Do sexual minority teenagers have greater health risks?

People who identify as gay or bisexual have long been known to be more likely than others to be at risk from behaviour which can affect their health, such as drug-taking, drinking and not doing enough exercise. But how does this affect today’s teenagers? In an era of greater social liberalism might these differences be disappearing? Professor Yvonne Kelly and Dr Cara Booker discuss new research which sheds light on the issue.

Numerous studies have shown people from sexual minorities tend to suffer disproportionately from a range of health issues, yet until now there has been a paucity of up-to-date, comprehensive evidence about the level of risk faced by this group in the UK. A recent report by the Equalities and Human Rights Commission called for more research.

Two studies have been able to shed new light on the issue. Evidence from Understanding Society, the UK Household Longitudinal Study, examines its impact on adults and suggests problems still persist despite recent social change. And research based on the Millennium Cohort Study (MCS), which has followed almost 12,000 children since their birth between 2000 and 2002, has presented an ideal opportunity to look at the health outcomes of young people while they are still growing up.

Sexual minority adolescents

MCS is a birth cohort study which has followed up children born in the UK just after the Millennium, and it has followed up its participants at nine months, 3, 5, 7, 11 and 14 years. So using this last sweep, it was possible to look at whether sexual minority adolescents experienced more adverse outcomes than their heterosexual peers.

Between January 2015, and April 2016, 9885 adolescents in the MCS provided a response about their sexual attraction. Six per cent identified themselves as experiencing same-sex or bisexual attraction. Of these, the large majority were female – particularly among those who said they were bisexual.

Among the 629 respondents in this group, 50 (29 female and 21 male) reported same-sex attraction only and 576 (451 female and 125 male) reported bisexual attraction – this was not the case in the samples taken for Understanding Society, where the gender split was more even.

This may be because there is a lot of fluidity in sexual orientation at younger ages – so girls who say they are bisexual at this age may not say so in the future. But the rates of young people who identify as non-heterosexual have increased over time and so we may expect more young people to be bisexual or non-heterosexual in the MCS sample, who are younger than those in the Understanding Society study.

In order to assess mental health, MCS respondents were asked if they had self-harmed in the past year; how they rated their self-esteem and their subjective wellbeing, and about their general life satisfaction. They were asked if they experienced depressive symptoms, and if they felt they were bullied or victimised. They were also asked if they had been involved in anti-social behaviour such as stealing or violence, how close they felt to their parents, whether they smoked, drank or took illegal drugs, and whether they had had unprotected sex. Their levels of physical activity and diet were also assessed.

Range of problems

The findings suggested sexual minority adolescents were more likely to suffer from a range of problems including high depressive symptoms, self-harm, lower life satisfaction, lower self-esteem and all forms of bullying and victimisation. Young people from sexual minorities also had higher odds of being less physically active, of perceiving themselves as overweight and of having dieted to lose weight. And they were more likely to suffer from more than one of these issues than their heterosexual peers were.

However, they were no more likely to engage in violence using a weapon, regular smoking, regular cannabis use, regular drinking, or other drug use. Sexual minority adolescents did not have increased odds of engaging in sexual activity or of engaging in risky sexual behaviour, and there was no difference between sexual minority adolescents and heterosexual adolescents regarding whether they had close friendships.

It has been suggested in the past that disparities may occur because sexual minorities experience stress factors such as bullying as well as facing the stress of navigating their identity. Their experience of prejudice and possible absence of support from family and others may be linked to mental distress, and this may lead to potentially risky behaviours such as substance misuse. However, activities such as drinking, smoking, drugs and sex are also part of normal adolescent development – so we would not want to suggest they’re always a major problem.

The teenage years are a time for experimenting and pushing boundaries, something discussed in an earlier Child of our Time blog on sexual behaviour.

Sexual minorities in adulthood

All this has implications for lifelong health and social outcomes. Recent research led by Dr Cara Booker used Understanding Society data from over 40,000 individuals aged 16 and over to explore the health inequalities of sexual minority UK adults.

Unlike the MCS study, this research included respondents who identified as ‘other’ and those who preferred not to say. And a distinction was drawn between those who identified as gay and those who identified as bisexual. Participants were asked about their physical and mental functioning, minor psychological distress, self-rated health, substance use and disability.

Overall, heterosexual respondents had the best health while bisexual respondents had the worst. Gay and lesbian respondents reported poorer health than heterosexuals, specifically with regard to mental functioning, distress and illness.

There were no differences in either mental or physical health between lesbian and gay respondents once socio-demographic characteristics were controlled for, and there were also some indicators on which bisexuals did not differ from other groups.

Those who were ‘other’ or preferred not to say were similar to each other and generally experienced fewer health inequalities than gay and lesbian respondents, but still had poorer health than heterosexuals. This suggests that health promotion interventions are needed for these individuals, who might not participate in interventions targeted toward known sexual minority groups.

Range of disparities

In conclusion, these two pieces of research suggest that a range of disparities based on sexual attraction are visible as early as 14 years of age, and are likely to persist through adult life.

These results highlight the need for further prevention efforts and intervention at the school, community, and policy level to ensure that sexual minority adolescents do not face lifelong negative social, economic, and health outcomes.

Health and educational practitioners should be aware of the increased risk for adverse outcomes in sexual minority adolescents.

Schools provide an ideal infrastructure to implement effective public health change and social policies. In light of this, a new UK curriculum that teaches students about gender and relationship diversity has been developed, but the guidance around its implementation currently lacks clarity. Therefore, at the policy level, clearer guidelines for schools are needed.

Better support for families could help, too, to alleviate tensions between parents and sexual minority adolescents. This needs further investigation.

In conclusion, despite high-profile UK policies such as the legalisation of same sex marriage in 2013 and the introduction of sexual orientation as a protected characteristic during the lifetime of the young people in this study, the evidence presented here indicates that large inequalities in social and health outcomes still exist for sexual minority adolescents growing up in the 21st century.

Mental health, social adversity, and health-related outcomes in sexual minority adolescents: a contemporary national cohort study, by Rebekah Amos, Eric Julian Manalastas, Ross White, Henny Bos and Praveetha Patalay, was published in Lancet Child Adolescent Health 2020; 4: 36–45 https://doi.org/10.1016/ S2352-4642(19)30339-6

Sexual orientation health inequality: Evidence from Understanding Society, the United Kingdom Household Longitudinal Study, by Cara L Booker, Gerulf Rieger and Jennifer B Unger, was published in Preventive Medicine 101, 2017, 126-132.

Author affiliations:

Professor Yvonne Kelly, ESRC International Centre for Lifecourse Studies, Institute of Epidemiology and Health Care, University College, London

Dr Cara L Booker, Institute for Social and Economic Research, University of Essex.

Time to help our children get a move on

World Health Organisation and United States guidelines say adolescents should do at least an hour’s moderate-to-vigorous physical activity each day. But a new global study shows eight out of 10 fail to meet that standard – and there is a widening gender gap. Professor Yvonne Kelly and Fran Abrams outline new research revealing worrying trends which demonstrate the need for political and social choices that will help young people enjoy the social, physical and mental benefits of being active.

Physical activity has many health benefits for young people – and globally, four in every five adolescents do not benefit from regular physical activity.

In 2018, the WHO launched a global action plan called More Active People for a Healthier World. It aimed to reduce the proportion of people doing insufficient physical activity by 15 per cent by 2030 among both adolescents and adults.

Now in a major new study WHO researchers have analysed information on 1.6 million school students aged 11-17 in 146 countries. They found some positive trends but argued much still needed to be done to encourage young people to exercise more.

There was a small reduction over 15 years in the proportion of boys not doing enough, though this still fell well short of the WHO’s target. But the proportion of girls meeting the target remained static and this led to a widening gender gap.

As has been shown in the UK such gender differences start early with lower levels of physical activity in girls emerging before they become teenagers.

The authors of a separate investigation using the Millennium Cohort Study (MCS) suggest the main reason for young people not exercising or sleeping enough is the amount of time they spend using screens. This is a hotly contested area, intuitively, ‘too much screen time’ and ‘too little exercise’ might appear to sit side by side. However, in this kind of study, it is not possible to infer that one causes the other.

The WHO study showed the majority of adolescents did not meet physical activity guidelines, putting their current and future health at risk. Although there were small reductions in insufficient activity among boys, the prevalence of insufficient physical activity in girls had remained unchanged since 2001.

Figure 1 Prevalence of insufficient physical activity among school-going adolescents aged 11–17 years, globally and by World Bank income group, 2001 and 2016

Huge dataset

The dataset used in the WHO study was huge – the young people studied had provided information for at least three years and the analysis covered four World Bank income groups, nine regions, and the globe as a whole for the years 2001–16. Saying that, although the research data covered more than 80 per cent of the global population, it still didn’t cover every county and region. And the estimates for low-income countries need to be treated with caution as the coverage there was much lower – only 36 per cent.

The overall analysis showed that more than eight out of 10 school-going adolescents aged 11–17 did not meet the recommendations for daily physical activity. The small improvements in boys’ activity levels, combined with the static position in girls’ activity, suggested a target of more than 30 per cent of adolescents meeting the recommended level by 2030 will not be met.

Globally, across all income groups and regions and in nearly all the countries analysed, girls were less active than boys.

And perhaps surprisingly, the research did not find that the problem was worse in higher-income countries. However, this was not the case for girls, for whom there was no clear pattern in relation to country income.

Differences in activity levels

In addition to variations related to gender and affluence, there were also differences in activity levels between different parts of the world. The boys least likely to meet activity targets were in the high-income Asia Pacific region, but the second-least likely were in lower-income Sub-Saharan Africa and particularly in Sudan and Zambia.

The boys most likely to meet the targets were found in high-income western and south Asian countries with large populations such as the USA, Bangladesh, and India.

These variations might be driven by specific characteristics of particular countries – for example, as the research looked at school children the picture might be skewed in countries where disadvantaged children often do not attend school, or in places where the tradition of school or community sport is strong.

For girls, the largest proportions failing to meet the targets were in Asia Pacific and particularly in South Korea- though in some of those countries girls’ participation in education is low and that might have affected the study’s sample.

The recent MCS study by academics from Loughborough University and University College London used data from 3899 adolescents. This study, in which young people were fitted with activity monitors, found that while nine out of 10 were getting the recommended amount of sleep, just four in ten met exercise targets and a quarter were keeping to the recommended screen time. These figures were higher than those in the WHO study, which could be explained by the different methods used to measure activity and which show just how important it is to consider HOW activity is measured.

The study looked at some correlates of physical activity and showed that adolescent girls who had depressive symptoms were less likely to meet all three of these recommendations (8-10 hours of sleep, no more than two hours of screen time and at least an hour a day of physical activity), while those from better-off backgrounds were more likely to meet them. Among boys, those who were obese and those who had depressive symptoms were less likely to meet the recommendations. However, it is not possible to rule out the potential for cyclical associations to be at play here as low levels of physical activity could lead to depressed mood and to weight gain.

What can be done?

More research is needed to understand the causes of non-participation in exercise – social, economic, cultural, environmental and technological.
Policy change should be prioritised and should encourage all forms of physical education – sport, active play, and recreation as well as safe walking and cycling.
Social marketing campaigns such as the National Lottery funded #thisgirlcan campaign combined with community-based interventions could be starting points to increase physical activity levels in girls, particularly in countries with wide gender differences. This approach has been identified as cost-effective.
Schools, families, sport and recreation providers, urban planners, and city and community leaders all need to become involved.

That four in every five adolescents do not experience the enjoyment and social, physical, and mental health benefits of regular physical activity is not a chance thing – it is the consequence of political choices.

Young people have the right to play and should be provided with the opportunities to realise their right to physical and mental health and wellbeing. Urgent action is needed, particularly through targeted interventions to promote and retain girls’ participation in physical activity. Policymakers and stakeholders should be encouraged to act now for the health of this young generation and of future ones.

Yvonne Kelly is Professor of Lifecourse Epidemiology and Director of the ESRC International Centre for Lifecourse Studies at UCL. She is editor of the Child of our Time blog.

Fran Abrams is CEO of the Education Media Centre and freelance journalist who writes for the Child of our Time blog.

Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants, by Regina Guthold, Leanne Riley, Fiona Bull and Gretchen Stevens, is published in The Lancet Child and Adolescent Health.

Regina Guthold, Leanne Riley and Fiona Bull are based at the Department for Prevention of Noncommunicable Diseases, WHO, Geneva, Switzerland and Gretchen Stevens is at the Department for Information, Evidence and Research, WHO, Geneva, Switzerland. Fiona Bull is also affiliated with the Department of Sport and Exercise Science, University of Western Australia, Perth.

Prevalence and Correlates of Meeting Sleep, Screen-Time, and Physical Activity Guidelines Among Adolescents in the United Kingdom, by Natalie Pearson, Lauren B Sherar and Mark Hamer, is published in JAMA Paediatrics:

Natalie Pearson and Lauren Sherar are at the School of Sport, Exercise & Health Sciences, Loughborough University, United Kingdom, and Mark Hamer is at the Institute of Sport Exercise & Health, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, United Kingdom.

Might population-wide increases in physical activity reduce socio-economic inequalities in the proportion of children who are overweight?

Just half of children in the UK achieve the World Health Organisation’s targets for daily activity, and in England the Government has set its own strategy to tackle this. But would increased physical activity lead to fewer children being overweight or obese? And would it help to address social inequalities in the proportion of children who are overweight? Research from Anna Pearce and colleagues at the UCL Great Ormond Street Institute of Child Health in London suggests more physical activity is unlikely to reduce the prevalence or inequalities in levels of overweight.

Childhood overweight is an important public health problem, with particularly high levels in children living in disadvantaged circumstances. Physical activity is an important determinant of childhood overweight. The World Health Organization (WHO) recommends children should undertake 60 minutes of moderate-to-vigorous physical activity every day. But for many families in England, as in other high-income countries, this is an aspiration rather than the reality.

The UK Government has identified a number of strategies to increase activity among children. But the potential for physical activity initiatives to help children achieve a healthy weight, if scaled up at the population level, hasn’t previously been assessed. In our research, we focused on the WHO target, and on the likelihood that achieving this will reduce socio-economic differences in levels of overweight or obesity.

We wanted to know how hypothetical government interventions to increase activity might reduce the prevalence and inequalities in childhood overweight at age eleven. Could population-wide interventions, aimed at all, or targeted interventions with high-risk groups, have the greatest effect?

What, specifically, might happen to the prevalence and social distribution of childhood overweight if all children achieved the WHO’s target of 60 minutes’ activity per day? What if we are only able to achieve smaller increases in activity than those required to meet the WHO target?

In our study, 27% children were overweight at age eleven. We found that hypothetical universal interventions to increase physical activity could lead to moderate reductions in this. For example, if 95 per cent of children met the target of 60 minutes of activity per day, the prevalence of overweight (including obesity) would drop to 22 per cent. But more realistic scenarios, in which interventions led to more moderate improvements in physical activity levels (of only a few minutes each day), would achieve only small reductions in overweight within the population.

Children from the most affluent backgrounds were less likely to be overweight – around one in five children in the top fifth of household incomes were overweight or obese at 11y, compared to one in three among those in the bottom fifth of household incomes. Our analysis suggested these stark social differences in overweight are unlikely to be reduced through meeting the WHO physical activity target. This is partly because children from the highest income group had the lowestlevel of daily activity, with a median of 59 minutes’ moderate to vigorous activity compared 62 minutes for the lowest fifth of the income range.

Even more intensive intervention scenarios, given only to high-risk families (for example those who were overweight or obese at an earlier age, or those living in disadvantaged neighbourhoods), appeared unlikely to address the stark social inequalities experienced by this cohort of children.

Activity targets

The WHO’s physical activity targets are ambitious and, if achieved, are likely to benefit children’s health and wellbeing in a multitude of ways. However our findings suggest that if the Government is serious about supporting children and families – particularly those from poorer backgrounds – to maintain healthy weights, it needs to look elsewhere.

We need, therefore, to know more about how other types of initiatives to reduce childhood overweight might work. Research which aims to inform this debate should look not just at activity levels but also at environmental factors that influence diet, such as taxes on high-sugar foods and foods provided in early-years settings.

What if all children achieved WHO recommendations on physical activity? Estimating the impact on socioeconomic inequalities in childhood overweight in the UK Millennium Cohort Study, by Anna Pearce, Steven Hope, Lucy Griffiths, Mario-Cortina-Borja, Catherine Chittleborough and Catherine Law, is published in the International Journal of Epidemiology, 2019, 134–147.

Anna Pearce is based at the University of Glasgow but carried out this work out in her previous position at the UCL Institute of Child Health.

Steven Hope, Mario Cortina-Borja, and Catherine Law are based at the Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK.

Lucy Griffiths is based at Swansea University but carried out this work out in her previous position at the UCL Institute of Child Health…

Catherine Chittleborough is at the School of Public Health, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.

This blog is based on independent research funded by the National Institute for Health Research (NIHR) Policy Research Programme (Children’s Policy Research Unit). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

I wanna hold your hand: helping young people prepare for happy healthy relationships

The teenage years are a time for experimenting and for pushing boundaries – particularly when it comes to intimate relationships. Such experimentation is a natural part of growing up. But there are potential risks, too – particularly if these early experiences aren’t positive ones. A new study from Professor Yvonne Kelly from UCL’s Department of Epidemiology and Public Health and colleagues, investigates what kinds of intimate behaviour 14 year-olds engage in, and asks how this insight can help to ensure young people are well prepared for healthy and happy adult relationships.

We know teenagers experiment with intimacy, often moving ‘up’ the scale from hand-holding or kissing to more explicitly sexual activity. But we also know teenage pregnancy numbers have been dropping in recent years. And our new study suggests that fewer young teenagers are actually having sexual intercourse than some might previously have thought.

We’ve all seen the headlines – studies have shown us (links) that 30 per cent of those born in the 1980s and 1990s had sex before the age of 16, and that among those born in the early 1990s a little under one in five had done so by age 15. But our new evidence, based on 14 year-olds born during or just after the year 2000, paints a rather different picture of this latest generation of teenagers.

Our research used data from the Millennium Cohort Study, the most comprehensive survey of adolescent health and development in the UK. It follows children born between September 2000 and January 2002 and has collected information on them at nine months and subsequently at age three, five, seven, 11, and 14 years. We used information from the most recently available data, when the study’s participants were 14 years old, and were able to look closely at the lives of 11,000 of them.

Intimate activities

Participants were asked about a range of ‘light’, ‘moderate’ and ‘heavy’ intimate activities. Handholding, kissing and cuddling were classed as ‘light,’ touching and fondling under clothes as ‘moderate’ and oral sex or sexual intercourse as ‘heavy.’

As might have been expected, more than half – 58 per cent – had engaged in kissing, cuddling or hand-holding, while 7.5 per cent, or one in 13, had experienced touching or fondling. But in contrast to other studies, (though our sample was younger than those mentioned above) we found only a very small proportion – 3.2 per cent or fewer than one in 30 – had been involved in ‘heavy’ activities in the year before they were interviewed for the study.

And most parents can take comfort from the fact that if their children aren’t participating in other risky activities such as drinking or smoking, they probably aren’t having sex either – there was clear evidence of links between heavier sexual activity and these factors.

We also found those who were most likely to confide worries in a friend rather than a parent, those whose parents didn’t always know where they were and those who stayed out late were more likely than others were to be engaged in heavier forms of sexual activity. Other potential links were found to drug-taking and as well as to symptoms of depression.

Our findings suggest young people who push boundaries may push several at once – that those who drink, smoke or stay out late, for instance, are more likely to engage in early sexual activity.

So, initiatives which aim to minimise risk and promote wellbeing are crucial – and they need to look at intimate activities, health behaviours and social relationships in relation to one another.

A key point is that if young people can learn about intimacy in a positive way at an early stage, then those good experiences can build foundations which will help them throughout their lives.

Most importantly young people need to know how to ensure their intimate experiences are mutually wanted, protected, and pleasurable. The concept of “sexual competence” – used to refer to sexual experiences characterised by autonomy, an equal willingness of partners, being ‘ready’ and (when relevant) protected by contraceptives – is important at all ages, as are close and open relationships with parents.

Better understanding of this interplay between personal relationships and behaviours are key to better support for young people. The right intervention at the right time can ensure a teenager’s intimate life is set on a positive course.

Partnered intimate activities in early adolescence – findings from the UK Millennium Cohort Study, by Yvonne Kelly. Afshin Zilanawala , Clare Tanton, Ruth Lewis and Catherine H Mercer,is published in the Journal of Adolescent Health.

*Afshin Zilanawala is based at the Research Department of Epidemiology and Public Health, University College London, and Oregon State University, United States.

Clare Tanton is based at London School of Hygiene & Tropical Medicine.

Ruth Lewis is based at the University of Glasgow.

Catherine H Merceris based at University College London.

Adolescent mental health and risky behaviour – how have things changed for millennials?

In recent years the incidence of adolescent mental health problems has been rising. But at the same time, risky behaviour such as substance abuse – which has been linked to such problems – has become less common. So what has been going on? Praveetha Patalay from University College London and Suzanne Gage from the University of Liverpool looked at how things have changed over a decade among millennials born in early 1990s and early 2000s.

Headlines about adolescents have been dominated in recent years by concerns about mental health and wellbeing.

We know the prevalence of mental health issues has been rising among this group – and that the phenomenon is not restricted to the UK: international comparisons have shown the trend is mirrored across the globe.

And there’s a growing recognition that adolescence is a key time in this respect – half of those who suffer later from a mental health disorder experience symptoms by the age of 14.

Changing behaviour

Yet we know from official reports that at the same time, some types of risky behaviour which are linked with poor mental health have become less common among the young. Adolescents in the UK are less likely to be under-age substance abusers, and the proportion of 14 year-olds who smoke regularly has dropped to just a quarter of what it was in 1982.

A new piece of research looks at how rates of different mental health and health related behaviours such as substance use but also sleep, weight perception and underage sex are changing.

The paper looks at data for two cohorts of UK adolescents – those who were 14 in 2005 and those who were the same age in 2015. It uses data from two UK birth cohort studies – 5,627 young people born in 1991-2 who were part of the Avon Longitudinal Study of Parents and Children, and 11,318 born 2000–02 who were part of the Millennium Cohort Study.

The researchers looked at trends in mental health problems such as depression and self-harm, and found a picture broadly similar to previous studies. These phenomena had become more prevalent over time, with the incidence of high levels of depressive symptoms rising from six per cent in 2005 to 15 per cent in 2015. In contrast with some other studies they found boys had suffered an increase just as great as girls.

Poor mental health in our teenage years can predict a whole range of negative outcomes later on – poor physical health, worse job prospects and poor personal relationships, for instance.

Behaviour and health

And yet these results showed significant drops in various types of behaviour which are linked with poor mental health. For instance, the proportion who had assaulted someone at age 14 dropped from 40 per cent in 2005 to 28 per cent in 2015. Fewer young people had tried alcohol, binge drinking, smoking or having sex by the age of 14.

In this sample, young people in 2015 were more likely to have later bedtimes, to wake up earlier and to sleep less than the recommended eight hours. They were more likely to see themselves as overweight and to have higher Body Mass Index, or BMI.

These relationships aren’t simple. Other factors have changed over time, too. For instance the proportion of young people from ethnic minority backgrounds has risen, though that was taken into account.

The researchers suggest that increasing trends in risky behaviours such as decreasing sleep times, increasing weight and poor body image need to be investigated as potential explanatory factors for increasing mental health difficulties experienced by adolescents.

But there are some clear findings from this study. The rapid increase in depressive symptoms, self-harm, obesity and loss of sleep in adolescents over the past decade is an important finding in itself, and understanding the reasons for this could be a priority for both practitioners and policy-makers.

Changes in millennial adolescent mental health and health-related behaviours over 10 years: a population cohort comparison study is research by Praveetha Patalay and Suzanne H Gage and is published in the International Journal of Epidemiology.

Teenage depression: The potential pitfalls of too much social media use

A new mobile phone will be in the pockets of many teenagers as they head back to school in the coming days. The period between Xmas and New Year will have been spent signing up for social media apps where they can chat, share photos and videos with friends, all part of the excitement of owning a new device. But how many of these young people and their parents are aware of the potential pitfalls of spending too much time on social media sites? And what can parents, teachers and young people themselves do to maximize the benefits of life online whilst minimising those pitfalls? It’s a question that Yvonne Kelly, Director of the ESRC International Centre for Life course Studies at UCL and colleagues have been asking as part of a major programme of research on social media use and young people’s wellbeing. Today they publish key new research, which provides much-needed new evidence on the links between heavy social media use and depression in teenagers. The research shines light on the underlying processes that could be at work and that might explain the link between the two. Here, Yvonne explains how their research might help policymakers, educators, parents and young people themselves better understand and prevent the potential pitfalls of living too much of their life on social media platforms.

2018 has seen a growing chorus of voices including those of the former and current Health Secretaries, Jeremy Hunt and Matt Hancock calling for a thorough investigation of the links between social media use and the growing numbers of young people struggling with mental health issues. Indeed Matt Hancock issued “an urgent warning” on the potential dangers of social media on children’s mental health, stating that the threat of social media on mental health is similar to that of sugar on physical health.

The Chief Medical Officer, Dame Sally Davies has been tasked by the Government with leading that investigation and with coming up with evidence based recommendations around what constitutes safe social media use and what changes need to be made and by whom to make that a reality. The Royal College of Paediatrics and Child Health (RCPCH) recently issued the first ever guidance on managing children’s screen time, calling for further research particularly into social media.

In recent months, we and others have submitted written and oral evidence to two Parliamentary inquiries in this area and had discussions with the Royal Society for Public Health which is campaigning actively to get us all thinking harder about our social media use.

We’ve talked about our early research showing that 10 year-old girls who used social media sites for chatting had more social and emotional problems at age 15 than their peers who used them less or not at all. Those problems continued to get worse as they got older.

Our new research published in The Lancet’s EClinical Medicine draws stronger links between heavy social media use and depressive symptoms in girls and boys at the age of 14. We look at the possible ways in which social media use might linked to depressive symptoms. We consider 4 potential pathways – through young people’s sleep patterns, their experiences of online harassment, body image and self-esteem. It is the first research to look at all of these potential pathways at the same time.

Our data for this research came from the Millennium Cohort Study, which has followed the lives of some 19,000 children born at the turn of the century. This piece of research, looked at the social media use and mental health of nearly 11,000 of the study’s participants.

Social media use

In line with our earlier research, we saw that girls were heavier users of social media than boys with two fifthsof them using it for more than 3 hours per day (compared with one fifthof boys). Girls were a lot less likely NOT to use social media at all (4 per cent girls and 10 per cent boys).

Examining the underlying processes that might be linked with social media use and depression, we saw a number of really striking findings including:

40 per cent of girls and 25 per cent of boys had experience of online harassment or cyberbullying
78 per cent of girls and 68 per cent of boys were unhappy with their body/weight and 15 percent girls and 12 per cent of boys were unhappy with their appearance
13 per cent of girls and 9 per cent of boys had low self-esteem
13 per cent of girls and 11 per cent of boys reported getting fewer than 7 hours sleep per night and 40 per cent of girls and 28 per cent of boys said their sleep was often disrupted

Girls, it seems from these findings, are struggling more with these aspects of their lives than boys – in some cases considerably more. When we turned our attention to the signs of depression exhibited by our participants, we could see that here too girls fared worse with scores on average twice as high as those of boys.

The link between social media use and depressive symptoms was stronger for girls compared with boys. For girls, greater daily hours of social media use corresponded to a stepwise increase in depressive symptoms and the percent with clinically relevant symptoms. For boys, higher depressive symptom scores were seen among those reporting 3 or more hours of daily social media use.

There was a clear link between social media use and all the pathways we investigated – more time spent on social media related to having poorer sleep, more experiences of on-line harassment, unhappiness with the way they look and low self esteem. In turn, these things were directly related to having depressive symptoms.

A closer look at the pathways was also revealing. The most important routes from social media use to depressive symptoms were shown to be via poor sleep and online harassment.

Social media use linked directly to having poor sleep which in turn was related directly to having more depressive symptoms. The role of online harassment was more complex, with multiple pathways through poor sleep, self-esteem and body image, all of which linked directly to depressive symptoms.

Potential pitfalls and key routes

Our findings add weight to the growing evidence base on the potential pitfalls associated with lengthy time spent engaging on social media. In particular they point to poor sleep and online harrassment as being key routes between social media use and depression.

These findings are highly relevant to current policy development on guidelines for the safe use of social media and calls on industry to more tightly regulate hours of social media use for young people. They add weight to the Screen Time Guidance issued by the RCPCH today, particularly the suggestion to set and agree child appropriate time limits on screen use.

When it comes to social media use specifically, our research indicates that the a similar approach could be useful. Clinical, educational and family settings are all potential points of contact where young people could be encouraged and supported to reflect not only on their social media use, but also other aspects of their lives including on-line experiences and their sleep patterns.

At home, families may want to reflect on when and where it’s ok to be on social media and agree limits for time spent online. Curfews for use and the overnight removal of mobile devices from bedrooms might also be something to consider. School seems an obvious setting for children and young people to learn how to navigate online life appropriately and safely and for interventions aimed at promoting self-esteem. Clearly a large proportion of young people experience dissatisfaction with the way they look and how they feel about their bodies and perhaps a broader societal shift away from the perpetuation of what are often highly distorted images of idealised beauty could help shift these types of negative perceptions.

As we head into 2019, millions of young people will be getting their first experiences of life online using the devices they got for Xmas. They will rapidly become expert at downloading apps, posting photos and interacting with their peers. With the gift there was no instruction manual to help them understand and navigate some of the pitfalls our research outlines. We hope our work brings, at least, some guidance for all those keen to ensure these children continue to thrive and do well, so that they enjoy the benefits that new digital technology brings whilst staying safe and happy.

Social media use and adolescent mental health: Findings from the Millennium Cohort Study is research by Yvonne Kelly, Afshin Zilanawala, Cara Booker and Amanda Sacker and is published in The Lancet’s EClinicalMedicine journal.

Do children feel better outdoors?

Many of us believe it’s bad for children to spend too much time indoors or looking at screens – but what does research evidence tell us about the possible mental health benefits of interacting with nature? A major new review of the evidence by Suzanne Tillmann and colleagues at Western University and the The Lawson Foundation in Canada finds there is a positive link – but the researchers say more work needs to be done, as Fran Abrams explains.

We know that mental health issues that develop at an early age have the potential to burden people – and their families and friends – throughout life. And in recent years there have been lots of studies linking these problems to things that happen outside the family home: neighbourhood, environment, school. There have been an increasing number that have looked at positive effects – for example, the possible benefits of activities such as spending time in nature.

The researchers wanted to know more about this last factor – so they decided to look more closely at the connections between the natural environment and children’s mental health.

After searching academic databases, 35 studies published in English or French between 1990 and 2017, focused on children and teens ranging from nine months to 18 years, were included. Early adolescence was the most commonly-studied age, and three fifths of the papers came from the USA, UK or Canada. In those 35 studies there were a total of 100 individual findings.

Parks and green spaces

The papers looked at various kinds of activities which took place in natural areas such as parks, green spaces, water, gardens or forests. Fifteen focused on emotional well-being, 10 on attention deficit/hyperactivity disorder (ADHD), nine on overall mental health and nine on self-esteem, while others looked at stress, resilience, depression and health-related quality of life.

So, what did the findings show? Overall, the review showed nature could have a positive effect on many outcomes measuring mental health. But only around half of all 100 reported findings revealed statistically significant positive relationships between nature and mental health outcomes, with almost half reporting no statistical significance.

For some outcomes – ADHD, stress, resilience, overall mental health and health-related quality of life – there were more positive findings than there were non-significant ones. Studies which looked at emotional well-being, self-esteem, and depression had a greater number of non-significant findings than positive ones. Only one finding, on the impact of greenness on a subgroup of children, showed a negative effect.

So, what did we know already, and what do we know now that we didn’t know before?

We already knew nature had a significant impact on health – including physical, social and cognitive as well as mental health, especially when we look at the research on adults. However, here in this review we can see that there are quite a few studies with inconclusive results.

What has this review added? We now know a little more about the effects of nature on the mental health of those under the age of 18. It has highlighted the need for more rigorous tools to measure those effects and the growth of research on children’s mental health and nature in the past five years.

Framework

The research team have also devised a framework that might help future researchers by categorising papers into three groups based on types of nature interaction: ‘accessibility,’ meaning studies that look at mere opportunity to access outdoor space, ‘exposure,’ which means studies that look at incidental interactions with nature while taking part in another activity, and ‘engagement,’ which means a more direct engagement such as participation in a wilderness therapy programme.

Overall, the messages are mixed. But what this review does demonstrate is the need for more in-depth and more rigorous research. Maybe we need a standard way of measuring the effects of being in nature, its authors say. Certainly we need to continue to look at this area to find out why the research shows such mixed results. But the researchers believe spending time in nature can make a difference – so it’s vital that policy makers and planners think about how we can provide opportunities for children and young people to have those experiences.

Mental health benefits of interactions with nature in children and teenagers: a systematic review is research by Suzanne Tillmann, Danielle Tobin, William Alison and Jason Gilliland and is published in the Journal of Epidemiology and Community Health.

Taking time out to scroll free

As the Royal Society for Public Health launches its #ScrollFreeSeptember campaign, encouraging people to take a break from social media, Professor Yvonne Kelly from the ESRC International Centre for Lifecourse Studies at UCL, discusses new research on the negative impacts of social media use on young people’s health. She explains how the findings point to the need to limit the time that young people, especially girls, spend on social media.

The ScrollFreeSeptember campaign accompanies the launch of a second parliamentary inquiry in less than 12 months into the impact of social media use on young people’s mental health and well-being. Our Centre will be submitting a range of important new findings to that inquiry which seeks to grow the evidence base in an area where there is a great deal of hot debate, but where little is really known and understood.

For our team of researchers, the first indication that all was not well in the world of social media and young people’s mental health came in 2015 when we found that children who were heavy users of screen-based media were less happy and had more social and emotional problems than their peers who used it moderately. Children who used social media sites for chatting were also less likely to be happy and more likely to have problems than their peers who did not.

In March this year, our widely covered work on the trends for boys’ and girls’ social media use added weight to recent calls from the Children’s Commissioner for England to, as she put it, call time on a “life of likes”. In her report, Anne Longfield argued that there was clear evidence of children finding it hard to manage the impact of online life. She said children as young as eight were becoming anxious about their identity as they craved social media likes and comments for validation.

Social media and girls

Our research, based on the experiences of 10,000 children aged 10-15 who took part in the Understanding Society study, showed that this seemed to be the case particularly for girls who used social media for more than an hour a day. 10 year-old girls in the study who spent an hour or more on a school day chatting online had considerably more social and emotional problems later on – by age 15 – than girls of the same age who spent less or no time on social media. The number of problems they faced also increased as they got older, which was not the case for boys.

It was interesting to note that more girls than boys were using social media and for greater periods of time. At age 15, 43 percent of girls and 31 per cent of boys were using it for between one and three hours per day, with 16 and 10 per cent using it for more than four hours.

We think this tells us something important about the different ways that girls and boys interact with social media. For example, girls may be more likely than boys to compare their lives with those of friends and peers – whether those are ‘filtered’ selfies or positive posts about friendships, relationships or material possessions – these could lead to feelings of inadequacy, lower levels of satisfaction and poorer wellbeing.

The pressures associated with having peers like or ‘approve’ status updates and a perceived fall in or lack of popularity could add further pressure at, what for many teenagers is a tricky time in their lives.

Boys are more likely to be gaming than interacting online in the way just described and that wasn’t covered in this research, so it’s possible that for boys, changes in well-being may be more related to gaming success or skill.

But one of the key takeaways of this research is how social media use as a very young person is linked to lower levels of happiness later on – the effects are not short term – they have longer term consequences and

Social media and depression

More recently, we have turned our attention to the social media experiences of the children in the Millennium Cohort Study (MCS), using information on 11,000 14 year-olds to look at how social media use is linked with depression. We’ve also been asking ourselves what the pathways between these two things might look like, something that’s not really been done before. So, for example, are heavier users of social media getting too little sleep or having trouble getting to sleep because they are checking accounts at bedtime; are they experiencing cyberbullying either as victims or perpetrators; do they appear to have low self-esteem or a negative view of how they look? All these questions can help us better understand what’s at play and come up with better approaches to tackling these problems.

Preliminary findings reinforce the message that girls are particularly vulnerable to the negative effects of social media. Once again we see more girls than boys in this study using social media and for longer periods of time.

Does using social media affect literacy?

A follow up piece of research looks at whether there are links between the amount of time young people spend on social media and their levels of literacy. Findings suggest a link and that this is the same for boys and girls.

In this research we look at whether the more time young people spend on social media, the less time they have for the things that might improve their literacy such as reading for enjoyment and doing homework.

There are some clear messages from our research so far:

Heavy users of social media are less happy and have more problems at school and at home – interventions to help them limit and manage their social media use better are likely to be important
Girls are particularly vulnerable to the negative effects of social media and may be an important group to focus on among those looking to mitigate thse effects
More hours spent on social media appear to impact negatively on young people’s wellbeing and could have knock on effects for their longer term prospects at school and work

Social media companies have been accused by the former Health Secretary Jeremy Hunt among others of turning a blind eye to the problem and the chief medical officer Dame Sally Davies has been asked to recommend healthy limits for screen time.

Our research indicates that it may indeed be time for recommended healthy and safe limits of social media use, that a focus on girls, especially initiatives to boost their mental health could help mitigate some of the negative effects.

The RSPH is hoping that going scroll free this September might give us all a chance to get our social media use a little more balanced, to think about the benefits to be enjoyed and the negatives to be avoided.

As well as pausing to think about our social media use and how it affects us, it will be an opportunity to examine the facts of the matter, a time to digest new, solid evidence that these large scale studies can help us with and consider the potential longer term costs and consequences of doing nothing.

The forthcoming inquiry hopes to inform “progressive and practical solutions”, including a proposed industry Code of Practice and tools for educators, parents and young people themselves to help them enjoy the benefits and eliminate the negative effects of their social media. We wholly support those efforts and hope they result in positive changes that will make campaigns like ScrollFreeSeptember unnecessary in the future.

Time to ACE the way we measure the bad things that happen to children

Adverse Childhood Experiences (ACEs) have been a hot topic for policy work in child health and development in recent months. The Select Committee for Science and Technology announced an inquiry into evidence-based early-years interventions, with a particular focus on ACEs. Also a new All Party Parliamentary Group for the Prevention of Childhood Adversities was set up. Essential to the success of these policy initiatives is a fit for purpose method of measuring the negative things that happen to people when they are young, something Rebecca Lacey from the ESRC International Centre for Lifecourse Studies at University College London argues is often overlooked. As part of a new research project, she is hoping to change that.

When Norman Lamb MP launched the early-years intervention inquiry in late 2017, he expressed concern that research in this area was “not being effectively used” in the creation of health policy and other support arrangements. Part of the problem with effective evidence in this area is that the system used to ‘score’ the number of bad things that have happened to a child and assess their risk of poor outcomes later in life is often poorly thought through and rarely questioned.

In 1998 a landmark piece of research by Vincent Felitti and colleagues showed that adults who reported being abused as children, witnessing violence against their mother, living with a substance misuser, or someone who had been in prison or had a mental illness had an increased risk of numerous health problems, such as depression and drug misuse, when they grew up.

It also showed that the number of adversities that someone reported having experienced as a child was really important; the more adversities reported, the higher the risk of health problems in adulthood. This number of adversities is often known as an ‘ACE score’ and Felitti’s paper was the first to use this approach for childhood adversities. It’s an approach that has since been employed in hundreds of academic studies.

Advantages and disadvantages

ACE scores have several advantages. They’re easy to calculate by simply adding up the number of adversities each person has experienced. In a clinical setting, a simple screening tool can be used to identify people at particularly high risk of health problems. These are generally people who have experienced four or more adversities, regardless of which ones.

This approach also acknowledges that people reporting one adversity are much more likely to have experienced at least one other. In Felitti’s study more than half of the people reporting that they’d been psychologically abused as a child had also been physically abused. Similarly, 3 out of every 5 people who had a family member in prison also reported that someone in the household had substance misuse problems. This clustering of adversities is crucially important to recognise both in research and in policymaking.

However, there are many reasons why ACE scores aren’t helpful for policy use. In fact they were never ‘designed’ with policy use in mind. Because they lump together adversities which are often very different (for example, experiencing abuse is likely to be a different experience to having a parent in prison), it’s difficult to tell which adversities have the potential to have the most harmful effects on health. We also don’t always know a lot about how those adversities affect health. Knowing this information would help us to better inform where to target policies. The problem is further confused by different studies including different adversities in their ACE score. So when looking at the findings of different studies you can be comparing apples and pears.

Policy relevance

The heightened interest in ACEs combined with the recognition that early life is important for how a person’s life will pan out is really good news. But we do need to think more carefully about how we measure adversities in research and in particular how we can make our research more policy relevant.

For instance, if there’s a limited budget, which adversities would you try to tackle first? Are there particular childhood adversities which increase the risk of a child experiencing many other adversities? How do different types of adversities affect health? Is it appropriate to lump together very different types of adversities into an ACE score or is there a more appropriate way of treating the clustering of adversities in a less crude way? These are just some of the questions that need to be addressed quickly.

Whilst the research is underway, there are a few things that researchers and policymakers can think about. As a starting point researchers and policy makers and practitioners interested in this area need to think more critically about how adversities are measured, with an aim of being more meaningful and policy relevant. What do we and don’t we know by using ACE scores? What other approaches to adversity measurement could we explore?

Longitudinal studies are key

Longitudinal studies, such as the British Birth Cohorts, which collect information on children and their family circumstances over their lives, are key to improving the evidence base on ACEs and health. Many of the existing studies on ACEs and health have relied on people recalling information on what they experienced as a child. This is prone to error and bias, and can be affected by what people are experiencing at the time they are asked, such as depression or stress at work.

These studies can also help us better understand whether and how timing matters. Not only can we ask which adversities appear to be particularly harmful for health, but also, when exposure to specific adversities are particularly harmful. By doing this/taking this kind of approach, we can also identify the most fruitful times to intervene to help people flourish across their lives.

Finally, the communication of risk is really important. There are many advocates of ACEs who directly translate findings from observational, population-level research into their work with individuals. For instance, if a research study shows that children who experience 4 or more adversities are on average 6 times more likely to be depressed in adulthood, this doesn’t mean that every individual who experienced 4 adversities will be 6 times more likely to have depression in adulthood. This approach of directly translating population risk is not appropriate and if done means that research often gets miscommunicated in a way that’s too deterministic. The health (or other) consequences of ACEs are not inevitable.

The recent increase in policy interest gives us an opportunity to achieve a step-change in the way we look at adverse childhood experiences. If we seize this opportunity, the research community can play a key role in supporting the desire of policy makers and politicians to be effective in achieving their aim of helping at-risk children, adults affected by earlier bad experiences, the NHS, all those working in this area and UK taxpayers.

Wheezing: Can breastfeeding for longer make a difference?

Public health bodies put a lot of effort into encouraging mothers to breastfeed, and for good reasons. Successive studies have shown breastfeeding has a range of health benefits, including a lower risk of wheezing illnesses, which can be linked to asthma. But which of these illnesses are most likely to respond? Is a breastfed child less likely to develop wheezing after age five, or age seven, for instance? Or is the protective effect mainly measurable only in younger children? Professor Maria Quigley from the National Perinatal Epidemiology Unit at the University of Oxford, along with colleagues at Oxford and UCL, has been looking at how and when breastfeeding is associated with wheezing.

Asthma is the most common chronic condition affecting children and young people in the UK. It’s the most common reason why children are admitted to hospital, and sadly each year a few still die from the condition. According to the British Lung Foundation three children in every hundred under the age of five have been diagnosed with asthma at some point; and by age 10 that figure rises to one in 10.

There’s no cure, and so the priority for public health bodies has been to understand the disease better, to manage it better and to learn more about the factors that can protect us from it. One such protective factor is breastfeeding: two recent pieces of research have shown there is a lower risk among breastfed children, but that the effect is stronger among the very young – both for asthma and for wheezing, which has many causes and which does not necessarily develop into asthma.

Childhood wheezing can follow a variety of patterns – it can set in early but clear up before adulthood, for instance, or it can start later but continue into later life. Some wheezing will start in childhood and will continue.

Millennium Cohort Study

We wanted to look at how breastfeeding might affect these different types, so we used data from the Millennium Cohort Study, which has followed the lives of almost 19,000 children born in the UK between September 2000 and January 2002. Their parents were interviewed when they were 9 months old, and again when they were 3, 5, 7 and 11 years.

Our study focused on just over 10,000 children who were seen at all of those points and who were the product of single as opposed to multiple birth. Mothers were asked whether they had tried to breastfeed, and for how long their children had been breastfed.

Among our sample, seven out of 10 children had been breastfed: a little more than one in ten of the study sample for less than a week; a fifth for between one and three weeks, just over one in six for three to six months and around a quarter for six to nine months.

We found that at age 9 months, 6.5 per cent of children had a history of wheezing. At age 3 years, 19.5 per cent had such a history in the past year. As the children got older, though, this proportion decreased – 16 per cent at age five, 11.8 per cent at age seven and 11.4 per cent at age 11.

Overall, 37 per cent of children had suffered from wheezing at least once between 9 months and 11 years. A little under a fifth (18.8 per cent) had wheezing at younger age which cleared up when they got older, while 6.2 per cent had wheezing which started later and 11.8 per cent had persistent wheezing.

Feeding and wheezing

When we looked at the association between breastfeeding and wheezing, we found the children who had been breastfed for longest were less likely to suffer from wheezing.

But this effect lessened with time. For example, those breastfed for six to nine months were less likely to wheeze between the ages of nine months and five years, but by the age of 11 this group had no significant advantage over those who were breastfed for less time.

What does our study tell us about the relationship between breastfeeding and wheezing? The picture is a complex one. There are many causes of wheezing and of asthma, and those causes change over time. So in order to draw firm conclusions about cause and effect, we would need a much more complex dataset. It would be interesting, for instance, to look at clinical information on children’s allergies or their lung function.

But what we can say is that age matters – in order to understand how breastfeeding affects the development of wheezing during childhood, we must take a longer and more nuanced view.

Breastfeeding And Childhood Wheeze: Age-Specific Analyses and Longitudinal Wheezing Phenotypes as Complementary Approaches To The Analysis Of Cohort Data is research by Maria Quigley (University of Oxford), Claire Carson (University of Oxford) and Yvonne Kelly (UCL). It is published in the American Journal of Epidemiology.