaver for very many people, right across the live course, not just young people.

Then we've got older teens having real difficulties in the UK context, in terms of the education system. We had debacles over public examinations.

We've got young people doing online learning in their first and second years of undergraduate life, having a miserable time because they're all stuck in their bedrooms, looking at a sea of black dots, empty windows whilst they're undoing their online learning in the lectures and seminars.

Jennifer: My daughter included, who spent a grand total of six weeks at her University. Everything was online, and she didn't meet one person in her course.

Yvonne: These things are making young people tremendously unhappy. Universities are ramping up provision for more face-to-face time, but it's online time. We're meeting our students more often over this last year than we would have done face-to-face pre-pandemic, because of the need for increased student support in the higher education sector. It's a really, really complex picture. For some young people, maybe perhaps socially anxious in school settings, if we're thinking back to school children age. The pandemic could have been somewhat of a relief because kids simply don't have to go to school and deal with those situations. They may have been feeling that, again, safer, the idea of emotional safety.

It's a really, really complex picture, which, again, goes back to experiences and those broader structural forces. Youth unemployment, we're yet to feel the full economic devastation of the pandemic in the UK and elsewhere. Youth unemployment levels are predicted to be sky-high.

Jennifer: Actually, the overall mixed picture which you're both describing in terms of the impact of the pandemic on mental health, it's probably if you dig underneath the aggregate data, you can't worry about certain groups in particular. Those in particularly experiencing poverty and food insecurity, which I understand is being reported quite highly in some of the surveys of children. Those are some of the things out there that are really going to injure mental health and wellbeing.

Yvonne: Absolutely, and inequalities that will result from this. There's a wide set of predictions and hypotheses around this. It's yet to be tested, but the economic impacts are being felt in many different ways.

Jennifer: Family stress and parents mental health and so on. I suppose the question there is, even if the picture isn't clear now, what's the likely long-term impact of this? I was just looking back, actually, The Children of Katrina, which was, obviously, Katrina was a hurricane, very different emergency insults compared to a pandemic, but nevertheless, a sudden thing that happened. The book by, I think it was Alice Fothergill and colleagues who wrote that book followed that through, and nearly, five, seven years later, there were big impacts. What's your hunch about whether we're going to carry something forwards from the pandemic?

Indeed, the amplitude of higher mental ill-health amongst teens, is that going to just be a higher amplitude and then just drop back as people reach adulthood or is that also going to be carried forwards? In other words, are we just all facing a bigger demand and prevalence of mental ill-health and anxiety into the future from the pandemic and from these underlying trends?

Jean: Generally speaking, the younger that someone experiences their first episode of depression, the more likely it's going to recur throughout life. If we go on that, even just based on the pre-pandemic statistics of the rising depression among young people, we're probably going to have depression among adults, going forward, for this generation, but that remains to be seen.

Yvonne: We have to test it, and it will be decades before we know the answer definitively. If we think about, I think, you said at the top, Jennifer, that's three-quarters of mental ill-health emerges in the adolescent period. We know that, from a life course perspective, that's got major knock-on effects, not just for mental health, but also different aspects of physical health, thinking more broadly in terms of entering the labour market, productivity, all of those things. Potentially there's a ticking time bomb there, not just in terms of mental ill-health but also there are those broader consequences as well.

We have we don't know for sure yet, but if we follow the life course, the evidence from previous generations on, on life-course effects of mental ill-health, then yes, we see a very long shadow.

Jennifer: Jean, if you're sitting alongside Joe Biden and you have his ear, Yvonne, you're the Chief Policy Advisor to Boris Johnson, what are the kinds of things, the priorities that you would be talking to them about to try to remedy. Perhaps I could start off with Jean first. What kinds of broad things would you be saying to Joe Biden and his team?

Jean: Well, I would probably end up focusing on the low-hanging fruit, that I think there's three policy and public health, things in this area. One is we have existing law that says you're not supposed to have your own social media account in your own name before you're 13 years old, and it's never enforced. There are lots of 12, 11, 10-year-olds who have social media accounts because they just lie about their birthday. Let's start there. There you go, enforce existing law around that. Maybe considering no phones during the school day. France has already done that, especially in younger grades, that, sure they might need them before and after school, but bell to bell, there's really no reason to need that phone.

Then that helps with learning. The third thing is some education campaign around devices and sleep, that we should not have our devices in our bedrooms overnight because there's a raft of research on how devices interfere with sleep. In some universities where I've given talks, the way that they've done it, as I said, we're going to start having alarm clocks in people's bedrooms, because that's what people say, ‘I have to have my device in my bedroom at night because it's my alarm clock.’

Jennifer: My daughter tries this.

Jean: Right. My answer to that is, ‘I have some advice for you, buy an alarm clock. You can buy it on Amazon on your phone, and then put your phone in another room and get a good night's sleep.’

Jennifer: Right. I hear you. That's great. Thank you. Yvonne, putting you in number 10, and you can wave a magic wand, what are the types of things you'd be advising?

Yvonne: Well, those low-hanging individual-level fruits are there. In addition to those, in the UK context, there has to be a real major rethink about the way we're setting young people up for their entry into adulthood, around educational provisions, and so on. I think I would go more broadly as well. Of course, they are longer-term goals, but we cannot ignore... When we're thinking about inequalities and development in young people's wellbeing, we can think on the individual level, and we have to attend to those things, but we have to think those broader structural determinants as well, which might not be barrier-peeling from the Tufts of policymakers and politicians.

It isn't a quick answer, but I really do think we need to pay attention to those broader structural determinants in addition to the individual-level factors.

Jennifer: Thank you very much. To plug that, we funded a health foundation, The Young People's Inquiry, where we came to exactly the same conclusion, Yvonne because the transitions are so difficult for teens, and particularly leaving home with very little support in some cases or not enough support. We'll put that reading also in the show notes.

We must leave it there. I'd like to thank our two guests, Professors Jean Twenge and Yvonne Kelly for a really rich discussion of the issues and one or two solutions. For links to our key reading on the subject, as ever, you'll find them in our show notes, wherever you find this podcast. While you're there, we'd love it if you could give us a friendly rating. As you know, in this monthly podcast, we alternate between health and healthcare, usually adding in a dollop of politics. Next time, we'll be turning back to the NHS. Post-pandemic, is it now time for another one mystery for you to get the funding of our prized national asset onto a more resilient footing?