Richard Graham: Child and adolescent mental health in the 21st century

Richard_Graham_PortraitThe Duchess of Cambridge’s support for children’s mental health at the beginning of the first Children’s Mental Health Week was welcome, necessary, and urgent. At a time when austerity measures are impacting on so many services, it is vital to have such endorsement; the evidence for children’s mental health services is solid and compelling and their care should not be displaced by the needs of adults. Even so, the demand is great, the capacity of services very limited, and so in future we must draw upon technology that can create new ways of reaching out to young people.

If we engage and partner with young people in improving their mental health and wellbeing, we face unprecedented challenges that the earliest practitioners in the field would not recognise. From the earliest days of the first Child Guidance Clinic in 1923, the rate of social and technological change that has influenced child development over the past century is daunting to apprehend.

No parent, educational practitioner, or health practitioner has previously had to struggle with the complexity, scale, and sheer multiplicity of the worlds that young people now inhabit. Even comprehending the immersive allure of games such as Minecraft challenges the thinking of adults for whom three, if not four, television channels and the radio was sufficient entertainment. Yet some understanding of this is likely to help engage a reluctant child in a therapeutic process.

The extent to which digital media impresses itself onto our services was further brought home to me very recently. An adolescent who was experiencing panic episodes had searched for understanding and support not through Google Search or Wikipedia, but through YouTube “vlogs.” While I consider this a vote of no confidence in Google Search and an example of how, paradoxically, many adolescents seek information from (metaphorically speaking) the individual horse’s mouth, I also felt completely out of step with such behaviours, which will continue to influence health and the seeking of help.

Health information is now social, personal, and part of an ever evolving stream of video content. As I’ve dug deeper, I’ve learnt that cameras on phones are used to document the locking of doors for someone with obsessive-compulsive disorder, or as a therapeutic tool that helps gauge portion size for someone struggling with anorexia.

The challenge for us goes further than a mere noting of trends. Any appraisal of a child’s wellbeing and physical or mental health that does not include an assessment of the young person’s digital life will be partial and blind to a plethora of risks—the most common of which may simply be that of the short wavelength light from a tablet or smartphone, which when used at night can disrupt sleep. Yet how many of us routinely appraise the digital world of tablets, smartphones, and social media that are now embedded in the lives of all children? These will all have an impact upon a child’s mental wellbeing, even if research is yet to determine whether the risks are greater or less than the advantages these technologies offer.

Our clinical practice, and indeed our research, will suffer if we cannot communicate with young people about the worlds of digital media, and how within them distress and mental disorders find expression. Indeed, we may not even be able to persuade them to attend our services. As smaller, intelligent, connected devices (wearables) are increasingly incorporated into the lives of children from earliest infancy, mental functioning is now intertwined with digital devices. This is not a comment on whether or not this is either a good or bad process; the challenge is to understand the interface between ourselves and the technology. And if we can speak to that, there are some very welcome rewards when we deepen our understanding of the digital lives of young people.

I have been helped over the past decade by adolescents who have patiently educated me in this respect, and it is very definitely the case that the level of knowledge needed does not have to be great. What’s more important is a recognition of the personal value that a smartphone, app, or game may have for them. I have also been very fortunate to work with some leading figures in the worlds of e-safety and social media too, most notably Annie Mullins OBE, director of safety and trust, EU, at Recognising that mental health for young people will now relate to digital wellbeing, we developed two modules for MindEd, which can help professionals working with young people start the journey of understanding a young person’s digital life.

If the Duchess of Cambridge wanted to know how to start a conversation with a young person about their mental wellbeing, she could do a lot worse than by asking how they keep in touch with friends or what phone they have. Genuine interest and understanding of the messaging apps, social media sites, and streaming services that young people use can change their perception of us into something more credible. Our models for mental disorder may also evolve in step with this, and our interventions will reflect the actual lives of young people today, and not the practices of the pre-digital era.

Dr Richard Graham is a consultant child and adolescent psychiatrist at the Nightingale Hospital, and former clinical director of the adolescent department at the Tavistock & Portman NHS Foundation Trust. He founded the UK’s first dedicated Technology Addiction Service for Young People at Nightingale Hospital in 2010. For the last decade his work has centred on the impact of technology on development, firstly focusing on the role played by visual media in body image disorders, and more recently through exploring the influence of connected devices, social media, apps, and video games on adolescents and younger children.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.