Abstract
Mental well-being is a basic human right that allows children and young people to realise their full potential. In Aotearoa however, the prevalence of good mental well-being among our young people has been declining alongside rising intergenerational inequality, housing insecurity, unregulated social media, increasing climate threats, and other major global issues known to influence mental health. Vulnerable groups, including Māori, Pacific, Rainbow youth, and disabled young people, are especially affected, often due to compounded socioeconomic challenges and increased exposure to social isolation or discrimination.
This report brings together data from three main sources – the New Zealand Health Survey (NZHS), the National Minimum Dataset (NMDS), and the Programme for the Integration of Mental Health Data (PRIMHD) – to paint a picture of the mental health of our tamariki and rangatahi. The annual NZHS asks parents and young people a range of questions related to their mental health including whether they felt they needed professional help but did not receive it. The NMDS provides information about admission to hospital, including to the emergency department, whilst PRIMHD provides information about those children and young people seen by specialist mental health teams, including drug and alcohol services.
Although these data sources are informative, they cannot paint the complete picture of the mental health of our tamariki and rangatahi. This is because we do not have reliable primary care data or information about children and young people not admitted to hospital or not seen by a mental health service. Furthermore, the stigma associated with poor mental health means that many will not even reach the notice of a service provider. As a result, this report is likely to underestimate the true burden of illness. Researchers in Aotearoa have underscored the need for an up-to-date, comprehensive mental health and addiction study that includes previously neglected groups, including infants and young children and indigenous and other priority groups. A study such as this is imperative to monitor the prevalence of mental health concerns among infants, children, and young people in Aotearoa and as an evidence base to inform investment and service delivery.
Results from the NZHS indicate that the prevalence of diagnosed mood disorders among young people aged 15–24 years has increased dramatically; over the last decade, the prevalence of anxiety and depression has more than doubled from 10% to 24% and the number of rangatahi experiencing high or very high levels of psychological distress in the last month has increased from 1 in 20 to 1 in 5 individuals. Although ‘doctor-diagnosed’ rates of mood disorder for younger children aged 2–14 years have remained relatively low over time with an overall prevalence of around 4%, a higher proportion of children in this age group (13%) have ‘concerning’ scores on the emotional symptoms subscale of the Strengths and Difficulties Questionnaire. This points to a larger burden in this age group than the ‘doctor-diagnosed’ rates suggest.
In keeping with data from the NZHS, admissions of 0–24-year-olds to hospital for mental or behavioural disorders have increased steadily since 2007, reaching a peak of just over 7,000 hospitalisations and a rate of over 4 per 1,000 in 2020. Between 2021 and 2022, the numbers and rates of hospitalisation fell slightly. The reason for this decrease is unclear although it may reflect, in part, some recovery from the impact of the COVID-19 pandemic on the mental health of our young people. Most hospitalisations (>70%) were non-emergency department hospitalisations, indicating the need for extended care.
Children aged under 15 years accounted for only 12% of all hospitalisations. A greater proportion of these were non-ED admissions compared with older individuals. Rates of hospitalisation in the younger group remained less than 1 per 1,000, even in peak years. The most common reasons for admission were disorders of psychological development (including autism), stress-related disorders (including anxiety and PTSD), and eating disorders, together constituting around 60% of all admissions in this age group. For young people aged 15–24 years, rates of hospitalisation were more than 10-fold higher than those of younger tamariki. Mood (depressive) and anxiety disorders comprised 34% of all hospitalisations in this age group while hospitalisations for mental and behavioural disorders due to psychoactive substance use (most commonly alcohol intoxication and psychotic disorder due to psychoactive substance use) added a further 25% and hospitalisations for schizophrenia, schizotypal, and delusional disorders comprised a further 21%.
In addition to age, the burden of mental ill-health varied according to other demographic characteristics. The most striking differences exist between children living with and without a disability. In the NZHS, a disability is defined as having at least a lot of difficulty with seeing, hearing, walking, communication, self-care, behaviour management, or anxiety or depression. Parents of children with a disability report rates of conduct, hyperactivity, emotional, and peer problems that are between 3 and 10 times that reported by parents of children living without a disability. This has major service implications with these parents more than 6 times as likely to seek medical help for their children and more than 10 times as likely to report unmet need for professional help for their children’s mental health. It is important to note here that the survey cannot distinguish whether symptoms are part of the disability itself, related to distress about the presence of a disability, or related to the treatment that a child might have received. Further, reported symptoms may be entirely unrelated to disability and due to other factors, such as moving house or bereavement. In general, however, disability in children is overwhelmingly neurodevelopmental/mental health-related rather than sensory or physical.
Social and economic disadvantage is also associated with both greater disease burden and higher service use. Children living in the most deprived circumstances experience more than 2 times the rate of conduct disorders and peer problems compared with those living in more privileged circumstances. A deprivation gradient also exists for hospitalisations and for use of mental health services with higher admission rates being associated with children living in quintiles 4 and 5 (lowest 40% of socioeconomic status) compared with those living in quintile 1 (highest socioeconomic status). These differences are most marked for young people aged 15–24 years.
The analyses presented in this report all show important differences by ethnic group. Children and young people of Asian ethnicity have significantly lower rates of conduct problems and hyperactivity compared with non-Asian children. Asian children were also significantly less likely than were non-Asian children to have consulted a GP or nurse about mental health in the previous 12 months or to have been hospitalised (similar for all levels of deprivation). Conversely, tamariki Māori had concerning scores for hyperactivity, conduct, and peer problems at rates significantly higher than for non-Māori children and were more likely to seek care from medical professionals although the levels of unmet need were similar for the two groups. Hospitalisation rates for Māori were slightly higher than for non-Māori but the deprivation gradients for children of Māori and European ethnicity were broadly similar, with the exception of those living with the most severe socioeconomic deprivation.
In terms of differences by sex/gender, rates of peer problems and hyperactivity for boys were 1.4–2 times those of girls. Utilisation of specialist mental health services was low for very young children and increased with age to peak at around 15 years. The rates for boys outnumbered those for girls up until about the age of 12 when the pattern reversed. A similar pattern of sex/gender distribution was seen for hospitalisations. The levels of unmet need were similar for younger boys and girls (6.6%) but were higher for young women (18%) compared with young men (11%).
Each year, between 67,000 and 73,000 tamariki and rangatahi were seen by publicly funded specialist mental health, alcohol and drug services across the country. This has remained fairly constant over recent years although, as with hospitalisation data, analysis of PRIMHD data also shows a noticeable recent decline in the number and rate of young people seen by these services. Over three-quarters of all children and young people received some or all of their care from DHB providers, most commonly (>80%) a community team.
The PRIMHD dataset has a number of important limitations (see ‘Publicly funded mental health service use’), not least of which is that it does not include services provided by paediatricians and, therefore, excludes children who may have been seen in paediatric outpatient settings. However, even after taking into account this limitation, the data reported here suggest that current service utilisation represents only a fraction of actual need. This is supported by responses to the NZHS; around 15% of rangatahi report unmet need for mental health care – the highest of all adult age groups. These data show that young people consulted family, whānau, and/or friends at twice the rate that they consulted any other health professional. Barriers to receiving appropriate care are likely to include the stigma associated with mental illness and difficulty in accessing and navigating the health system, including difficulty getting primary care appointments and referrals to specialist mental health services, geographic isolation, cost, and services not being culturally appropriate.
There is good evidence for the effectiveness of both targeted and universal mental health promotion interventions. For children and young people, these exist across the age spectrum in pre-school, school, community, and workplace settings. In the early years, where the critical foundations are laid, these include psychological and social support for pregnant and new mothers, parenting and home visiting programmes to improve child developmental outcomes and parenting practices and reduce parental stress, especially for disadvantaged families. Multi-component interventions for children of parents with mental health problems reduce children’s risk of future mental health problems.
The scale of mental ill-health in Aotearoa’s children and young people indicates the need for sustainable funding and resource allocation to improve mental health accessibility, particularly for marginalised communities. Enhancing culturally inclusive services, investing in community-driven mental health supports, and bolstering primary care capacities are likely to help address some of the current gaps in access to care. Poor mental health reflects social and economic pressures compounded by structural inequities and is largely preventable. Meaningful improvements to the mental health and well-being of our tamariki and rangatahi can, therefore, only be achieved by tackling the wider determinants of health through population-based strategies.