child health problems essay

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• Published: 26 August 2024

Defining child health in the 21st century

• Ruth E. K. Stein 1  

Pediatric Research ( 2024 ) Cite this article

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The concept of child health has evolved over many decades and has gone from defining health as the absence of disease and disability to a much more sophisticated understanding of the ways in which a confluence of many factors leads to a healthy childhood and to producing the infrastructure for a healthy lifetime. We review the evolution of these ideas and endorse the definition featured in Children’s Health, the Nation’s Wealth , which states tha t child health is: “… the extent to which individual children or groups of children are able or enabled to: (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.”

The definition of child health and the model presented form a framework for conducting and interpreting research in child health and understanding the ways in which influences affect child health.

They also demonstrate how child health is the foundation for life-long health.

Child health is dynamic and is always changing.

There are many influences affecting child health at any given time.

Because each child’s health is different, they may react in distinctive ways to a new health challenge.

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This model is best represented by a kaleidoscope of influences (biology, social and built environment, behavior, policies, and services) working together over a child’s life and developmental trajectory. The model has life-long implications for adult health and well-being and has far-reaching implications for promoting children’s health and for understanding research in child health. Pediatrics is a field devoted to improving the health of children, but what does that really mean? There are several aspects to this all-important question. How do we currently view and define child health? How do we understand the things that underpin a healthy childhood? What is the significance of child health for life-long health? The answers to these questions are important for all our endeavors as child-oriented clinicians and are key to our ongoing research efforts to improve child health.

Approaches to child health

The concept of child health has evolved over many decades and has gone from defining health as the absence of disease and disability to a much more sophisticated understanding of the ways in which a confluence of many factors leads to a healthy childhood and to producing the infrastructure for a healthy lifetime. While this is true in the United States and most of the upper income nations and the elite in many other communities, many low- and middle-income countries still experience high childhood morbidity and mortality and low rates of immunizations that protect children from many diseases. Thus, for many of them, the absence of disease continues to be a major marker of improvements in child health.

The recognition that health is more than the absence of disease was relatively novel when it was written into the constitution of the World Health Organization (WHO) in 1945. In April 7, 1948, the WHO Charter was adopted and definition was formally recognized. It stated “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” ( https://www.who.int/about/accountability/governance/constitution ). There were several other rather revolutionary components to the constitution, including the notion that health was a human right, a call for equity in health, and the statement that governments had a responsibility for insuring health ( https://www.who.int/about/accountability/governance/constitution ). Unfortunately, the latter two elements are still not always accepted as fundamental in the United States.

An often-overlooked component of the WHO Charter is the principle that: “Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development” ( https://www.who.int/about/accountability/governance/constitution ). This last principle is the only component that mentions development, something that is fundamental to childhood and yet was not incorporated into most people’s thinking about health at the time. It should be emphasized that there was little thought to differentiating the definitions of health for children and adults.

Over the next several decades, the focus was on the elimination of diseases, something that became possible with the explosion of new biomedical understanding of the causes and mechanisms for disease and the morbidity and mortality that they caused. This was a period during which there was development of a library of antibiotics and vaccines to treat and prevent many infectious diseases. The dominance of biomedical sciences resulted in a focus primarily on aspects of physical health, with emotional, cognitive, or social well-being being relatively ignored during that period. As a result, the notion that health was more than the absence of diseases got relatively little attention and a biomedical model of health dominated most discussions, whether focused on children or adults.

The mid 1970’s saw an explosion of new thoughts about child health and the key role of child development. Major elements of this new thinking were the increasing focus on differences in the biology of children and adults and in the appreciation of the extent to which factors outside of biology influenced health, especially among young children. In terms of appreciating differences between child and adult health, there was increasing recognition of the rapidly changing nature of children’s physical and behavioral characteristics; of their inherent dependency, especially early in life, and the differences in their exposure to environmental hazards and in the way that manifest poor health. The growing awareness of their biological differences led to recognition of such variations as their relative surface area, their play which placed them in closer proximity to ground level pollutants, and a myriad of metabolic differences that pediatric research had revealed.

Additionally, there was growing data on a variety of key factors other than the child’s vulnerability to infectious disease that were coming to the fore. One was the importance of infant attachment for healthy development; another was the recognition of how environmental factors such as lead were detracting from healthy development and well-being, and a third was recognition of child abuse and neglect by Henry Kempe. 1 In addition, the implementation of Medicaid and the Children and Youth projects had brought many underserved communities into traditional medical venues, where clinicians were increasingly recognizing the impact of poverty on child health. These ideas were crystalized in Robert Haggerty’s studies of Child Health and the Community , published in 1975, 2 which examined health care in Monroe country, a microcosm of the US population and focused on many factors in the lives of children beyond their biology and exposure to infectious diseases.

In response to these trends and to the increasing recognition of non-infectious causes of disease, three new broad models were put forward, each of which made major contributions to the conceptualization of child health.

The first of these was from George Engel, a psychiatrist at the University of Rochester, who proposed a revolutionary concept, which he called the “biopsychosocial” model of child health. 3 His thesis was that biological, psychological, and social components each contributed to health and that all these factors had to be considered. 3 The notion that the body and mind were connected was not entirely new and has been cited as going back at least to Descartes, but had been neglected during the focus on biology as the primary cause of illness. Engel reintroduced the concept that the social and psychological contributions to illness and well-being needed to be considered in medical science and health care, both as causes of disease and as important in their treatment. 4 Broadening the notion of health to include factors outside of biology required consideration of how these elements interacted. Engel’s model was a Venn diagram with overlap of the three types of factors: biological, social, and psychological factors. The interaction of these elements resulted in the manifestations of illness and the elements that needed to be considered in approaching care and understanding health.

At about the same time, a second set of ideas about how these factors affected one another came from a psychologist, Arnold Sameroff, 5 who developed the notion of factors relating to health affected one another in a transactional way. He proposed that the parent, child, and environment interact in ways in which each affects the other and it is the sum of those interactions that leads to the child’s development and affects the child’s health and well-being. The notion of reciprocity and interactions of multiple factors remains key in thinking today. 5

The third idea was the ecological model developed by Uri Bronfenbrenner, also a psychologist, who proposed a series of systems that influence one another and in total affect child health and development. 6 The five components ranged from the microsystem (the child’s relationship with his or her immediate environment, school, and family) to macrosystems (culture, economy, customs, and bodies of knowledge). Each layer of the environment was visualized as a concentric circle, with the child in the middle. To a large degree it was his thinking about the broader set of factors that impact child health that has stayed with us and has helped us to think beyond the child’s immediate context when considering influences on health. Bronfenbrenner’s view of the way that environment interacted with the child’s health and development dominated for many years. 6

After these three models were proposed, there was little innovative thinking about child health for a rather long period. During the ensuing decades most people accepted that the context in which a child was growing impacted his or her mental and physical health and contributed to well-being. An increasing number of studies focused on the broader issues affecting child health and on how these issues altered the manifestations of health and the outcomes of treatment. Yet none of this thinking led to a reformulation of how to define child health.

Current definition

In 2001, at Congress’s request the Office of Disease Prevention and Health Promotion of the United States Department of Health and Human Services funded the Board of Children, Youth, and Families (BoCYF) of the National Research Council and the Institute of Medicine to do a study to assess the ways that child health was monitored in the United States and to make recommendations about ways to improve its measurement. 7 This Committee on the Evaluation of Children’s Health: Measures of Risk, Protective and Promotional Factors for Assessing Child Health in the Community was charged with examining what was known about child health, the risk and protective factors and how the assessment of child health could be improved. The BoCYF convened a multidisciplinary committee to conduct the study. The first step that the committee undertook was to define child health and to do so it looked at available definitions of health. The committee noted that in general definitions of child health were not distinct from those for adult health. The WHO definition, as modified by the Ottawa Convention was the primary definition available. In the Ottawa Convention the term health was viewed as “the extent to which a group or individual can fulfil their ambitions and needs, on the one hand, and evolve with or adapt to the environment, on the other” ( https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference ). It further stated that “Health is thus seen as a resource for everyday life, not as the goal of life; it is a positive concept that emphasises [sic] social and individual resources as well as physical capabilities. Thus, health promotion is not just a health issue, but goes beyond healthy lifestyles to well-being” ( https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference ). This was the first time promotion of health was specifically advocated by a large number of countries. 8

In examining the Ottawa Convention definition, the committee became aware that there were no clear references to the notion of development, which is such a critical component of child health and a fundamental concept in pediatrics. This is because using the WHO and Ottawa definitions, an individual who did not develop at all after birth might be considered entirely healthy–something most people would not agree with.

Based on the special characteristics of children’s health and the prior definitions, “the committee sought a comprehensive and integrative definition and conceptualization of health that reflects the dynamic nature of childhood, is conceptually sound, is based on the best scientific evidence, and provides a basis for both measuring and improving child health.” 7 (page 32) Further, it recognized “that health and well-being are a result of interactions of many biological, psychological, social, cultural, and physical factors.” 7 (pages 32 and 33)

The committee defined child health:

“… as the extent to which individual children or groups of children are able or enabled to: (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.” 7 (pages 32 and 33)

Several features of this definition are noteworthy. First is the continued conceptualization of health as a positive construct – more than the absence of illness or disease. Second, it incorporates the special characteristics, particularly rapid development and continuous change throughout childhood, as essential components of health. It also considers all the many influences that interact over time in different ways as children develop and change, and it acknowledges the ways children interact with their specific environments and the long-term implications of these environmental factors. This definition underscores the long reach of child health into adulthood underscoring that the health of children has profound effects on the health of the adults they will become. It acknowledges that the manifestations of health may vary for different communities and cultures and encompasses all aspects of health: physical, emotional, cognitive, and social health.

Domains of health

So how did the committee conceptualize the measurement of child health? First, it should be acknowledged that most commonly used measures are actually proxies of health or measures of only one aspect of the more complex construct embodied in the definition. For example, we might use body mass index to define obesity, or measure only cognitive functioning on a psychological test.

The model also emphasized the importance of tracking data on children’s health or aspects of their health on trajectories in a manner that is like the ways weight, length, are tracked. One cannot know the meaning of most isolated measures without knowing their place on a trajectory. For example, it is impossible to know if 20 pounds is a healthy weight or not without knowing the child’s age and prior weights. Similarly, one would have trouble determining the developmental health of child who speaks in 3-word sentences without knowing his age and whether his language was previously more or less advanced. Assessing trajectories was viewed as an essential part of efforts to improve children’s health. This requires longitudinal data.

Nevertheless, the committee conceptualized three domains of health that should be the basis for measuring child health: Health conditions : disorders or illnesses of body systems; Functioning : manifestation of health on an individual’s daily life, and Health potential : development of assets and positive aspects of health, such as resilience, competence, capacity, and developmental potential.

In considering the measurement of health conditions, it is important to note that these conditions can either be acute or chronic. Health conditions are the most traditional way of measuring health –or its absence. These conditions are usually inventoried by clinician diagnoses or by questionnaires inquiring about specific conditions or diseases. Those that are chronic can be assessed using two major approaches. The first is using a list or inventory of individual conditions. However, the list of such conditions is extensive because of the large number of uncommon disorders, and no list can be complete and be feasible to administer. Unfortunately, evidence shows that the more examples that are provided on a list, the more likely people will respond to the option of “or any other condition.” This finding is clearly counterintuitive and limits the utility of a list approach.

Another method of inventorying chronic conditions depends on a non-categorical or generic approach. 9 , 10 , 11 This approach explores the consequences of conditions, as well as their duration, based on a noncategorical definition. 12 The definition includes having a condition that lasts or is expected to last a year and having at least one of three types of consequences of conditions: Increased use of health care beyond the usual for age; dependence on a compensatory mechanism or assistance to function in a typical way; or the presence of functional limitations. 12 Three instruments that operationalize that definition have been developed and are in use. 13 , 14 , 15 , 16

This approach allows the identification of children with ongoing conditions without having to name the condition. A non-categorical approach is now incorporated into several national surveys using the shortest of these instruments, the CSHCN Screener. 15 It is used to track both the number of children with conditions and disparities in the ways in which care is delivered to children both with and without ongoing conditions.

Functioning has been defined by the International Classification of Functioning, Disability and Health as “an umbrella term for body function, body structures, activities and participation. It denotes the positive or neutral aspects of the interaction between a person’s health condition(s) and that individual’s contextual factors (environmental and personal factors)” ( https://www.cdc.gov/nchs/data/icd/icfoverview_finalforwho10sept.pdf ). Functioning is viewed as the way in which an individual can do things and is the final expression of health of individuals. One strength of this type of measure is that it can assess the consequences of many coexisting conditions and both conditions and their treatment. This is not something that is possible to assess when considering conditions as proposed above. Even when multiple conditions are inventoried individually, it does not give any indication of their combined effect on the child’s health. Also, in some instances, there are more symptoms or impairments from the treatment than from the condition itself, such as when encountering serious side effects from chemotherapy, during treatment or when the original condition itself is in remission. There are few other ways in which to get the type of summative information that can be obtained by assessing functioning. 17

There are relatively few measures of functional limitations specifically developed for children. Many of the measures of functioning in the past have focused on gross motor functioning and some of them measure only one type of functioning, such as cognition, which is measured by a range of psychological tests. More recently there have been attempts to develop more comprehensive measures. Few of them work across populations, culture, levels of health/disability and ages. Some more comprehensive measures are age specific, such as measures of development or of school readiness. 18 In general, such measures assess a range of skills including independence, physical, social, cognitive, emotional, and language skills. Nevertheless, there are few functional measures that work across populations, cultures, levels of health/disability and ages. Among the range of measures that are broader and in use are FSII (R) 19 ; Wee FIM 20 and Functional Status Scale 21 and health quality of life measures. 22 Each of them has a different focus and measures different aspects of functioning.

There are even fewer measures of health potential, but this is an important area for future research. This domain is critical to improving understanding of why some children experiencing a major stress are able to bounce back and overcome the trauma, while others are stunted in their further development, or never rebound at all. Some areas that are included are resilience, problem solving ability, resistance to illness, immunization status, ability to develop positive peer relations, and physical fitness. How these factors fit together and become protective is an area worthy of exploration, but clearly some children differentiate themselves from others by their ability to rebound from adversity or illness, while others suffer long-term consequences of poor health and well-being.

Finally, it is important to acknowledge that the entire field of measurement is complicated by the fact that many children, especially younger ones cannot reliably respond to questionnaires on their own. As a result, most measures require responses from other individuals, typically caregivers. Others are completed by clinicians. Their biases and differences in their frames of reference may further complicate all these measures.

Factors influencing health

In exploring the issue of risk and protective factors that influence and affect health status, the committee realized that many known factors did not fall neatly into either category. In some cases, it was because they may be both risks and protective depending on the context (i.e: peer groups). In others, it’s effect was dependent on the level of exposure, as might be characterized by iron on iodine, both of which can cause problems if they are insufficient or be toxic if exposure is excessive.

Rather than think of them in terms of risk or protective factors, the committee chose to conceptualize the factors that affect child health as influences , since many may be both risks and protective, depending on the context and level of exposure.

The influences were grouped into six categories following the model of Healthy People 2010, which was the operant model at the time. 23 One objection to that model was that it was very linear, something that seemed at odds to the ways in which influences are understood to interact. However, the committee thought that the major categories or domains in the model that affected health were sound. These components were: biology, behavior, physical environment, social influences, services, and policy. Another significant modification of the Healthy People 2010 model was the considerable expansion of services and policy domains beyond those of health policy and health services, which was the original intent of the 2010 model. This is because the committee recognized that a wide range of services (e.g. education, welfare, and sanitation services) and policies (e.g. tax, law enforcement, road safety and environmental policies) have considerable impact on child health. Each of these categories was conceptualize as having many elements within them. A partial list of components of these domains is shown in Table  1 . Both within the groupings and across groupings these influences interact with one another and their relative importance changes over time and through development. Some of these changes are predictable and others depend on what the individual child experiences. For example, in early childhood the family is probably the most important social influence, while later in development other components, such as the community and the peer group, have greater impact. In terms of unique experiences, changes in the family composition or family dislocation, illness or toxic exposures may have great impact in one child’s development, in contrast with those who experience long term stability.

A new model

Altogether various influences interact over time and throughout development in a way that can be compared to and visualized as being like a kaleidoscope. That is to say, the patterns that emerge are partly determined by the initial constellation of factors at the time of the child’s birth. All prior exposures are embedded in his or her biology at birth and are incorporated into the initial template. But two individuals with different initial patterns will react differently to subsequent influences, even when they are exposed to the identical ones. Moreover, influences that are experienced by the individual at different stages of development will also have discrete effects, depending on when they are experienced. As a result, two children with different preexisting templates may react differently and their subsequent health will reflect those differences.

A picture of the component influences at any given time can be visualized as a Venn diagram (Fig.  1 ). Within each component, there are many subcomponents, as discussed in the section on influences, and each of those subcomponents may be of different importance at a given time and stage. They may be viewed as mini kaleidoscopes within the domain and are also similar to the whole domain in that they vary in their importance throughout development.

Multiple interacting influences.

As things change during a child’s development and over time, the kaleidoscope changes, depending on how the influences affect the individual or group of children (Fig.  2 ). The ways in which influences of various types affect a given child will depend on the arrangements of the preexisting template at the time of the new experience. This is like giving a twist to the crystals in the kaleidoscope, in which different sets of crystals will produce differing patterns.

Model of children’s health and its influences.

Additionally, the committee also recognized that there are some periods of time that are critical or sensitive and have magnified impact on health and development. Critical periods are ones in which an influence has a determinative effect on health, such as early prenatal exposure to Thalidamide during a critical period of embryogenesis, while sensitive periods are ones in which there is increased vulnerability, but no absolute effect. During these periods, exposure to certain influences has a more significant impact. For example, children who are not exposed to language in early infancy, may not recoup that loss completely, while that same lack of exposure later in development may have a far smaller effect. Similarly, parental separation or death may have different consequences depending on both the child’s template at the time of the occurrence and the age at which the trauma is experienced.

Nature vs nurture

For many generations people have argued about the role of nature versus nurture in determining health outcomes. However, in the last several decades this debate finally has some important answers, and we are finally beginning to understand how environments “get under our skin.” Since the mapping of the human genome, we have learned that the environment affects and alters the expression of our genes mainly by upregulating and down regulating them through epigenetic mechanisms. At other times exposures to specific influences actually interfere with gene replication and expression in a more deterministic fashion, as when there is exposure to radiation that alters the genes themselves.

Moreover, we now understand that adverse childhood experiences produce toxic stress and that when the allostatic load becomes too great, it produces changes in gene expression through epigenetic mechanisms. The ensuing changes affect multiple body systems including the brain, autonomic, neuroendocrine, immune, cardiovascular, and gastro-intestinal systems. 24 , 25 These changes have been associated with chronic inflammation, something that may affect long-term health and survival and sometimes can even be passed to the next generation, as has been shown for the effects of racism. Epidemiologic studies have long supported that increasing numbers of childhood exposures to these forms of stress are associated with physical and mental illness and premature death in adulthood. 26 , 27

It is important to also acknowledge the critical role that caregivers play in nurturing children and in buffering them against the noxious effects of stresses. This nurturance and buffering effect is something that is critical in helping children to thrive in spite of influences that threaten their health. It is also likely that those buffers are of special importance at times of transition in growth and development.

Implications

The implications of the committee’s definition and model of health are far reaching. One inherent implication of the model is that we can never measure all the factors that influence child health in any single study. As a result, it brings a new perspective to some of our efforts to interpret research data. For example, if two studies of outcomes of very low birth weight infants come to somewhat different conclusions about predictors of outcome, our tendency has been to try to determine which study was flawed and which was more reliable. Perhaps, instead we should question whether the subjects differed in some unmeasured, but significant, way that influenced their outcome.

The model also emphasizes that health does not derive primarily from medical care. In doing so it brings into question the ways in which our society divides budgets for the many kinds of services and policies that contribute to health and healthy development. The effects of decisions in these domains often omit consideration of their impact on children’s health and well-being. Some have suggested that we should have a process like our consideration of environmental impact for projects that would consider child health impact when new projects or policies are put into effect.

Finally, the model underscores the long reach of childhood influences on adult health. This is far more appreciated now, than at the time of the committee report, because of several factors. First is the increased understanding of epigenetics and the long-term implications of changes in gene expression. Another factor is the growing literature on the effects of adverse childhood experiences (ACES). It is now unquestionable that these societal issues impact both child wellbeing and adult health and survival. Our awareness of these factors has also led to far more consideration of other social factors, and to the appreciation of the influence of social determinants of health. These include economic stability, education access and quality, health care access and quality, neighborhood and built environment, social and community context ( https://health.gov/healthypeople/priority-areas/social-determinants-health ) – a list quite like those in the Committee’s model.

The growing awareness of the long reach of child health is important for the field of pediatrics, which has long suffered from a lack of investment. This is a result of the degree to which finances have driven investment in health and health care. In general child health costs are so much lower than the costs of adult care, except for care of the very low birth weight infant and certain malignancies. As appreciation grows for the importance of environmental factors during childhood on ultimate health, we can hope that investments increase in relatively low-cost preventive measures that may alter longer term outcomes.

Future projections

Given our increased knowledge about the impact of environment and life events on children, we would be remiss if we did not highlight the changing nature of the world in which we live. The numerous wars around the world are massively disrupting children’s lives and causing mass migration. The COVID pandemic caused millions of deaths, including those of many caregivers, and world-wide disruption of daily life with loss of educational and social opportunities for countless numbers of children. Many of these losses appear to be having long-reaching impact on their education, development, and mental health. 28 Additionally, the direct and indirect effects of climate change, which is making some areas of the globe less habitable, and subjecting others to catastrophic weather event, fires, and floods, are producing massive dislocations. Many of these influences are affecting the children who are already most vulnerable.

When children experience these catastrophes, it has lasting effects on their health and developmental trajectories. In addition to the frequent events themselves, they are often accompanied by loss of caregivers, whose protection is so important to helping children deal with stresses, and to loss of routines, which provide stability and a sense of normalcy. Additionally, they often lose educational opportunities that would enable them to develop skills that would improve their future welfare. Even when there are no direct physical or observable injuries, all these factors increase children’s allostatic load and are embedded in their gene expression, causing inflammation and premature aging of many body systems, and setting them up for future poor health. It is important for the child health community to do all that it can to help buffer these effects and to help inform policy makers of their long impacts and costs to the individual and to society. The definition and model inform the child health community that our failure to do so is likely to be accompanied by a generation whose health and well-being is in peril.

Conclusions

We believe that the definition that the committee adopted and the model of how health evolves has had a major impact on thinking in the field. To some extent it forecast the CDC’s Health People 2020’s model of health “that recognized a life stages perspective. This approach recognizes that specific risk factors and determinants of health vary across the life span. Health and disease result from the accumulation (over time) of the effects of risk factors and determinants” ( https://wayback.archive-it.org/5774/20220413162937/https://www.healthypeople.gov/2020/leading-health-indicators/Leading-Health-Indicators-Development-and-Framework ). The emphasis on child development may have had some role in helping other clinicians to focus on the fact that development does not stop when one reaches adulthood. It is entirely compatible with the Healthy People 2030’s goal to “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all” 29 and can serve as a guiding principle for pediatrics and our society. It suggests that society should want to invest in children because they are our nation’s most important resource. The definition of child health presented by the committee has many useful principles that can guide our research, clinical care, and policies to try to protect long-term thriving of the maximum number of children. It is one that can continue to guide our work for many decades to come.

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Children and youth’s perceptions of mental health—a scoping review of qualitative studies

• Linda Beckman 1 , 2 ,
• Sven Hassler 1 &
• Lisa Hellström 3  

BMC Psychiatry volume  23 , Article number:  669 ( 2023 ) Cite this article

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Recent research indicates that understanding how children and youth perceive mental health, how it is manifests, and where the line between mental health issues and everyday challenges should be drawn, is complex and varied. Consequently, it is important to investigate how children and youth perceive and communicate about mental health. With this in mind, our goal is to synthesize the literature on how children and youth (ages 10—25) perceive and conceptualize mental health.

We conducted a preliminary search to identify the keywords, employing a search strategy across electronic databases including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts and Google Scholar. The search encompassed the period from September 20, 2021, to September 30, 2021. This effort yielded 11 eligible studies. Our scoping review was conducted in accordance with the PRISMA-ScR Checklist.

As various aspects of uncertainty in understanding of mental health have emerged, the results indicate the importance of establishing a shared language concerning mental health. This is essential for clarifying the distinctions between everyday challenges and issues that require treatment.

We require a language that can direct children, parents, school personnel and professionals toward appropriate support and aid in formulating health interventions. Additionally, it holds significance to promote an understanding of the positive aspects of mental health. This emphasis should extend to the competence development of school personnel, enabling them to integrate insights about mental well-being into routine interactions with young individuals. This approach could empower children and youth to acquire the understanding that mental health is not a static condition but rather something that can be enhanced or, at the very least, maintained.

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Introduction

In Western society, the prevalence of mental health issues, such as depression and anxiety [ 1 ], as well as recurring psychosomatic health complaints [ 2 ], has increased from the 1980s and 2000s. However, whether these changes in adolescent mental health are actual trends or influenced by alterations in how adolescents perceive, talk about, and report their mental well-being remains ambiguous [ 1 ]. Despite an increase in self-reported mental health problems, levels of mental well-being have remained stable, and severe psychiatric diagnoses have not significantly risen [ 3 , 4 ]. Recent research indicates that understanding how children and youth grasp mental health, its manifestations, and the demarcation between mental health issues and everyday challenges is intricate and diverse. Wickström and Kvist Lindholm [ 5 ] show that problems such as feeling low and nervous are considered deep-seated issues among some adolescents, while others refer to them as everyday challenges. Meanwhile, adolescents in Hellström and Beckman [ 6 ] describe mental health problems as something mainstream, experienced by everyone at some point. Furthermore, Hermann et al. [ 7 ] point out that adolescents can distinguish between positive health and mental health problems. This indicates their understanding of the complexity and holistic nature of mental health and mental health issues. It is plausible that misunderstandings and devaluations of mental health and illness concepts may increase self-reported mental health problems and provide contradictory results when the understanding of mental health is studied. In a previous review on how children and young people perceive the concept of “health,” four major themes have been suggested: health practices, not being sick, feeling good, and being able to do the desired and required activities [ 8 ]. In a study involving 8–11 year olds, children framed both biomedical and holistic perspectives of health [ 9 ]. Regarding the concept of “illness,” themes such as somatic feeling states, functional and affective states [ 10 , 11 ], as well as processes of contagion and contamination, have emerged [ 9 ]. Older age strongly predicts nuances in conceptualizations of health and illness [ 10 , 11 , 12 ].

As the current definitions of mental health and mental illness do not seem to have been successful in guiding how these concepts are perceived, literature has emphasized the importance of understanding individuals’ ideas of health and illness [ 9 , 13 ]. The World Health Organization (WHO) broadly defines mental health as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, work productively and fruitfully and make a contribution to his or her community [ 14 ] capturing only positive aspects. According to The American Psychology Association [ 15 ], mental illness includes several conditions with varying severity and duration, from milder and transient disorders to long-term conditions affecting daily function. The term can thus cover everything from mild anxiety or depression to severe psychiatric conditions that should be treated by healthcare professionals. As a guide for individual experience, such a definition becomes insufficient in distinguishing mental illness from ordinary emotional expressions. According to the Swedish National Board of Health and Welfare et al. [ 16 ], mental health works as an umbrella term for both mental well-being and mental illness : Mental well-being is about being able to handle life's difficulties, feeling satisfied with life, having good social relationships, as well as being able to feel pleasure, desire, and happiness. Mental illness includes both mild to moderate mental health problems and psychiatric conditions . Mild to moderate mental health problems are common and are often reactions to events or situations in life, e.g., worry, feeling low, and sleep difficulties.

It has been argued that increased knowledge of the nature of mental illness can help individuals to cope with the situation and improve their well-being. Increased knowledge about mental illness, how to prevent mental illness and help-seeking behavior has been conceptualized as “mental health literacy” (MHL) [ 17 ], a construct that has emerged from “health literacy” [ 18 ]. Previous literature supports the idea that positive MHL is associated with mental well-being among adolescents [ 19 ]. Conversely, studies point out that low levels of MHL are associated with depression [ 20 ]. Some gender differences have been acknowledged in adolescents, with boys scoring lower than girls on MHL measures [ 20 ] and a social gradient including a positive relationship between MHL and perceived good financial position [ 19 ] or a higher socio-economic status [ 21 ].

While MHL stresses knowledge about signs and treatment of mental illness [ 22 ], the concern from a social constructivist approach would be the conceptualization of mental illness and how it is shaped by society and the thoughts, feelings, and actions of its members [ 23 ]. Studies on the social construction of anxiety and depression through media discourses have shown that language is at the heart of these processes, and that language both constructs the world as people perceive it but also forms the conditions under which an experience is likely to be construed [ 24 , 25 ]. Considering experience as linguistically inflected, the constructionist approach offers an analytical tool to understand the conceptualization of mental illness and to distinguish mental illness from everyday challenges. The essence of mental health is therefore suggested to be psychological constructions identified through how adolescents and society at large perceive, talk about, and report mental health and how that, in turn, feeds a continuous process of conceptual re-construction or adaptation [ 26 ]. Considering experience as linguistically inflected, the constructionist approach could then offer an analytical tool to understand the potential influence of everyday challenges in the conceptualization of mental health.

Research investigating how children and youth perceive and communicate mental health is essential to understand the current rise of reported mental health problems [ 5 ]. Health promotion initiatives are more likely to be successful if they take people’s understanding, beliefs, and concerns into account [ 27 , 28 ]. As far as we know, no review has mapped the literature to explore children’s and youths’ perceptions of mental health and mental illness. Based on previous literature, age, gender, and socioeconomic status seem to influence children's and youths’ knowledge and experiences of mental health [ 10 , 11 , 12 ]; therefore, we aim to analyze these perspectives too. From a social constructivist perspective, experience is linguistically inflected [ 26 ]; hence illuminating the conditions under which a perception of health is formed is of interest.

Therefore, we aim to study the literature on how children and youth (ages 10—25) perceive and conceptualize mental health, and the specific research questions are:

What aspects are most salient in children’s and youths’ perceptions of mental health?

What concepts do children and youth associate with mental health?

In what way are children's and youth’s perceptions of mental health dependent on gender, age, and socioeconomic factors?

Literature search

A scoping review is a review that aims to provide a snapshot of the research that is published within a specific subject area. The purpose is to offer an overview and, on a more comprehensive level, to distinguish central themes compared to a systematic review. We chose to conduct a scoping review since our aim was to clarify the key concepts of mental health in the literature and to identify specific characteristics and concepts surrounding mental health [ 29 , 30 ]. Our scoping review was conducted following the PRISMA-ScR Checklist [ 31 ]. Two authors (L.B and L.H) searched and screened the eligible articles. In the first step, titles and abstracts were screened. If the study included relevant data, the full article was read to determine if it met the eligibility criteria. Articles were excluded if they did not fulfill all the eligibility criteria. Any uncertainties were discussed among L.B. and L.H., and the third author, S.H., and were carefully assessed before making an inclusion or exclusion decision. The software Picoportal was employed for data management. Figure  1 illustrates a flowchart of data inclusion.

PRISMA flow diagram outlining the search process

Eligibility criteria

We incorporated studies involving children and youth aged 10 to 25 years. This age range was chosen to encompass early puberty through young adulthood, a significant developmental period for young individuals in terms of comprehending mental health. Participants were required not to have undergone interviews due to chronic illness, learning disabilities (e.g., mental health linked to a cancer diagnosis), or immigrant status.

Studies conducted in clinical settings were excluded. For the purpose of comparing results under similar conditions, we specifically opted for studies carried out in Western countries .

Given that this review adopts a moderately constructionist approach, intentionally allowing for the exploration of how both young participants and society in general perceive and discuss mental health and how this process contributes to ongoing conceptual re-construction, the emphasis was placed on identifying articles in which participants themselves defined or attributed meaning to mental health and related concepts like mental illness. The criterion of selecting studies adopting an inductive approach to capture the perspectives of the young participants resulted in the exclusion of numerous studies that more overtly applied established concepts to young respondents [ 32 ].

Information sources

We utilized electronic databases and reached out to study authors if the article was not accessible online. Peer-reviewed articles were exclusively included, thereby excluding conference abstracts due to their perceived lack of relevance in addressing the review questions. Only research in English was taken into account. Publication years across all periods were encompassed in the search.

Search strategy

Studies concerning children’s and youths’ perceptions of mental health were published across a range of scientific journals, such as those within psychiatry, psychology, social work, education, and mental health. Therefore, several databases were taken into account, including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts, and Google Scholar, spanning from inception on September 20, 2021 to September 30, 2021. We involved a university librarian from the start in the search process. The combinations of search terms are displayed in Table 1 .

Quality assessment

We employed the Quality methods for the development of National Institute for Health Care Excellence (NICE) public health guidance [ 33 ] to evaluate the quality of the studies included. The checklist is based on checklists from Spencer et al. [ 34 ], Public Health Resource Unit (PHRU) [ 26 , 35 ], and the North Thames Research Appraisal Group (NTRAG) [ 36 ] (Refer to S2 for checklist). Eight studies were assigned two plusses, and three studies received one plus. The studies with lower grades generally lacked sufficient descriptions of the researcher’s role, context reporting, and ethical reporting. No study was excluded in this stage.

Data extraction and analysis

We employed a data extraction form that encompassed several key characteristics, including author(s), year, journal, country, details about method/design, participants and socioeconomics, aim, and main results (Table 2 ). The collected data were analyzed and synthesized using the thematic synthesis approach of Thomas and Harden [ 37 ]. This approach encompassed all text categorized as 'results' or 'findings' in study reports – which sometimes included abstracts, although the presentation wasn’t always consistent throughout the text. The size of the study reports ranged from a few sentences to a single page. The synthesis occurred through three interrelated stages that partially overlapped: coding of the findings from primary studies on a line-by-line basis, organization of these 'free codes' into interconnected areas to construct 'descriptive' themes, and the formation of 'analytical' themes.

The objective of this scoping review has been to investigate the literature concerning how children and youth (ages 10—25) conceptualize and perceive mental health. Based on the established inclusion- and exclusion criteria, a total of 11 articles were included representing the United Kingdom ( n  = 6), Australia ( n  = 3), and Sweden ( n  = 2) and were published between 2002 and 2020. Among these, two studies involved university students, while nine incorporated students from compulsory schools.

Salient aspects of children and youth’ perceptions of mental health

Based on the results of the included articles, salient aspects of children’s and youths’ understandings revealed uncertainties about mental health in various ways. This uncertainty emerged as conflicting perceptions, uncertainty about the concept of mental health, and uncertainty regarding where to distinguish between mild to moderate mental health problems and everyday stressors or challenges.

One uncertainty was associated with conflicting perceptions that mental health might be interpreted differently among children and youths, depending on whether it relates to their own mental health or someone else's mental health status. Chisholm et al. [ 42 ] presented this as distinctions being made between ‘them and us’ and between ‘being born with it’. Mental health and mental illness were perceived as a continuum that rather developed’, and distinctions were drawn between ‘crazy’ and ‘diagnosed.’ Participants established strong associations between the term mental illness and derogatory terms like ‘crazy,’ linking extreme symptoms of mental illness with others. However, their attitude was less stigmatizing when it came to individual diagnoses, reflecting a more insightful and empathetic understanding of the adverse impacts of stress based on their personal realities and experiences. Despite the initial reactions reflecting negative stereotypes, further discussion revealed that this did not accurately represent a deeper comprehension of mental health and mental illness.

There was also uncertainty about the concept of mental health , as it was not always clearly understood among the participating youth. Some participants were unable to define mental health, often confusing it with mental illness [ 28 ]. Others simply stated that they did not understand the term, as in O’Reilly [ 44 ]. Additionally, uncertainty was expressed regarding whether mental health was a positive or negative concept [ 27 , 28 , 40 , 44 ], and participants associated mental health with mental illness despite being asked about mental health [ 28 ]. One quote from a grade 9 student illustrates this: “ Interviewer: Can mental health be positive as well? Informant: No, it’s mental” [ 44 ]. In Laidlaw et al. [ 46 ], with participants ranging from 18—22 years of age, most considered mental health distinctly different from and more clinical than mental well-being. However, Roose et al. [ 38 ], for example, the authors discovered a more multifaceted understanding of mental health, encompassing emotions, thoughts, and behavior. In Molenaar et al.[ 45 ], mental health was highlighted as a crucial aspect of health overall. In Chisholm et al. [ 42 ], the older age groups discussed mental health in a more positive sense when they considered themselves or people they knew, relating mental health to emotional well-being. Connected to the uncertainty in defining the concept of mental health was the uncertainty in identifying those with good or poor mental health. Due to the lack of visible proof, children and youths might doubt their peers’ reports of mental illness, wondering if they were pretending or exaggerating their symptoms [ 27 ].

A final uncertainty that emerged was difficulties in drawing the line between psychiatric conditions and mild to moderate mental health problems and everyday stressors or challenges . Perre et al. [ 43 ] described how the participants in their study were uncertain about the meaning of mental illness and mental health issues. While some linked depression to psychosis, others related it to simply ‘feeling down.’ However, most participants indicated that, in contrast to transient feelings of sadness, depression is a recurring concern. Furthermore, the duration of feeling depressed and particularly a loss of interest in socializing was seen as appropriate criteria for distinguishing between ‘feeling down’ and ‘clinical depression.’ Since feelings of anxiety, nervousness, and apprehension are common experiences among children and youth, defining anxiety as an illness as opposed to an everyday stressor was more challenging [ 43 ].

Terms used to conceptualize mental health

When children and youth were asked about mental health, they sometimes used neutral terms such as thoughts and emotions or a general ‘vibe’ [ 27 ], and some described it as ‘peace of mind’ and being able to balance your emotions [ 38 ]. The notion of mental health was also found to be closely linked with rationality and the idea of normality, although, according to the young people, Armstrong et al. [ 28 ], there was no consensus about what ‘normal’ meant. Positive aspects of mental health were described by the participants as good self-esteem, confidence [ 40 ], happiness [ 39 , 43 ], optimism, resilience, extraversion and intelligence [ 27 ], energy [ 43 ], balance, harmony [ 39 , 43 ], good brain, emotional and physical functioning and development, and a clear idea of who they are [ 27 , 41 ]. It also included a feeling of being a good person, feeling liked and loved by your parents, social support, and having people to talk with [ 27 , 39 ], as well as being able to fit in with the world socially and positive peer relationships [ 41 ], according to the children and youths, mental health includes aspects related to individuals (individual factors) as well as to people in their surroundings (relationships). Regarding mental illness, participants defined it as stress and humiliation [ 40 ], psychological distress, traumatic experiences, mental disorders, pessimism, and learning disabilities [ 27 ]. Also, in contrast to the normality concept describing mental health, mental illness was described as somehow ‘not normal’ or ‘different’ in Chisholm et al. [ 42 ].

Depression and bipolar disorder were the most often mentioned mental illnesses [ 27 ]. The inability to balance emotions was seen as negative for mental health, for example, not being able to set aside unhappiness, lying to cover up sadness, and being unable to concentrate on schoolwork [ 38 ]. The understanding of mental illness also included feelings of fear and anxiety [ 42 ]. Other participants [ 46 ] indicated that mental health is distinctly different from, and more clinical than, mental well-being. In that sense, mental health was described using reinforcing terms such as ‘serious’ and ‘clinical,’ being more closely connected to mental illness, whereas mental well-being was described as the absence of illness, feeling happy, confident, being able to function and cope with life’s demands and feeling secure. Among younger participants, a more varied and vague understanding of mental health was shown, framing it as things happening in the brain or in terms of specific conditions like schizophrenia [ 44 ].

Gender, age, socioeconomic status

Only one study had a gender theoretical perspective [ 40 ], but the focus of this perspective concerned gender differences in what influences mental health more than the conceptualization of mental health. According to Johansson et al.[ 39 ], older girls expressed deeper negative emotions (e.g., described feelings of lack of meaning and hope in various ways) than older boys and younger children.

Several of the included studies noticed differences in age, where younger participants had difficulty understanding the concept of mental health [ 39 , 44 ], while older participants used more words to explain it [ 39 ]. Furthermore, older participants seemed to view mental health and mental illness as a continuum, with mental illness at one end of the continuum and mental well-being at the other end [ 42 , 46 ].

Socioeconomic status

The role of socioeconomic status was only discussed by Armstrong et al. [ 28 ], finding that young people from schools in the most deprived and rural areas experienced more difficulties defining the term mental health compared to those from a less deprived area.

This scoping review aimed to map children's and youth’s perceptions and conceptualizations of mental health. Our main findings indicate that the concept of mental health is surrounded by uncertainty. This raises the question of where this uncertainty stems from and what it symbolizes. From our perspective, this uncertainty can be understood from two angles. Firstly, the young participants in the different studies show no clear and common understanding of mental health; they express uncertainty about the meaning of the concept and where to draw the line between life experiences and psychiatric conditions. Secondly, uncertainty exists regarding how to apply these concepts in research, making it challenging to interpret and compare research results. The shift from a positivistic understanding of mental health as an objective condition to a more subjective inner experience has left the conceptualization open ranging from a pathological phenomenon to a normal and common human experience [ 47 ]. A dilemma that results in a lack of reliability that mirrors the elusive nature of the concept of mental health from both a respondent and a scientific perspective.

“Happy” was commonly used to describe mental health, whereas "unhappy" was used to describe mental illness. The meaning of happiness for mental health has been acknowledged in the literature, and according to Layard et al. [ 48 ], mental illness is one of the main causes of unhappiness, and happiness is the ultimate goal in human life. Layard et al. [ 48 ] suggest that schools and workplaces need to raise more awareness of mental health and strive to improve happiness to promote mental health and prevent mental illness. On the other hand, being able to experience and express different emotions could also be considered a part of mental health. The notion of normality also surfaced in some studies [ 38 ], understanding mental health as being emotionally balanced or normal or that mental illness was not normal [ 42 ]. To consider mental illness in terms of social norms and behavior followed with the sociological alternative to the medical model that was introduced in the sixties portraying mental illness more as socially unacceptable behavior that is successfully labeled by others as being deviant. Although our results did not indicate any perceptions of what ‘normal’ meant [ 28 ], one crucial starting point to the understanding of mental health among adolescents should be to delineate what constitutes normal functioning [ 23 ]. Children and youths’ understanding of mental illness seems to a large extent, to be on the same continuum as a normality rather than representing a medicalization of deviant behavior and a disjuncture with normality [ 49 ].

Concerning gender, it seemed that girls had an easier time conceptualizing mental health than boys. This could be due to the fact that girls mature verbally faster than boys [ 50 ], but also that girls, to a larger extent, share feelings and problems together compared to boys [ 51 ]. However, according to Johansson et al. [ 39 ], the differences in conceptualizations of mental health seem to be more age-related than gender-related. This could be due to the fact that older children have a more complex view of mental health compared to younger children.. Not surprisingly, the older the children and youth were, the more complex the ability to conceptualize mental health becomes. Only one study reported socioeconomic differences in conceptualizations of mental health [ 28 ]. This could be linked to mental health literacy (MHL) [ 18 ], i.e., knowledge about mental illness, how to prevent mental illness, and help-seeking behavior. Research has shown that disadvantaged social and socioeconomic conditions are associated with low MHL, that is, people with low SES tends to know less about symptoms and prevalence of different mental health problems [ 19 , 21 ]. The perception and conceptualizations of mental health are, as we consider, strongly related to knowledge and beliefs about mental health, and according to von dem Knesebeck et al. [ 52 ] linked primarily to SES through level of education.

Chisholm et al. [ 42 ] found that the initial reactions from participants related to negative stereotypes, but further discussion revealed that the participants had more refined knowledge than at first glance. This illuminates the importance of talking to children and helping them verbalize their feelings, in many respects complex and diversified understanding of mental health. It is plausible that misunderstandings and devaluations of mental health and mental illness may increase self-reported mental health problems [ 5 ], as well as decrease them, preventing children and youth from seeking help. Therefore, increased knowledge of the nature of mental health can help individual cope with the situations and improve their mental well-being. Finding ways to incorporate discussions about mental well-being, mental health, and mental illness in schools could be the first step to decreasing the existing uncertainties about mental health. Experiencing feelings of sadness, anger, or upset from time to time is a natural part of life, and these emotions are not harmful and do not necessarily indicate mental illness [ 5 , 6 ]. Adolescents may have an understanding of the complexity of mental health despite using simplified language but may need guidance on how to communicate their feelings and how to manage everyday challenges and normal strains in life [ 7 ].

With the aim of gaining a better understanding of how mental health is perceived among children and youth, this study has highlighted the concept’s uncertainty. Children and youth reveal a variety of understandings, from diagnoses of serious mental illnesses such as schizophrenia to moods and different types of behaviors. Is there only one way of understanding mental health, and is it reasonable to believe that we can reach a consensus? Judging by the questions asked, researchers also seem to have different ideas on what to incorporate into the concept of mental health — the researchers behind the present study included. The difficulties in differentiating challenges being part of everyday life with mental health issues need to be paid closer attention to and seems to be symptomatic with the lack of clarity of the concepts.

A constructivist approach would argue that the language of mental health has changed over time and thus influence how adolescents, as well as society at large, perceive, talk about, and report their mental health [ 26 ]. The re-construction or adaptation of concepts could explain why children and youth re struggling with the meaning of mental health and that mental health often is used interchangeably with mental illness. Mental health, rather than being an umbrella term, then represents a continuum with a positive and a negative end, at least among older adolescents. But as mental health according to this review also incorporates subjective expressions of moods and feelings, the reconstruction seems to have shaped it into a multidimensional concept, representing a horizontal continuum of positive and negative mental health and a vertical continuum of positive and negative well-being, similar to the health cross by Tudor [ 53 ] referred to in Laidlaw et al. [ 46 ] A multidimensional understanding of mental health constructs also incorporates evidence from interventions aimed at reducing mental health stigma among adolescents, where attitudes and beliefs as well as emotional responses towards mental health are targeted [ 54 ].

The contextual understanding of mental health, whether it is perceived in positive terms or negative, started with doctors and psychiatrists viewing it as representing a deviation from the normal. A perspective that has long been challenged by health workers, academics and professionals wanting to communicate mental health as a positive concept, as a resource to be promoted and supported. In order to find a common ground for communicating all aspects and dimensions of mental health and its conceptual constituents, it is suggested that we first must understand the subjective meaning ascribed to the use of the term [ 26 ]. This line of thought follows a social-constructionist approach viewing mental health as a concept that has transitioned from representing objective mental descriptions of conditions to personal subjective experiences. Shifting from being conceptualized as a pathological phenomenon to a normal and common human experience [ 47 ]. That a common understanding of mental health can be challenged by the healthcare services tradition and regulation for using diagnosis has been shown in a study of adolescents’ perspectives on shared decision-making in mental healthcare [ 55 ]. A practice perceived as labeling by the adolescents, indicating that steps towards a common understanding of mental health needs to be taken from several directions [ 55 ]. In a constructionist investigation to distinguish everyday challenges from mental health problems, instead of asking the question, “What is mental health?” we should perhaps ask, “How is the word ‘mental health’ used, and in what context and type of mental health episode?” [ 26 ]. This is an area for future studies to explore.

Methodological considerations

The first limitation we want to acknowledge, as for any scoping review, is that the results are limited by the search terms included in the database searches. However, by conducting the searches with the help of an experienced librarian we have taken precautions to make the searches as inclusive as possible. The second limitation concerns the lack of homogeneous, or any results at all, according to different age groups, gender, socioeconomic status, and year when the study was conducted. It is well understood that age is a significant determinant in an individual’s conceptualization of more abstract phenomena such as mental health. Some of the studies approached only one age group but most included a wide age range, making it difficult to say anything specific about a particular age. Similar concerns are valid for gender. Regarding socioeconomic status, only one study reported this as a finding. However, this could be an outcome of the choice of methods we had — i.e., qualitative methods, where the aim seldom is to investigate differences between groups and the sample is often supposed to be a variety. It could also depend on the relatively small number of participants that are often used in focus groups of individual interviews- there are not enough participants to compare groups based on gender or socioeconomic status. Finally, we chose studies from countries that could be viewed as having similar development and perspective on mental health among adolescents. Despite this, cultural differences likely account for many youths’ conceptualizations of mental health. According to Meldahl et al. [ 56 ], adolescents’ perspectives on mental health are affected by a range of factors related to cultural identity, such as ethnicity, race, peer and family influence, religious and political views, for example. We would also like to add organizational cultures, such as the culture of the school and how schools work with mental health and related concepts [ 56 ].

Conclusions and implications

Based on our results, we argue that there is a need to establish a common language for discussing mental health. This common language would enable better communication between adults and children and youth, ensuring that the content of the words used to describe mental health is unambiguous and clear. In this endeavor, it is essential to actively listen to the voices of children and youth, as their perspectives will provide us with clearer understanding of the experiences of being young in today’s world. Another way to develop a common language around mental health is through mental health education. A common language based on children’s and youth’s perspectives can guide school personnel, professionals, and parents when discussing and planning health interventions and mental health education. Achieving a common understanding through mental health education of adults and youth could also help clarify the boundaries between everyday challenges and problems needing treatment. It is further important to raise awareness of the positive aspect of mental health—that is, knowledge of what makes us flourish mentally should be more clearly emphasized in teaching our children and youth about life. It should also be emphasized in competence development for school personnel so that we can incorporate knowledge about mental well-being in everyday meetings with children and youth. In that way, we could help children and youth develop knowledge that mental health could be improved or at least maintained and not a static condition.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Beckman, L., Hassler, S. & Hellström, L. Children and youth’s perceptions of mental health—a scoping review of qualitative studies. BMC Psychiatry 23 , 669 (2023). https://doi.org/10.1186/s12888-023-05169-x

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Friday essay: Bad therapy or cruel world? How the youth mental health crisis has been sucked into the culture wars

Professor of Psychology, The University of Melbourne

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Rates of mental ill health among young people are on the rise. Between the years 2020 and 2022, 39% of Australians aged 16 to 24 had a mental disorder in the previous year , compared to 26% in that age range in 2007, and 27% of those aged 18–24 in 1997.

The recent Lancet Psychiatry commission on youth mental health documents equally steep increases in mental illness in the United States, UK and Denmark. Governments, mental health services, educational institutions and parents are struggling to respond. But what is behind these trends?

Two accounts seem to be emerging. According to one, which I’ll call the “cruel world” narrative, young people are distressed because the world is in bad shape and getting worse.

Facing climate emergency, unaffordable housing, precarious employment, rising inequality and other dire mega-trends, they are canaries in a societal coalmine. By this account, the mental health crisis is the direct result of systemic adversity.

The alternative, which I’ll call the “cultural trend” narrative, is a little less bleak. Young people are experiencing more mental illness not primarily because the world is grim and getting grimmer, but because cultural shifts have shaped how they perceive and inhabit it.

This narrative suggests a culture preoccupied with harm creates vulnerability and leads people to view life problems through a psychiatric lens. Adversity and social dislocation undoubtedly contribute to young people’s distress, but the way therapeutic culture frames their suffering makes it worse.

The two narratives offer different prescriptions.

From the “cruel world” perspective, the ultimate causes of the mental health crisis are the basic structures of our society, economy and ecology. Only systemic, macro-level changes can arrest them.

For proponents of the “cultural trend” narrative, the focus of intervention is more micro. We should challenge the social practices and technologies that create vulnerability and undermine mental health.

As a social psychologist, I take it as self-evident that adverse social environments play a leading role in the creation of mental ill health: that we can’t isolate human misery from its broader context. However, I’m equally certain that culture plays a crucial part.

A range of cultural changes that could plausibly undermine mental health are well underway: increased immersion in the digital world, rising political polarisation and preoccupation with risk and harm, among others. Separating them from the tangled skein of factors that contribute to the youth mental health crisis is a matter of urgency.

Abigail Shrier’s new book Bad Therapy , a forceful exposition of the “cultural trend” narrative, provides a golden opportunity to explore some of them.

Youth mental health and the culture wars

Journalist and cultural critic Soraya Chemaly’s recent book The Resilience Myth exemplifies the first narrative. Young people are distressed “because the world is distressing, and adults have failed them”. Their sensitivity and emotional honesty place them at higher risk of distress than their elders, and the ubiquity of trauma, oppression and existential climate threat tip that risk into illness.

Chemaly’s solutions lean towards the revolutionary. Her targets include individualism, rigid gender ideologies, capitalism and white supremacy.

Social psychologist Jonathan Haidt’s The Anxious Generation presents a version of the second narrative. Haidt does not deny the magnitude of the challenges young people face. However, he questions whether their rising rates of mental ill health directly follow increases in adversity.

This inflection point in the trajectory of young people’s mental ill health appears to have occurred in the early 2010s. However, many of the systemic trends now held responsible for the crisis – like climate change and rising income inequality – have been building over a much longer period, when rates of ill health were relatively stable. By implication, the precipitating causes must be more specific, recent developments.

Haidt identifies two such changes: the advent of smartphones and “safetyism”. His focus on smartphones has been widely reported . But his equally important emphasis on the cultural preoccupation with protecting us from harm has received less attention.

Haidt argues that parental and institutional over-protection hampers the development of young people’s resilience and autonomy. Citing the idea of “anti-fragility” he proposes that risk, challenge and failure are required to build strength.

By now, it should be obvious that the youth mental health crisis has become politicised, sucked into the vortex of the culture wars.

The crisis can be attributed either to an uncaring system that oppresses the most vulnerable, or to emerging social trends that do young minds no favours. It can be addressed either by progressive social change, such as economic redistribution and environmental protection, or by winding back some damaging cultural developments, such as promoting unsupervised play for children and restricting access to smartphones in schools .

Blaming ‘bad therapy’

Whereas Haidt spends much of his book on the damage done by young people’s immersion in the digital world, in Bad Therapy, Shrier castigates mental health experts for contributing to the crisis they claim to be addressing.

Shrier is a controversial figure. Her previous book Irreversible Damage drew protests and bans for critiquing youth gender medicine and arguing that social contagion plays a role in the rise of girls seeking gender transition.

The former lawyer and Wall Street Journal columnist, who has not previously written at length on mental health, is just as fierce in prosecuting the case against the growing influence of mental health expertise.

Bad Therapy begins by arguing that the rise in mental ill health among young people is not merely a response to deepening life challenges. Instead, Shrier writes, it is driven by destructive cultural shifts and misguided experts. She suggests many people who are experiencing ordinary problems in living have been led to believe their unhappiness is psychiatric in nature.

Shrier is quick to clarify that distress often is genuinely severe. There are “two distinct groups of young people”, she argues: those experiencing “profound mental illness” and “the worriers; the fearful; the lonely, lost, and sad”.

This second group is Shrier’s battleground. These “worriers” have fallen victim to shifts in education and parenting, and to the expansionism of the mental health field. On this point, she doesn’t mince her words. “No industry refuses the prospect of exponential growth,” she writes, and “the mental health industry is minting patients faster than it can cure them.” As a result, “we rush to remedy a misdiagnosed condition with the wrong sort of cure”.

Shrier challenges the common view that mental health interventions – therapy for short – are invariably beneficial. She reviews evidence suggesting therapy is less helpful than it is touted to be, and that it can sometimes be actively harmful. For instance, “psychological debriefing” immediately after exposure to traumas can interfere with recovery .

Mental health treatment can undermine recovery, she suggests, by “hijack[ing] our normal processes of resilience” and creating dependency on professionals. It can crystallise illness by applying diagnostic labels too liberally.

Diagnoses may bring relief to anxious and desperate parents, but they can also affect how their children perceive themselves and are perceived by others. Much like therapeutic staples such as trauma and chemical imbalance , diagnostic terms can convey the view that young people are fundamentally damaged and have little control over their predicaments.

Many of these critiques of therapy chime with familiar attacks on medicalisation . But Shrier also advances some newer criticisms. Mental health treatment can induce rumination and a passive focus on feelings: common features of anxiety and depression. “Bad therapy encourages hyperfocus on one’s emotional states, which in turn makes symptoms worse.”

Therapy can also affirm young people’s worries and encourage public sharing of distress in ways that can entrench unhelpful patterns. “A dose of repression,” Shrier counters, “appears to be a fairly useful psychological tool for getting on with life.”

Mental health workers overlook the possibility that talk therapy can have these adverse consequences, Shrier argues – although it is no less plausible that some psychological treatments may do harm than that some medications can have adverse side effects. Without questioning therapists’ desire to help, she takes the hardheaded view that they have incentives not to acknowledge the harm they may be causing.

Should teachers be delivering therapy?

The clear implication of Shrier’s argument is that we should challenge, rather than expand, therapeutic approaches to young people’s mental health. Instead, she finds that American schools are riddled with bad therapy, often under the banner of “social-emotional learning”.

Shrier maintains that social-emotional learning licenses psychologically untrained teachers to work in a therapeutic mode. It encourages excessive self-focus, demands emotional disclosure and can expose children to dual relationships, all out of view of their parents.

Social-emotional learning and related elements of therapeutic schooling don’t just encourage unhelpful inwardness, she argues. She contends they also use questionable teaching methods and draw time and energy away from academic learning.

Of one effort to smuggle emotional learning into a maths class, Shrier writes: “I began to wonder whether this wasn’t some sort of ploy by the Chinese Communist Party to obliterate American mathematical competence.” She concludes that

social-emotional learning turns out to be a lot like the Holy Roman Empire. Neither social, nor good for emotional health, nor something that can be learned.

Schools’ therapeutic missions also undermine how they educate disadvantaged students. Shrier contends that some “trauma-informed” practice prejudges students who have experienced hardship as fragile and in need of blanket mental health interventions, while lowering expectations for their behaviour and academic achievement. Meanwhile, classroom chaos is created by excessive accommodation of disruptive students.

Shrier takes aim at the outsized role “trauma” plays in currently popular accounts of mental ill health. She reserves some of her sharpest criticism for psychiatrist Bessel van der Kolk , whose bestselling book, The Body Keeps the Score, places trauma front and centre in mental ill health, and physician Gabriel Maté , who claims trauma contributes to everything from cancer to ADHD.

Seeing childhood trauma as the buried root of most adult mental health problems conflicts with copious evidence that resilience is the normal response to adversity – and that trauma memories tend to be recalled accurately, rather than locked voiceless in the body. Shrier maintains that the concept of trauma has become trivialised through over-use. She chastises experts for characterising problems ranging from anger outbursts to procrastination as trauma responses.

In the school environment, the consequences of elevating trauma are troubling:

under the banner of “whole child” education and “trauma-informed” care, educators greet every child with the emotional analogue of a gurney, all but begging kids to hop in. They never wait to see who might be injured because every child is encouraged to see herself as overtaxed and worn out. They encourage every child, constantly, to think about herself and her struggles.

Against ‘gentle’ parenting and ‘overmanaged’ kids

Shrier condemns schools for usurping parental authority, but argues that contemporary parenting also subverts itself.

“Gentle” styles of child-rearing end up creating anxious, unresilient children whose demands are endlessly accommodated and whose dependency is reinforced. A strange combination of permissiveness and over-involvement makes for exhausted parents who are unwilling to exercise adult authority or to impose consequences on behaviour, she argues.

Liberal American parents may look askance at earlier styles of parenting, but by placing emotional wellness front and centre in their relationships with their children, they are making their task harder and more thankless.

As Shrier observes:

forty-year-old parents – accomplished, brilliant, and blessed with a spouse – treat the raising of kids like a calculus problem that was put to them in the dead of night: Get it right or I pull this trigger .

Ultimately, the failures of therapeutic parenting are another strike against the mental health experts who advocated for it. Shrier urges parents to cut themselves loose from the advice of parenting sages, for the good of their children: “love means occasionally telling an expert to get lost”.

Concretely, parents should step back, stop compulsively monitoring and over-praising their children, reduce scheduled activities, enforce consequences and encourage independent behaviour. She writes: “if you could do something at their age, let them give it a whirl”.

A parent’s goal should be to set their children free from an “overmanaged, veal-calf life” and ensure they experience “all of the pains of adulthood, in smaller doses, so that they build up immunity to the poison of heartache and loss”.

Not all therapy is bad therapy

Bad Therapy is an unashamedly polemical book. Shrier has strong views on what is wrong with the culture of mental health in the US –  and takes these supposed failings as examples of broader progressive trends she opposes.

The mental health crisis troubles her not only for its human costs, but because it erodes key conservative values: self-reliance, strength, parental authority and freedom from institutional compulsion.

Shrier’s rhetoric is sharp-elbowed, with a memorable turn of phrase. Some villains are identified and savaged, though the criticised cabal of mental health experts is often a faceless mass. The book is studded with revealing case studies and she interviews many leading scientists, like Paul Bloom, author of Against Empathy , memory expert Elizabeth Loftus , leading trauma psychologist Richard McNally , and generational difference researcher Jean Twenge .

Though she presents herself as defending science against ideology, at times Shrier’s claims run ahead of the data. There is little evidence that mental health interventions are creating ill health on a large scale, for example, or that increases in self-diagnosis among young people account for increases in their levels of distress.

Some schools may implement socio-emotional learning in problematic ways. But studies typically find that they benefit academic achievement . And though there is evidence that today’s young adults are reaching some developmental milestones later than earlier generations, there is little direct evidence that gentle parenting is responsible for the delays.

Shrier tends to present the mental health world as a monolith. But anyone working in it knows it to be criss-crossed with divisions: between researchers and practitioners, consumers and professionals, medical and non-medical workers, and numerous disciplines and therapeutic tribes.

The idea that this Babel of voices is united in a process of crisis creation is hard to credit. Not all therapy is bad therapy. Indeed, many of the positions Shrier espouses – for facing challenges head on and experiencing the consequences of our behaviour, and against safetyism, over-medication and the therapeutic excavation of our childhoods – are gospel for mainstream cognitive behaviour therapists.

Correcting concerning trends

Even so, for all its exaggerations and simplifications, Bad Therapy is a timely corrective to some real and concerning trends. It is increasingly clear that over-diagnosis of mental illness is common, especially among young people, and that diagnostic labelling can have adverse implications .

It now seems likely that campaigns to boost mental health awareness sometimes backfire and pathologise ordinary unhappiness. School-based prevention initiatives are sometimes ineffective and can even reduce wellbeing.

Most of all, it is becoming obvious that although there is a high unmet need for treatment, simply expanding the current mental health system – training more therapists, funding more sessions and services, further boosting awareness of mental health, embedding a therapeutic sensibility in more of our institutions – cannot be relied on to substantially reduce mental ill health.

Research on the so-called “treatment-prevalence paradox” demonstrates that large increases in service provision have failed to reduce rates of mental illness. Current treatment practices have only modest efficacy in real-world settings. Reasons likely include the complexity and recurring nature of many mental health problems, and the low quality implementation and short-lived benefit of many treatments.

Some treatments also clearly do more harm than good, for some patients. A recent evaluation of Australia’s Better Access program, which gives Medicare rebates to help people access mental health care, found that patients who sought help for relatively mild distress were three times more likely to deteriorate than to improve (patients in more severe distress typically improved).

In this context, Shrier has some grounds to be sceptical that doing more of the same will turn around the mental health crisis. There is no question that more needs to be done – but believing that the solution is to scale up current practice seems, as Samuel Johnson said of a second marriage, a triumph of hope over experience.

Shrier addresses her concluding chapters to parents, urging them to reclaim the confidence that they know what’s right for their child. The trouble is, parents rarely know to which of Shrier’s “two distinct groups of young people” their child belongs.

How could they know? No bright line separates the supposed victims of therapy culture from the profoundly ill. Faced with a loved one’s distress, what can parents do but seek the forms of help that are currently available?

Our young people will continue to be funnelled toward mental health treatment in alarming numbers. We can only hope it will become more effective and less necessary.

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What Everyone Should Know About Child Mental Health

A psychologist's guide to spotting red flags in children..

Posted September 2, 2024 | Reviewed by Michelle Quirk

• Understanding Child Development
• Take our ADHD Test
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• It's challenging for parents to distinguish normal development from potential mental health problems.
• We need to view mental health the same as physical health and seek professional help when needed.
• Early detection and intervention are crucial for a child's well-being.

Raising kids is a difficult, often thankless task, even when things go smoothly: Childhood is basically a constant state of change. The minute you get a handle on one behavior, your child is on to the next one with completely different milestones to meet. On top of the physical changes, there’s your child’s emotional functioning to worry about: All children get worried, sad, act out, or avoid things. How are parents supposed to know if you’re seeing things that are within a normative developmental range or a cause for concern?

Recognizing When "Just a Mood" Becomes Something More

When parents walk into my office, they’ll often tell one of two stories:

We saw the signs of this behavior early, but figured he would grow out of it. It’s five years later and we think we waited too long. Help us, please.

My kid doesn’t know how easy she has it. When I was her age, I had so much less, and I was fine. Here she is, struggling, probably because she hasn’t learned to deal with hard things like I have.

Both types of parents don’t know enough about what mental health and wellness looks like in children—and it’s no fault of their own. But if we want to solve a problem, we need to first identify it. We need to talk more about when behaviors become concerning, such as the difference between sadness and depression , or when anxiety needs treatment. We’re language-based creatures, and we often fall into the trap of believing that, because a child isn’t old enough to express themselves with words, they must not have the rich inner lives (and struggles) that adults do. That is patently untrue. Children don’t yet have the meta-cognitive abilities to talk about what is going on in their minds, but they can still suffer the consequences of an unhealthy relationship with their emotions.

Mental health is tricky because the borders between normal and pathological are fuzzy. Take anxiety, for example. Anxiety is a normal, adaptive response to threat that is good for us as humans. We look both ways before crossing the street because of a normal amount of anxiety about getting hit by cars, for example. We buy insurance because we worry about potentially terrible things that may happen, but probably won’t. At the same time, we can recognize that a teenager who avoids school and isolates in his room because of social worries has too much anxiety that keeps him from doing the things teenagers need to do—socializing with friends, achieving more independence, and attending school. This warning system that is meant to keep us safe is causing problems in his life, not alleviating them.

Very Concretely, These Are Behaviors That Concern Me as a Psychologist, and Warrant Immediate Attention at Any Age:

• Sadness lasting more than two weeks
• A change in level of social interest, increased isolation
• A child discussing or actively hurting themselves
• Any talk of death or suicide
• Harmful, out-of-control behavior
• Big changes in eating habits
• Weight loss
• Sleep changes (too much or too little)
• Somatic concerns like headaches or stomachaches frequently
• Doing poorly in school/changes in academic performance
• School avoidance
• Changes in attention or levels of concentration

If your child is exhibiting any of the signs on this list, talk to someone: Often, pediatricians are excellent first-line resources, and they may direct you to a mental health provider. If you aren’t familiar with the mental health system, this call might feel daunting. I encourage parents to consider coming in for a consultation the same way they might consult with a medical doctor on a physical health issue with their children: This is just what we need to do to keep our children safe.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the 988 Suicide & Crisis Lifeline , or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.

Regine Galanti, Ph.D. , is a clinical psychologist who focuses on helping people access treatments that work for anxiety, OCD, and related issues.

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The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

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“It is not the bruises on the body that hurt. It is the wounds of the heart and the scars on the mind.” —Aisha Mirza “We can deny our experience but our body remembers.” —Jeanne McElvaney, Spirit Unbroken: Abby’s Story

Prevalence and Consequences of Childhood Maltreatment

Childhood Maltreatment Increases Risk for Illness Severity and Poor Treatment Response in Mood Disorders

Timing of childhood maltreatment: are there periods of heightened sensitivity, experiencing single subtypes of abuse and neglect versus experiencing multiple types, underlying mechanisms by which childhood maltreatment increases risk for mood disorders and contributes to disease course.

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Pathways to mood disorder outcomes, childhood maltreatment and associated alterations in neural structure and function, limitations and future directions, acknowledgments, information, published in.

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Child labor and health: a systematic literature review of the impacts of child labor on child’s health in low- and middle-income countries

Abdalla ibrahim.

1 CAPHRI, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands

Salma M Abdalla

2 Department of Epidemiology, Boston University, Boston, USA

Mohammed Jafer

3 Jazan University, Gizan, Kingdom of Saudi Arabia

Jihad Abdelgadir

4 Division of Global Neurosurgey and Neurology, Duke University, Durham, USA

5 Department of Neurosurgery, Duke University Medical Center, Durham, USA

Nanne de Vries

To summarize current evidence on the impacts of child labor on physical and mental health.

We searched PubMed and ScienceDirect for studies that included participants aged 18 years or less, conducted in low- and middle-income countries (LMICs), and reported quantitative data. Two independent reviewers conducted data extraction and assessment of study quality.

A total of 25 studies were identified, the majority of which were cross-sectional. Child labor was found to be associated with a number of adverse health outcomes, including but not limited to poor growth, malnutrition, higher incidence of infectious and system-specific diseases, behavioral and emotional disorders, and decreased coping efficacy. Quality of included studies was rated as fair to good.

Conclusion and recommendations

Child labor remains a major public health concern in LMICs, being associated with adverse physical and mental health outcomes. Current efforts against child labor need to be revisited, at least in LMICs. Further studies following a longitudinal design, and using common methods to assess the health impact of child labor in different country contexts would inform policy making.

Introduction

For decades, child labor has been an important global issue associated with inadequate educational opportunities, poverty and gender inequality. 1 Not all types of work carried out by children are considered child labor. Engagement of children or adolescents in work with no influence on their health and schooling is usually regarded positive. The International Labor Organization (ILO) describes child labor as ‘work that deprives children of their childhood, potential and dignity, and that is harmful to physical and mental development’. 2 This definition includes types of work that are mentally, physically, socially or morally harmful to children; or disrupts schooling.

The topic gained scientific attention with the industrial revolution. Research conducted in the UK, because of adverse outcomes in children, resulted in acts for child labor in 18 02. 3 Many countries followed the UK, in recognition of the associated health risks. The ILO took its first stance in 1973 by setting the minimum age for work. 4 Nevertheless, the ILO and other international organizations that target the issue failed to achieve goals. Child labor was part of the Millennium Development Goals, adopted by 191 nations in 20 00 5 to be achieved by 2015. Subsequently, child labor was included in the Sustainable Development Goals, 6 which explicitly calls for eradication of child labor by 2030.

Despite the reported decline in child labor from 1995 to 2000, it remains a major concern. In 2016, it was estimated that ~150 million children under the age of 14 are engaged in labor worldwide, with most of them working under circumstances that denies them a playful childhood and jeopardize their health. 7 Most working children are 11–14 years, but around 60 million are 5–11 years old. 7 There are no exact numbers of the distribution of child labor globally; however, available statistics show that 96% of child workers are in Africa, Asia and Latin America. 1

Research into the impacts of child labor suggests several associations between child labor and adverse health outcomes. Parker 1 reported that child labor is associated with certain exposures like silica in industries, and HIV infection in prostitution. Additionally, as child labor is associated with maternal illiteracy and poverty, children who work are more susceptible to malnutrition, 1 which predisposes them to various diseases.

A meta-analysis on the topic was published in 20 07. 8 However, authors reported only an association of child labor with higher mortality and morbidity than in the general population, without reporting individual outcome specific effects. 8 Another meta-analysis investigated the effects of adverse childhood experiences (ACEs), including child labor, on health. They reported that ACEs are risk factors for many adverse health outcomes. 9

To our knowledge, this is the first systematic review that attempts to summarize current evidence on the impacts of child labor on both physical and mental health, based on specific outcomes. We review the most recent evidence on the health impacts of child labor in low- and middle-income countries (LMICs) according to the World Bank classification. We provide an informative summary of current studies of the impacts of child labor, and reflect upon the progress of anti-child labor policies and laws.

Methodology

Search strategy.

We searched PubMed and ScienceDirect databases. Search was restricted to publications from year 1997 onwards. Only studies written in English were considered. Our search algorithm was [(‘child labor’ OR ‘child labor’ OR ‘working children’ OR ‘occupational health’ OR ‘Adolescent work’ OR ‘working adolescents’) AND (Health OR medical)]. The first third of the algorithm was assigned to titles/abstracts to ensure relevance of the studies retrieved, while the rest of the terms were not. On PubMed, we added […AND (poverty OR ‘low income’ OR ‘developing countries’)] to increase the specificity of results; otherwise, the search results were ~60 times more, with the majority of studies being irrelevant.

Study selection

Studies that met the following criteria were considered eligible: sample age 18 years or less; study was conducted in LMICs; and quantitative data was reported.

Two authors reviewed the titles obtained, a.o. to exclude studies related to ‘medical child labor’ as in childbirth. Abstracts of papers retained were reviewed, and subsequently full studies were assessed for inclusion criteria. Two authors assessed the quality of studies using Downs and Black tool for quality assessment. 10 The tool includes 27 items, yet not all items fit every study. In such cases, we used only relevant items. Total score was the number of items positively evaluated. Studies were ranked accordingly (poor, fair, good) (Table ​ (Table1 1 ).

Characteristics of studies included

* The quality is based on the percentage of Downs and Black 10 tool, < 50% = poor, 50–75% = fair, > 75% = good.

** BMI, body mass index.

*** HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus.

Data extraction and management

Two authors extracted the data using a standardized data extraction form. It included focus of study (i.e. physical and/or mental health), exposure (type of child labor), country of study, age group, gender, study design, reported measures (independent variables) and outcome measures (Table ​ (Table1). 1 ). The extraction form was piloted to ensure standardization of data collection. A third author then reviewed extracted data. Disagreements were solved by discussion.

Search results

A flow diagram (Fig. ​ (Fig.1) 1 ) shows the studies selection process. We retrieved 1050 studies on PubMed and 833 studies on Science Direct, with no duplicates in the search results. We also retrieved 23 studies through screening of the references, following the screening by title of retrieved studies. By reviewing title and abstract, 1879 studies were excluded. After full assessment of the remaining studies, 25 were included.

Study selection process.

Characteristics of included studies

Among the included studies ten documented only prevalence estimates of physical diseases, six documented mental and psychosocial health including abuse, and nine reported the prevalence of both mental and physical health impacts (Table ​ (Table1). 1 ). In total, 24 studies were conducted in one country; one study included data from the Living Standard Measurement Study of 83 LMIC. 8

In total, 12 studies compared outcomes between working children and a control group (Table ​ (Table1). 1 ). Concerning physical health, many studies reported the prevalence of general symptoms (fever, cough and stunting) or diseases (malnutrition, anemia and infectious diseases). Alternatively, some studies documented prevalence of illnesses or symptoms hypothesized to be associated with child labor (Table ​ (Table1). 1 ). The majority of studies focusing on physical health conducted clinical examination or collected blood samples.

Concerning mental and psychosocial health, the outcomes documented included abuse with its different forms, coping efficacy, emotional disturbances, mood and anxiety disorders. The outcomes were measured based on self-reporting and using validated measures, for example, the Strengths and Difficulties Questionnaire (SDQ), in local languages.

The majority of studies were ranked as of ‘good quality’, with seven ranked ‘fair’ and one ranked ‘poor’ (Table ​ (Table1). 1 ). The majority of them also had mixed-gender samples, with only one study restricted to females. 24 In addition, valid measures were used in most studies (Table ​ (Table1). 1 ). Most studies did not examine the differences between genders.

Child labor and physical health

Fifteen studies examined physical health effects of child labor, including nutritional status, physical growth, work-related illnesses/symptoms, musculoskeletal pain, HIV infection, systematic symptoms, infectious diseases, tuberculosis and eyestrain. Eight studies measured physical health effects through clinical examination or blood samples, in addition to self-reported questionnaires. All studies in which a comparison group was used reported higher prevalence of physical diseases in the working children group.

Two studies were concerned with physical growth and development. A study conducted in Pakistan, 11 reported that child labor is associated with wasting, stunting and chronic malnutrition. A similar study conducted in India compared physical growth and genital development between working and non-working children and reported that child labor is associated with lower BMI, shorter stature and delayed genital development in working boys, while no significant differences were found among females. 12

Concerning work-related illnesses and injuries, a study conducted in Bangladesh reported that there is a statistically significant positive association between child labor and the probability to report any injury or illness, tiredness/exhaustion, body injury and other health problems. Number of hours worked and the probability of reporting injury and illness were positively correlated. Younger children were more likely to suffer from backaches and other health problems (infection, burns and lung diseases), while probability of reporting tiredness/exhaustion was greater in the oldest age group. Furthermore, the frequency of reporting any injury or illness increases with the number of hours worked, with significant variation across employment sectors. 13 A study in Iran reported that industrial workrooms were the most common place for injury (58.2%). Falling from heights or in horizontal surface was the most common mechanism of injury (44%). None of the patients was using a preventive device at the time of injury. Cuts (49.6%) were the most commonly reported injuries. 14

Other studies that investigated the prevalence of general symptoms in working children in Pakistan, Egypt, Lebanon, Jordan and Indonesia reported that child labor is negatively associated with health. 15 – 19 Watery eyes, chronic cough and diarrhea were common findings, in addition to history of a major injury (permanent loss of an organ, hearing loss, bone fractures, permanent disability). 20 One study, conducted in India reported that working children suffered from anemia, gastrointestinal tract infections, vitamin deficiencies, respiratory tract infections, skin diseases and high prevalence of malnutrition. 21 Another study—of poor quality—in India reported that child labor was associated with higher incidence of infectious diseases compared to non-working children. 22

Only a few studies focused on specific diseases. A study in Brazil compared the prevalence of musculoskeletal pain between working and non-working children. Authors reported that the prevalence of pain in the neck, knee, wrist or hands, and upper back exceeded 15%. Workers in manufacturing had a significantly increased risk for musculoskeletal pain and back pain, while child workers in domestic services had 17% more musculoskeletal pain and 23% more back pain than non-workers. Awkward posture and heavy physical work were associated with musculoskeletal pain, while monotonous work, awkward posture and noise were associated with back pain. 23 A study in Nicaragua, which focused on children working in agriculture, reported that child labor in agriculture poses a serious threat to children’s health; specifically, acute pesticides poisoning. 24

A study conducted in India reported that the prevalence of eyestrain in child laborers was 25.9%, which was significantly more than the 12.4% prevalence in a comparison group. Prevalence was higher in boys and those who work more than 4 h daily. 25 Another study conducted in India documented that the difference between working and non-working children in the same area in respiratory morbidities (TB, hilar gland enlargement/calcification) was statistically significant. 26

A study in Iran explored the prevalence of viral infections (HIV, HCV and HBV) in working children. 27 The study reported that the prevalence among working street children was much higher than in general population. The 4.5% of children were HIV positive, 1.7% were hepatitis B positive and 2.6% hepatitis C positive. The likelihood of being HIV positive among working children of Tehran was increased by factors like having experience in trading sex, having parents who used drugs or parents infected with HCV.

Lastly, one study was a meta-analysis conducted on data of working children in 83 LMIC documented that child labor is significantly and positively related to adolescent mortality, to a population’s nutrition level, and to the presence of infectious diseases. 8

Child labor and mental health

Overall, all studies included, except one, 28 reported that child labor is associated with higher prevalence of mental and/or behavioral disorders. In addition, all studies concluded that child labor is associated with one or more forms of abuse.

A study conducted in Jordan reported a significant difference in the level of coping efficacy and psychosocial health between working non-schooled children, working school children and non-working school children. Non-working school children had a better performance on the SDQ scale. Coping efficacy of working non-schooled children was lower than that of the other groups. 29

A study conducted in Pakistan reported that the prevalence of behavioral problems among working children was 9.8%. Peer problems were most prevalent, followed by problems of conduct. 30 A study from Ethiopia 31 reported that emotional and behavioral disorders are more common among working children. However, another study in Ethiopia 28 reported a lower prevalence of mental/behavioral disorders in child laborers compared to non-working children. The stark difference between these two studies could be due to the explanation provided by Alem et al. , i.e. that their findings could have been tampered by selection bias or healthy worker effect.

A study concerned with child abuse in Bangladesh reported that the prevalence of abuse and child exploitation was widespread. Boys were more exposed. Physical assault was higher towards younger children while other types were higher towards older ones. 32 A similar study conducted in Turkey documented that 62.5% of the child laborers were subjected to abuse at their workplaces; 21.8% physical, 53.6% emotional and 25.2% sexual, 100% were subjected to physical neglect and 28.7% were subjected to emotional neglect. 33

One study focused on sexual assault among working females in Nigeria. They reported that the sexual assault rate was 77.7%. In 38.6% of assault cases, the assailant was a customer. Girls who were younger than 12 years, had no formal education, worked for more than 8 h/day, or had two or more jobs were more likely to experience sexual assault. 34

Main findings of this study

Through a comprehensive systematic review, we conclude that child labor continues to be a major public health challenge. Child labor continues to be negatively associated with the physical and psychological health of children involved. Although no cause–effect relation can be established, as all studies included are cross-sectional, studies documented higher prevalence of different health issues in working children compared to control groups or general population.

This reflects a failure of policies not only to eliminate child labor, but also to make it safer. Although there is a decline in the number of working children, the quality of life of those still engaged in child labor seems to remain low.

Children engaged in labor have poor health status, which could be precipitated or aggravated by labor. Malnutrition and poor growth were reported to be highly prevalent among working children. On top of malnutrition, the nature of labor has its effects on child’s health. Most of the studies adjusted for the daily working hours. Long working hours have been associated with poorer physical outcomes. 18 , 19 , 25 , 26 , 35 It was also reported that the likelihood of being sexually abused increased with increasing working hours. 34 The different types and sectors of labor were found to be associated with different health outcomes as well. 13 , 18 , 24 However, comparing between the different types of labor was not possible due to lack of data.

The majority of studies concluded that child labor is associated with higher prevalence of mental and behavioral disorders, as shown in the results. School attendance, family income and status, daily working hours and likelihood of abuse, in its different forms, were found to be associated with the mental health outcomes in working children. These findings are consistent with previous studies and research frameworks. 36

Child labor subjects children to abuse, whether verbally, physically or sexually which ultimately results in psychological disturbances and behavioral disorders. Moreover, peers and colleagues at work can affect the behavior of children, for example, smoking or drugs. The effects of child labor on psychological health can be long lasting and devastating to the future of children involved.

What is already known on this topic

Previous reviews have described different adverse health impacts of child labor. However, there were no previous attempts to review the collective health impacts of child labor. Working children are subjected to different risk factors, and the impacts of child labor are usually not limited to one illness. Initial evidence of these impacts was published in the 1920s. Since then, an increasing number of studies have used similar methods to assess the health impacts of child labor. Additionally, most of the studies are confined to a single country.

What this study adds

To our knowledge, this is the first review that provides a comprehensive summary of both the physical and mental health impacts of child labor. Working children are subjected to higher levels of physical and mental stress compared to non-working children and adults performing the same type of work. Unfortunately, the results show that these children are at risk of developing short and long-term health complications, physically or mentally.

Though previous systematic reviews conducted on the topic in 19 97 1 and 20 07 8 reported outcomes in different measures, our findings reflect similar severity of the health impacts of child labor. This should be alarming to organizations that set child labor as a target. We have not reviewed the policies targeting child labor here, yet our findings show that regardless of policies in place, further action is needed.

Most of the current literature about child labor follow a cross-sectional design, which although can reflect the health status of working children, it cannot establish cause–effect associations. This in turn affects strategies and policies that target child labor.

In addition, comparing the impacts of different labor types in different countries will provide useful information on how to proceed. Further research following a common approach in assessing child labor impacts in different countries is needed.

Limitations of this study

First, we acknowledge that all systematic reviews are subject to publication bias. Moreover, the databases used might introduce bias as most of the studies indexed by them are from industrialized countries. However, these databases were used for their known quality and to allow reproduction of the data. Finally, despite our recognition of the added value of meta-analytic methods, it was not possible to conduct one due to lack of a common definition for child labor, differences in inclusion and exclusion criteria, different measurements and different outcome measures. Nevertheless, to minimize bias, we employed rigorous search methods including an extensive and comprehensive search, and data extraction by two independent reviewers.

Compliance with ethical standards

The authors declare that they have no conflict of interest.

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Child Healthcare: Importance and Challenges Essay

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Children are the future. This is an immutable fact. Every society has the mandate and responsibility of caring and providing for them. United Nations member states passed the famous Millennium Development Goals in the year 2000. Some of the practices seek to improve the overall child’s health and the health condition of mothers ( Reduce Child Mortality).

Child healthcare faces many challenges amid laws and regulations passed by State and Federal governments. Pediatricians and health practitioners experience challenges that are beyond their control. Clinical experts express optimism citing that implementation of Clinical Advocacy will improve on children’s condition and the overall family’s situation.

Inadequate infrastructure is an enormous impediment to child care for the disabled. Before the period 1990, most health facilities lacked ample parking for the handicapped. The US Congress passed the Americans with Disability Act to ensure that children and parents with disabilities were offered protection from discrimination in the provision of services ( ADA National Network ).

A language barrier is another setback limiting service delivery in the child care unit. In a survey conducted by the Medicine National Institute of Health, it was observed that 84% of patients who visited health facilities spoke English. The rest of the patients mostly spoke Chinese, Russian and Spanish. The report warns that non-English speakers had higher adjusted odds of readmission (Gannon 1).

Hospital management has come up with measures that aim to solve the prevalent language barrier. For instance, a hospital in Boston paid for the services of an interpreter, a Jewish, to translate for the Russian patient admitted to the child care unit (Palfrey 90).

The treatment for children has become expensive to most parents. In the year 2013, a report compiled by Child Poverty Action Group has indicated that the UK incurs a total of 29 billion pounds yearly due to child poverty. Out of this, 20.5 billion pounds translate into a direct cost to the government.

To overcome the issue of child poverty, clinicians encourage parents to obtain health insurance cover for their children. As such, some clinics can refuse to offer treatment in the event that the patient fails to produce an insurance cover. Medical practitioners, however, blame the state terming that the process of acquiring health insurance cover is hindered by the strict administrative bottlenecks that the government has put in place (Palfrey 92).

Time is another barrier that limits service delivery. Pediatricians have developed ways that can help reduce the time spent on asking questions. Clinicians are encouraged to ask open-ended questions, which patients quickly understand. It will as well help organize the doctor’s schedule (Palfrey 98).

Children have the right to play. Research done in the US warns that children who are not playful are likely to suffer physical fitness in the future. The United Nations Convention on the Right of the Child entitles children with the right to engage in recreational activities and play (Forbes 45).

Accident is another significant risk to children’s health. According to the report published by Royal Society for the Prevention of Accidents, over one million children below the age of 15 are involved in various accidents yearly. Although it warned that most of the accidents happened in the living room, it was alleged that fatal injuries occured in the kitchen. The figure of children hurt in the kitchens estimated at 67000 yearly ( Accident to Children ). Safety agencies in various states offer education for both drivers and the students. The measure aims at inculcating road safety measure and the importance of observing road signs. For instance, in the city of Osage, Kansas, the Ministry of Transportation supports driver’s safety event for secondary students. Local police stations in Cambridge, Massachusetts, inspect car seats free of costs. Sinai Hospital in Chicago donates infant car seat to every mother who has attended the facility more than two times (Palfrey 110).

Coordination, accessibility, family centeredness, compassionate delivery and culturally active understanding are the fundamental pillars of change. Clinical Advocacy Principal lobbies for child’s well-being by embracing the above pillars (Palfrey 118).

Works Cited

“Accidents to Children.” RoSPA Home Safety RSS . Web. 2015.

“ADA National Network.” Welcome to the Americans With Disabilities Act National Network . Web. 2015.

Forbes, Ruth. Beginning to Play Young Children from Birth to Three , Buckingham: Open University Press, 2004. Print.

Gannon, Frank. “Language Barriers.” EMBO Reports . Web. 2015.

Palfrey, Judith. Child Health in America Making a Difference through Advocacy . Baltimore: Johns Hopkins UP, 2006. Print.

“Reduce Child Mortality.” Millennium Development Goal 4 .Web. 2015.

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• Chicago (A-D)
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IvyPanda. (2022, April 11). Child Healthcare: Importance and Challenges. https://ivypanda.com/essays/child-healthcare-importance-and-challenges/

"Child Healthcare: Importance and Challenges." IvyPanda , 11 Apr. 2022, ivypanda.com/essays/child-healthcare-importance-and-challenges/.

IvyPanda . (2022) 'Child Healthcare: Importance and Challenges'. 11 April.

IvyPanda . 2022. "Child Healthcare: Importance and Challenges." April 11, 2022. https://ivypanda.com/essays/child-healthcare-importance-and-challenges/.

1. IvyPanda . "Child Healthcare: Importance and Challenges." April 11, 2022. https://ivypanda.com/essays/child-healthcare-importance-and-challenges/.

Bibliography

IvyPanda . "Child Healthcare: Importance and Challenges." April 11, 2022. https://ivypanda.com/essays/child-healthcare-importance-and-challenges/.

Mental health effects of poverty, hunger, and homelessness on children and teens

Rising inflation and an uncertain economy are deeply affecting the lives of millions of Americans, particularly those living in low-income communities. It may seem impossible for a family of four to survive on just over $27,000 per year or a single person on just over $15,000, but that’s what millions of people do everyday in the United States. Approximately 37.9 million Americans, or just under 12%, now live in poverty, according to the U.S. Census Bureau .

Additional data from the Bureau show that children are more likely to experience poverty than people over the age of 18. Approximately one in six kids, 16% of all children, live in families with incomes below the official poverty line.

Those who are poor face challenges beyond a lack of resources. They also experience mental and physical issues at a much higher rate than those living above the poverty line. Read on for a summary of the myriad effects of poverty, homelessness, and hunger on children and youth. And for more information on APA’s work on issues surrounding socioeconomic status, please see the Office of Socioeconomic Status .

Who is most affected?

Poverty rates are disproportionately higher among most non-White populations. Compared to 8.2% of White Americans living in poverty, 26.8% of American Indian and Alaska Natives, 19.5% of Blacks, 17% of Hispanics and 8.1% of Asians are currently living in poverty.

Similarly, Black, Hispanic, and Indigenous children are overrepresented among children living below the poverty line. More specifically, 35.5% of Black people living in poverty in the U.S. are below the age of 18. In addition, 40.7% of Hispanic people living below the poverty line in the U.S. are younger than age 18, and 29.1% of American Indian and Native American children lived in poverty in 2018. In contrast, approximately 21% of White people living in poverty in the U.S. are less than 18 years old.

Furthermore, families with a female head of household are more than twice as likely to live in poverty compared to families with a male head of household. Twenty-three percent of female-headed households live in poverty compared to 11.4% of male-headed households, according to the U.S. Census Bureau .

What are the effects of poverty on children and teens?

The impact of poverty on young children is significant and long lasting. Poverty is associated with substandard housing, hunger, homelessness, inadequate childcare, unsafe neighborhoods, and under-resourced schools. In addition, low-income children are at greater risk than higher-income children for a range of cognitive, emotional, and health-related problems, including detrimental effects on executive functioning, below average academic achievement, poor social emotional functioning, developmental delays, behavioral problems, asthma, inadequate nutrition, low birth weight, and higher rates of pneumonia.

Psychological research also shows that living in poverty is associated with differences in structural and functional brain development in children and adolescents in areas related to cognitive processes that are critical for learning, communication, and academic achievement, including social emotional processing, memory, language, and executive functioning.

Children and families living in poverty often attend under-resourced, overcrowded schools that lack educational opportunities, books, supplies, and appropriate technology due to local funding policies. In addition, families living below the poverty line often live in school districts without adequate equal learning experiences for both gifted and special needs students with learning differences and where high school dropout rates are high .

What are the effects of hunger on children and teens?

One in eight U.S. households with children, approximately 12.5%, could not buy enough food for their families in 2021 , considerably higher than the rate for households without children (9.4%). Black (19.8%) and Latinx (16.25%) households are disproportionately impacted by food insecurity, with food insecurity rates in 2021 triple and double the rate of White households (7%), respectively.

Research has found that hunger and undernutrition can have a host of negative effects on child development. For example, maternal undernutrition during pregnancy increases the risk of negative birth outcomes, including premature birth, low birth weight, smaller head size, and lower brain weight. In addition, children experiencing hunger are at least twice as likely to report being in fair or poor health and at least 1.4 times more likely to have asthma, compared to food-secure children.

The first three years of a child’s life are a period of rapid brain development. Too little energy, protein and nutrients during this sensitive period can lead to lasting deficits in cognitive, social and emotional development . School-age children who experience severe hunger are at increased risk for poor mental health and lower academic performance , and often lag behind their peers in social and emotional skills .

What are the effects of homelessness on children and teens?

Approximately 1.2 million public school students experienced homelessness during the 2019-2020 school year, according to the National Center for Homeless Education (PDF, 1.4MB) . The report also found that students of color experienced homelessness at higher proportions than expected based on the overall number of students. Hispanic and Latino students accounted for 28% of the overall student body but 38% of students experiencing homelessness, while Black students accounted for 15% of the overall student body but 27% of students experiencing homelessness. While White students accounted for 46% of all students enrolled in public schools, they represented 26% of students experiencing homelessness.

Homelessness can have a tremendous impact on children, from their education, physical and mental health, sense of safety, and overall development. Children experiencing homelessness frequently need to worry about where they will live, their pets, their belongings, and other family members. In addition, homeless children are less likely to have adequate access to medical and dental care, and may be affected by a variety of health challenges due to inadequate nutrition and access to food, education interruptions, trauma, and disruption in family dynamics.

In terms of academic achievement, students experiencing homelessness are more than twice as likely to be chronically absent than non-homeless students , with greater rates among Black and Native American or Alaska Native students. They are also more likely to change schools multiple times and to be suspended—especially students of color.

Further, research shows that students reporting homelessness have higher rates of victimization, including increased odds of being sexually and physically victimized, and bullied. Student homelessness correlates with other problems, even when controlling for other risks. They experienced significantly greater odds of suicidality, substance abuse, alcohol abuse, risky sexual behavior, and poor grades in school.

What can you do to help children and families experiencing poverty, hunger, and homelessness?

There are many ways that you can help fight poverty in America. You can:

• Volunteer your time with charities and organizations that provide assistance to low-income and homeless children and families.
• Donate money, food, and clothing to homeless shelters and other charities in your community.
• Donate school supplies and books to underresourced schools in your area.
• Improve access to physical, mental, and behavioral health care for low-income Americans by eliminating barriers such as limitations in health care coverage.
• Create a “safety net” for children and families that provides real protection against the harmful effects of economic insecurity.
• Increase the minimum wage, affordable housing and job skills training for low-income and homeless Americans.
• Intervene in early childhood to support the health and educational development of low-income children.
• Provide support for low-income and food insecure children such as Head Start , the National School Lunch Program , and Temporary Assistance for Needy Families (TANF) .
• Increase resources for public education and access to higher education.
• Support research on poverty and its relationship to health, education, and well-being.
• Resolution on Poverty and SES
• Pathways for addressing deep poverty
• APA Deep Poverty Initiative

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CREDITS DIRECTED BYJonathan Olinger, Michael Trainer SERIES CREATIVE DIRECTOR Michael Trainer WRITERS Lindsay Branham NARRATED BY Rachel Brosnahan PRODUCED BY DTJ (www.dtj.org) PRODUCER Lindsay Branham EXECUTIVE PRODUCER Michael Trainer CINEMATOGRAPHY Jonathan Olinger, Ricky Norris ORIGINAL SCORE Ryan O'Neal ASSOCIATE PRODUCER Adam Butterfield LEAD EDITOR Jonathan Olinger EDITOR Austin Peck VISUAL EFFECTS Dan DiFelice MOTION GRAPHICS Dan Johnson COLOR Matt Fezz SOUND DESIGN Ben Lukas Boysen SOUND MIX Charles de Montebello, CDM Studios, NYC ADDITIONAL FOOTAGE BY UNICEF, DTJ, We Rise VOICE OVER RECORDING CDM Studios, NYC VERY SPECIAL THANKS TO: Jane Rosenthal, Nancy Lefkowitz

Defeat Poverty

Introduction to child health

Oct. 18, 2012

• Open access
• Published: 14 February 2022

The health consequences of child marriage: a systematic review of the evidence

• Suiqiong Fan 1 &
• Alissa Koski 1 , 2  

BMC Public Health volume  22 , Article number:  309 ( 2022 ) Cite this article

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Child marriage, defined as marriage before 18 years of age, is a violation of human rights and a marker of gender inequality. Growing attention to this issue on the global development agenda also reflects concerns that it may negatively impact health. We conducted a systematic review to synthesize existing research on the consequences of child marriage on health and to assess the risk of bias in this body of literature.

Methods and findings

We searched databases focused on biomedicine and global health for studies that estimated the effect of marrying before the age of 18 on any physical or mental health outcome or health behaviour. We identified 58 eligible articles, nearly all of which relied on cross-sectional data sources from sub-Saharan Africa or South Asia. The most studied health outcomes were indicators of fertility and fertility control, maternal health care, and intimate partner violence. All studies were at serious to critical risk of bias. Research consistently found that women who marry before the age of 18 begin having children at earlier ages and give birth to a larger number of children when compared to those who marry at 18 or later, but whether these outcomes were desired was not considered. Across studies, women who married as children were also consistently less likely to give birth in health care facilities or with assistance from skilled providers. Studies also uniformly concluded that child marriage increases the likelihood of experiencing physical violence from an intimate partner. However, research in many other domains, including use of contraception, unwanted pregnancy, and sexual violence came to divergent conclusions and challenge some common narratives regarding child marriage.

Conclusions

There are many reasons to be concerned about child marriage. However, evidence that child marriage causes the health outcomes described in this review is severely limited. There is more heterogeneity in the results of these studies than is often recognized. For these reasons, greater caution is warranted when discussing the potential impact of child marriage on health. We provide suggestions for avoiding common biases and improving the strength of the evidence on this subject.

Trial registration

The protocol of this systematic review was registered with PROSPERO (CRD42020182652) in May 2020.

Peer Review reports

Introduction

Marriage before the age of 18, often referred to as child marriage, is a violation of human rights that hinders educational attainment and literacy and may increase the likelihood of living in poverty in adulthood [ 1 , 2 , 3 , 4 , 5 ]. Girls are far more likely to marry than boys, and these consequences contribute to existing gender gaps in educational outcomes in some settings [ 6 , 7 ]. The United Nations Sustainable Development Goals list child marriage as an indicator of gender inequality and call for an end to the practice by the year 2030 [ 8 ]. Child marriage remains ongoing throughout much of the world despite intensifying efforts to eliminate it [ 9 ].

In addition to its consequences on education, growing attention to child marriage as a global development issue also seems to reflect increasing consideration of its potential impacts on population health. Multinational organizations including the World Bank, the United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF) include the potential for harmful consequences on health among the foremost concerns regarding this practice [ 2 , 10 , 11 , 12 , 13 ]. These organizations highlight relationships between child marriage and early childbearing [ 11 , 12 , 13 ], obstetric complications [ 12 , 13 ], violence [ 2 , 12 ], and sexually transmitted infections [ 12 ], among other adverse outcomes.

We undertook this systematic review to synthesize the results of existing research regarding the impact of child marriage on the health of persons who marry before the age of 18. We evaluated the range of health outcomes that have been studied and the geographic distribution of those studies. We also assessed the risk of bias in individual studies and the likelihood that their results reflect causal relationships.

We searched three databases for literature on the relationship between child marriage and health: MEDLINE, Embase, and Ovid Global Health. These databases were chosen because they focus on biomedicine and human health. We aimed to include as broad a range of health outcomes as possible and focusing our search within these databases allowed us to avoid defining specific health outcomes within our search terms. Instead, we searched for studies of child marriage within these databases. This approach made our search terms more concise and the range of outcomes more inclusive. Specific search terms used for each database are included in Supplementary File 1 . We registered our protocol with PROSPERO (CRD42020182652) in May 2020 and conducted our database searches shortly afterward.

We also searched Google Scholar to identify relevant grey literature. Haddaway et al. [ 14 ] found that the majority of grey literature tends to appear within the first 200 citations returned by Google Scholar and recommend focusing on the first 200-300 records. We followed this recommendation and evaluated the first 300 records returned, as sorted by relevance. Search terms used in Google Scholar are also included in Supplementary File 1 . We reviewed the bibliographies of all included studies in an effort to identify any relevant citations not picked up through searches of the databases described above. The search strategy was developed with assistance from a research librarian at McGill University.

Citations returned from searches of all four databases were imported into EndNote X9 and duplicate citations removed [ 15 ]. We transferred all unique citations into Rayyan to facilitate the review process [ 16 ]. A single reviewer (SF) examined the title and abstract of each unique citation for eligibility according to pre-defined criteria specified in the registered protocol. Articles were brought forward for full-text review if they described etiologic studies that used quantitative methods to estimate the effect of child marriage on one or more health outcomes. We defined child marriage as formal or informal union prior to the age of 18. If the title and abstract did not specify the age thresholds used to define child marriage, they were brought forward for full-text review. For example, abstracts that referred to the effect of adolescent or teen marriage without explicitly stating how those exposures were defined were brought forward. Eligible health outcomes included physical or mental health disorders or symptoms of those disorders, as well as health behaviours. Eligible health behaviours included actions like smoking or dietary habits as well as health care seeking, such as prenatal care. We restricted our review to studies in which outcomes were measured at the individual level and to those that measured the effect of child marriage on the individuals married; studies that examined the effect of age at marriage on the offspring of the persons who married were excluded. Studies written in English, French or Chinese were eligible for inclusion.

We excluded studies that used solely qualitative methods and quantitative studies that relied exclusively on hypothesis testing to indicate differences between groups. For example, studies that used chi-squared tests to indicate whether the distribution of some characteristic differed between persons married before the age of 18 and those married at older ages were excluded, even if the authors seemed to interpret their results as causal, because such testing does not result in a comparative effect measure (e.g., a risk difference or an odds ratio) and does not account for potential biases. We also excluded studies in which persons who married before the age of 18 were incorporated into a larger aggregate age category, making the effect of child marriage unidentifiable. For example, comparisons of outcomes among persons who married between 15 and 19 years of age with those who married between 20 and 24 years of age were not eligible for inclusion. Conference presentations and abstracts were also excluded.

Both authors read the full text of each article brought forward from the title and abstract review and independently judged their eligibility according to the inclusion and exclusion criteria described above. Discrepancies were resolved through discussion. The following information was extracted from each included study: authors, title, year of publication, the language of publication, country/region in which the study was conducted, study design, study population, sample size, data sources, statistical methods, outcomes, and results.

Risk of bias assessment

We assessed the risk of bias within each included study using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool developed by members of the Cochrane Bias Methods Group and the Cochrane Non-Randomised Studies Methods Group [ 17 ]. ROBINS-I is designed to evaluate the risk of bias in non-randomized studies by considering how closely the study’s design and methods approximate an ideal randomized trial. To illustrate, in a hypothetical cluster-randomized trial to estimate the causal effect of child marriage on a specified health outcome, the treatment or intervention would be marriage before the age of 18 years. All children in a specific area (a region, a state, a community, etc.) would be randomized at a very young age to one of two treatment groups: those randomized to the intervention would marry at some point prior to their 18th birthdays (a = 1), while those randomized to the control group would marry on their 18th birthday or any later age (a = 0). All children would then be followed up over a period of time sufficient to observe the specified outcome of interest. In the ideal randomized trial, all persons would adhere to their assigned treatment (i.e., remain married) and would remain in the study until follow-up was complete. After the follow-up period, the probability of the outcome among those assigned to a = 1 would be compared with the same probability among those assigned to a = 0. Under these conditions, we could expect that there would be no differences between those children who married before the age of 18 and those who married afterward aside from age at marriage. As a result, if the probability of the outcome among those randomly assigned to marry as children differed from the probability among those randomly assigned to marry after their 18th birthdays, one could interpret that difference as the causal effect of child marriage [ 18 ].

Of course, a randomized trial like this would be unethical and could never actually be conducted. Researchers interested in the effects of child marriage on health must rely on non-randomized study designs to estimate the causal effect of interest. Without the benefit of randomization, it becomes challenging to identify the causal effect of child marriage because those who marry as children are different from those who marry at later ages in many ways. For example, girls who marry before the age of 18 come from poorer households and from communities with greater gender inequality, on average, compared to those who marry at later ages. These differences are likely to affect their health through causal pathways other than age at marriage, such as the experience of violence or limited ability to access education or health care. This means that a naïve comparison of health outcomes between those who marry as children and those who marry as adults is likely to mix up the consequences of age at marriage with the consequences of childhood poverty and gender inequality.

The ROBINS-I tool requires assessors to carefully consider the potential for multiple sources of bias including confounding, inappropriate selection of participants into the study (i.e., selection bias), mishandling of missing data, and problems with the measurement of exposures and outcomes (i.e., information bias). The potential for bias in each domain is assessed through a series of signaling questions and a summary judgement of low, moderate, serious, or critical risk of bias is then made within each domain. A cross-domain judgement of the risk of bias for the entire study is made based on the risk within each individual domain. Both authors independently assessed the risk of bias in each included study. Disagreements in any single domain or across domains were resolved by discussion.

We identified a set of variables likely to confound estimates of the effect of child marriage on a wide range of health outcomes in advance to facilitate assessment of bias in this domain. These variables and their relationships to child marriage and health, broadly defined, are illustrated in the simplified Directed Acyclic Graph (DAG) in Fig.  1 . The prevalence of child marriage has fallen over time in many countries, which means that the likelihood of marrying before the age of 18 differs across birth cohorts [ 6 , 19 ]. As discussed above, childhood socioeconomic conditions and gender inequality may lead to child marriage. They may also influence health later in life through a variety of causal pathways. We also considered spousal characteristics a source of confounding because the presence of an available spouse may drive child marriage. For example, a potential husband willing to pay a bride price for a young wife may motivate a family to marry a girl child. The same characteristics of the spouse that may motivate the marriage, such as his age, wealth, and attitudes regarding gender equity, may influence the married child’s health later in life through mechanisms like controlling behaviour. In studies that use pooled data from across multiple regions or countries, it is also important to control for confounding by country/regional-level variables that affect both the probability of child marriage and health. The DAG also illustrates our assumption that the effects of child marriage on health are often mediated through educational attainment and socioeconomic conditions after marriage.

Directed acyclic graph illustrating assumed causal relationships between child marriage and a wide range of health outcomes

We synthesized results narratively. Included studies considered a wide range of health outcomes, as intended given our search strategy. We found it most intuitive and pragmatic to synthesize results within broad outcome categories, such as the effects of child marriage on contraceptive use, on maternal health care, and on mental health. These categories emerged from the data and were not pre-specified. Meta-analyses were not conducted because the studies examined a wide range of health outcomes that were measured in different ways. The serious risk of bias in all included studies, discussed below, also made quantitative synthesis inappropriate.

Our search strategy returned a total of 2767 unique records from MEDLINE, Embase, Ovid Global Health and Google Scholar, as shown in Fig.  2 . After title and abstracting screening, the full text of 126 articles was reviewed. Fifty-six of these studies met our inclusion criteria and two additional eligible studies were identified through citation tracking, for a total of 58 included articles.

PRISMA flow diagram illustrating the process used to identify eligible studies

Selected characteristics of all 58 studies included in our review are presented in Table  1 . These studies were published between 1989 and 2020 but the vast majority ( n  = 55, 95%) were published in 2010 or later and more than half ( n  = 31, 53%) were published between 2016 and 2020, which reflects the relatively recent rise of child marriage on global health and development agendas. Included studies were based in 70 countries across the globe, as illustrated in Fig.  3 . Nearly all studies, 57 of 58, were based in low- and middle-income countries according to World Bank classifications [ 20 ]; the single exception was a study based in the United States [ 21 ]. The geographic distribution of studies included in our review was heavily focused in South Asia ( n  = 30, 52%) and Sub-Saharan Africa ( n  = 27, 47%), which is perhaps unsurprising given that countries in these regions have some of the highest rates of child marriage in the world [ 9 ]. However, more than half of the studies included in our review were based in just three countries: India ( n  = 13), Bangladesh ( n  = 8) and Ethiopia ( n  = 11). Studies from regions other than South Asia or Sub-Saharan Africa were nearly all included in a handful of studies that analyzed survey data from multiple countries simultaneously [ 22 , 23 , 24 ].

Nearly all included studies, 55 of 58 (95%), were based on the analysis of cross-sectional survey data. More than half ( n  = 34, 59%) relied on data from a single source, the Demographic and Health Surveys (DHS), or their precursor, the World Fertility Surveys (WFS).

Geographic distribution of included studies

Bias assessment

All studies included in our review were determined to be at serious or critical risk of bias based on assessment using ROBINS-I. The summary risk of bias assessment for each study is listed in Table  1 ; risk of bias within each ROBINS-I domain in each study is detailed in Supplementary File 2 . Confounding was the most prevalent concern. Every study was deemed to be at serious to critical risk of bias in this domain, most often because of failure to account for important sources of confounding and inappropriate adjustment for variables affected by age at marriage that are on the causal pathway. Cross-sectional surveys like the DHS often do not collect information necessary to control for confounding. Failure to control for major sources of confounding like childhood poverty and gender inequality may result in overestimation of the harmful effects of child marriage. The second common source of bias was adjustment for variables measured after marriage that are likely on the causal pathway between age at marriage and the health outcomes being studied. To illustrate, the authors of many studies included in this review acknowledged that age at marriage may dictate how long a girl stays in school and that her educational attainment may subsequently influence a wide range of health outcomes. Unfortunately, they then adjusted for educational attainment in regression analyses. This will very likely result in biased estimates because educational attainment was measured after marriage and is more likely to be a mediator than a confounder (Fig.  1 ) [ 79 , 80 ]. Adjusting for it may remove some of the effect of child marriage on health and lead to underestimates of effect. Given that these two issues may bias results in different directions, predicting the net direction of confounding within studies is challenging. Other sources of bias also affected many of the studies in this review, including selection and measurement biases. Few authors discussed the potential influence of bias on their estimates or their conclusions.

The health consequences of child marriage

Studies included in our review estimated the effect of child marriage on a variety of health outcomes. The most common outcomes were measures of reproductive health, such as fertility and fertility control, maternal health care utilization, intimate partner violence, mental health, and nutritional status. The following paragraphs synthesize the literature in each of these categories. In light of the serious risk of bias in all included studies, we interpreted these results with a high degree of caution. We assessed the direction of effect measures, meaning whether the study found that child marriage increased or decreased the probability of experiencing the outcome, and the consistency of directionality across studies within each outcome category. We also assessed the precision of effect measures by evaluating the width of confidence intervals surrounding those measures. We did not interpret the magnitude of the effect estimates from individual studies due to the risk of bias.

The effect of child marriage on the number and timing of births

Eleven studies estimated the effect of child marriage on the number of children born, though this outcome was not consistently measured. Some studies estimated the effect of child marriage on the odds of having given birth to any children [ 34 , 50 , 63 ], the odds of having three or more children [ 24 , 46 , 50 , 63 , 75 ], four or more children [ 34 ], five or more children [ 37 , 69 ], or a continuous measure of the total number of children ever born [ 24 , 25 , 30 , 46 , 54 ]. The age ranges of the people included in these studies also differed, leading to variation in the time frame over which these births could have occurred. Child marriage was correlated with higher fertility in nearly all studies regardless of how the outcome was defined. The only exception was a study from Ethiopia that found no effect [ 30 ]. Ten of these studies focused on fertility exclusively among women. Misunas et al. [ 24 ] focused on men and came to similar conclusions: child marriage increased the odds that men aged 20-29 had fathered three or more children and increased the average number of children fathered by the ages of 40-49 [ 24 ].

A second commonly examined outcome was the likelihood of giving birth within the first year of marriage. Four studies based on data from South Asia [ 39 , 46 , 50 , 63 ] and one study based on pooled data from multiple countries in Africa [ 75 ] examined this outcome. Three of these studies [ 46 , 50 , 75 ] reported that marriage before the age of 18 decreased the odds of giving birth within the first year of marriage. The remaining two [ 39 , 63 ] did not find any evidence of a relationship between child marriage and this outcome.

We also identified five studies that estimated the effect of child marriage on the likelihood of giving birth before a specified age, often referred to as early, teen, or adolescent pregnancy [ 23 , 26 , 31 , 32 , 34 ]. Three of these studies found that child marriage increased the odds of giving birth before the age of 20 [ 26 , 31 , 32 ], the other two reported that child marriage increased the odds of giving birth before the age of 18 [ 23 , 34 ]. Two studies also estimated the effect of child marriage on mean age at first birth and found that those who married before the age of 18 gave birth for the first time at younger ages, on average, than those who married at older ages [ 32 , 46 ].

Collectively, this evidence indicates that women who marry as children often begin having children of their own at earlier ages when compared to their peers who marry after their 18th birthdays, and that they tend to have a larger number of children over their lifetimes. This is not surprising, given that marriage changes sexual behavior in ways that increase the risk of pregnancy. Essentially, girls who marry at earlier ages spend a longer time at risk of pregnancy than those who marry later.

The effect of child marriage on birth intervals

The World Health Organization recommends an interval of at least 24 months between a live birth and a subsequent pregnancy to reduce the risk of poor maternal health outcomes [ 81 ]. Five studies included in our review estimated the effect of child marriage on the likelihood of repeated childbirths in less than two years [ 39 , 50 , 62 , 63 , 75 ]. All five used samples of women between the ages of 20 and 24 who were included in DHS. A sixth study based on a small cross-sectional sample of women aged 15-49 from Ethiopia estimated the effect on repeated childbirth in less than three years [ 27 ]. These studies came to different conclusions. Two studies by the same author reported that child marriage increased the odds of repeated childbirth within two years in India [ 62 , 63 ] but another study based on the same data source found that women who married as children were less likely to have two births within a two-year period than those who married at older ages [ 39 ]. There were also differences in the results of research from Pakistan: one study reported that child marriage made it more likely that women would have two births within two years [ 50 ] while another found no evidence that child marriage influenced this outcome [ 39 ]. Child marriage protected against short birth intervals in Nepal [ 39 ] and in an analysis of data from 34 African countries [ 75 ]. There was no evidence that child marriage influence the likelihood of short birth intervals in Bangladesh [ 39 ].

These results, which range from harmful to protective effects, indicate that child marriage is not clearly or consistently correlated with short birth intervals.

Child marriage, unwanted or mistimed pregnancy, and pregnancy termination

Seven studies estimated the effect of child marriage on the likelihood of experiencing a mistimed or unwanted pregnancy [ 39 , 46 , 47 , 50 , 62 , 63 , 75 ]. All seven were based on analyses of DHS data. The DHS typically asks women whether pregnancies were wanted at the time they occurred, wanted later (i.e., mistimed), or not wanted. Interestingly, six of the seven studies that examined this outcome reduced these categorical responses into a binary measure: women were categorized as having an unwanted pregnancy if they reported that they had a mistimed pregnancy or if they became pregnant when they did not want any more children [ 39 , 46 , 50 , 62 , 63 , 75 ]. The rationale for doing this was not explained in any of the studies. The remaining study [ 47 ] only categorized instances in which a woman became pregnant at a time when she did not want any more children as unwanted.

Estimates of the effect of child marriage on this outcome are mixed. A study from 34 countries in Africa reported that child marriage protected against mistimed/unwanted pregnancies [ 75 ]. Studies from India, Pakistan, and Nepal concluded that child marriage increased the odds of experiencing mistimed/unwanted pregnancy [ 39 , 50 ]. Three studies from Bangladesh came to different conclusions. One found no relationship between child marriage and this outcome [ 39 ] while another reported that child marriage increased the odds of mistimed/unwanted pregnancy [ 46 ]. The third used a different definition of the outcome and found that marriage before the age of 15 was positively associated with unwanted pregnancy (mistimed pregnancies were treated as wanted) but no evidence that marriage between the ages of 15 and 17 affected the likelihood of unwanted pregnancy [ 47 ].

Three of these studies also estimated the effect of child marriage on the likelihood of experiencing two or more mistimed or unwanted pregnancies [ 39 , 62 , 63 ]. Godha et al. reported a large effect of child marriage on having multiple mistimed/unwanted pregnancies in India, Bangladesh, and Pakistan but results were inconclusive in Nepal [ 39 ]. Two studies by the same author reported that child marriage increased the odds of having multiple mistimed/unwanted pregnancies in India [ 62 , 63 ].

We identified eight studies of the effect of child marriage on pregnancy outcomes [ 39 , 47 , 48 , 50 , 57 , 63 , 66 , 75 ]. Six of these relied on the DHS, which typically asks female respondents, “Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?” [ 82 ]. The wording of this question makes it impossible to examine these outcomes separately. As a result, most studies based on the DHS used a composite outcome that grouped these three events despite differences in their intendedness. Five studies based on the DHS concluded that child marriage increased the odds of having a pregnancy end in either miscarriage, abortion, or stillbirth [ 39 , 48 , 50 , 63 , 75 ]. Exceptionally, the 2007 Bangladesh DHS asked a yes or no question regarding whether a woman had ever terminated a pregnancy. Using responses to this question, Kamal reported that marriage before the age of 15 was correlated with higher odds of termination but no evidence that marriage between 15 and 17 years of age influenced this outcome [ 47 ].

Two studies from India used other cross-sectional data sources and defined their outcomes differently. Santhya et al. used a combined outcome of miscarriage and stillbirth and found that child marriage increased the likelihood of experiencing either of these birth outcomes. [ 66 ]. Paul considered stillbirth and miscarriage separately. Marriage before the age of 15 increased the odds of stillbirth and miscarriage, but marriage between the ages of 15-17 was no less risky in this regard than marriage at 18 or later [ 57 ].

Child marriage and contraceptive use

Fifteen of the studies included in our review estimated the effect of child marriage on various aspects of contraceptive use [ 23 , 24 , 32 , 39 , 40 , 41 , 43 , 46 , 53 , 56 , 62 , 63 , 65 , 66 , 75 ]. All were based on cross-sectional data and thirteen used data from the DHS.

Of these fifteen studies, eight estimated the effect of child marriage on the likelihood that women were using contraception at the time the surveys were conducted [ 32 , 39 , 40 , 46 , 53 , 62 , 63 , 65 ]. As with other outcomes, results were mixed. Child marriage reportedly increased the likelihood of using modern contraception in India and Bangladesh [ 39 ]. Results from Pakistan and Nepal indicate that the same may be true in those countries but the estimates were imprecise [ 39 ]. A second study from Nepal concluded that child marriage led to lower odds of using modern contraception [ 65 ]. The two studies from Nepal used different samples of women, which may partially explain the differences in their results. A study based on pooled data from 18 African countries found that child marriage was correlated with a lower likelihood of using modern contraception [ 53 ]. However, results varied markedly between countries and across geographic regions; in some, child marriage appeared to increase the likelihood of using modern contraception [ 53 ]. In Ghana, de Groot et al. found that child marriage was not correlated with the odds of using any form of contraception or with the use of modern contraceptives [ 32 ].

Two other studies investigated the effect of child marriage on the use of any method of contraception, including those not classified as modern [ 40 , 46 ]. Marriage prior to the age of 15 led to lower odds of contraceptive use in Rwanda, but there was no indication that those who married between 15 and 17 years of age were any more or less likely to use contraception than those who married at older ages [ 40 ]. In Bangladesh, women who married as children were more likely to be using some form of contraception at the time of the survey than those who married at the age of 18 or older [ 46 ]. In yet another iteration of this outcome, Yaya [ 75 ] reported that women who married as children were more likely to have ever used modern contraception. A single study estimated the effect of child marriage among men on the likelihood that they were using modern contraception [ 24 ]. In five of ten countries studied, child marriage was not related to modern contraceptive use. In two (Honduras and Nepal), child marriage seemed to slightly increase the odds of contraceptive use, but it decreased the likelihood in Madagascar [ 24 ].

A second outcome that has received particular focus is whether a woman used contraception before her first pregnancy. All four studies that examined the effect of child marriage on this outcome were based on data from South Asia [ 39 , 56 , 63 , 66 ] and concluded that marrying as a child decreased the likelihood that a woman used contraception prior to her first pregnancy [ 39 , 56 , 63 , 66 ]. The authors of these studies frequently interpreted their results as an indicator of uncontrolled fertility that may place girls and their children at risk of poor health outcomes [ 39 , 56 , 63 ]. However, this relationship is more challenging to interpret because the outcome variables used did not capture whether pregnancies were desired shortly after marriage or the outcomes of those pregnancies.

Four studies estimated the impact of child marriage on the likelihood that a woman had an unmet need for contraception [ 23 , 32 , 41 , 43 ]. This outcome was conceptually defined as a woman who is sexually active but not using contraception and who reports a desire to delay the next birth (a need for spacing), have no more births (a need for limiting), or a combination of the two. Once again, conclusions differ between studies. Using pooled DHS data from 47 countries, Kidman and Heymann found that marrying as a child increased the likelihood that women had an unmet need for contraception to either space or limit births [ 23 ]. An analysis of DHS data from Ethiopia found that women who married as children were less likely to have an unmet need for spacing and less likely to have an unmet need for limiting births compared to women who married at older ages [ 41 ]. In Zambia, child marriage was correlated with a greater unmet need for spacing and for limiting [ 43 ]. In Ghana, de Groot et al. found that child marriage was not correlated with an unmet need for limiting [ 32 ]. These studies all used different samples, which may partially explain the differences in their results.

Child marriage and use of maternal health care

Nine of the studies included in our review estimated the effect of child marriage on the use of health care during pregnancy, at the time of delivery, and during the post-partum period, which we collectively refer to as maternal health care [ 33 , 39 , 49 , 53 , 58 , 62 , 66 , 67 , 74 ].

Studies of prenatal care defined their outcomes as the receipt of at least one prenatal checkup [ 49 , 62 ], the receipt of four or more prenatal checkups [ 49 , 58 , 67 ], or a count of the total number of prenatal checkups received [ 39 , 53 ]. Once again, results within countries come to different conclusions. In Nepal, one study found that women who married as children were less likely to receive four or more prenatal checkups [ 67 ] while another found no evidence that child marriage influenced this outcome [ 39 ]. A study from India found no indication that child marriage affected prenatal care [ 39 ] but two others concluded that child marriage decreased the likelihood of receiving at least one checkup and of receiving at least four checkups [ 58 , 62 ]. In one study from Pakistan, women who married as children were less likely to receive any prenatal care than those who married at older ages, but there was no difference in the likelihood of receiving four or more checkups [ 49 ]. A separate study from the same country reported that child marriage had no effect on the number of prenatal care checkups [ 39 ]. The effect of child marriage on the number of prenatal care visits varied between geographic regions in Africa. In some, child marriage appeared correlated with a decrease the number of visits while in others there was no effect [ 53 ].

Compared to other outcomes, the results of studies that estimated the impact of child marriage on the likelihood of delivering in a health care facility were remarkably consistent. Across geographic locations, all seven studies that examined this outcome concluded that child marriage reduced the likelihood of delivery in a health care facility [ 39 , 49 , 53 , 58 , 66 , 67 , 74 ]. Six of the same studies also found that women who married as children were less likely to have a skilled health care provider present during delivery [ 39 , 49 , 53 , 58 , 67 , 74 ].

Only two studies considered post-natal care [ 58 , 67 ]. One reported that child marriage led to lower likelihood of a post-natal checkup within 42 days of delivery in India [ 66 ] while the other found a lower likelihood of a checkup within 24 h of delivery in Nepal [ 75 ].

Child marriage and intimate partner violence

Sixteen studies estimated the effect of child marriage on the likelihood of experiencing intimate partner violence [ 22 , 23 , 29 , 35 , 38 , 42 , 51 , 53 , 55 , 60 , 62 , 64 , 66 , 70 , 71 , 77 ]. Fifteen of these studies were based on cross-sectional data [ 22 , 23 , 29 , 35 , 38 , 42 , 51 , 53 , 55 , 60 , 62 , 64 , 66 , 70 , 71 ] and eight (50%) were based on the DHS [ 22 , 23 , 51 , 53 , 60 , 62 , 64 , 70 ]. The DHS measures intimate partner violence by asking female respondents a series of questions regarding their experience of specific acts. For example, physical violence is assessed by asking women whether they have been slapped, kicked, or pushed, among other actions. Sexual violence is assessed by asking whether the respondent’s husband has forced her to have sex or perform sex acts when she did not want to. Emotional violence is measured by asking whether her spouse has humiliated or threatened her [ 83 ]. Studies based on data from sources other than the DHS tended to use the same or very similar questions to measure the experience of violence.

Physical violence was the most frequently examined outcome but was measured over different time frames across studies. Some estimated the likelihood of ever having experienced physical violence from a husband or partner while others considered only the year prior to the survey. Still, others focused on the 3 months prior to the survey [ 35 ], the 9 months between survey waves [ 77 ], or during pregnancy [ 38 ]. Regardless of the time period during which violence was measured, the conclusions of these studies were fairly consistent: nearly all reported that marrying as a child increased the likelihood of experiencing physical violence [ 22 , 38 , 51 , 55 , 60 , 64 , 66 , 71 , 77 ]. A study from Ethiopia found no indication that child marriage had an effect on this outcome but it considered a relatively short time period of 3 months [ 35 ].

Estimates of the effect of child marriage on the experience of sexual violence were much less consistent. Two studies from India came to conflicting conclusions. Raj et al. found that child marriage did not increase the likelihood of experiencing sexual violence at any point or in the year prior to the 2005-06 National Family Health Survey [ 64 ]. However, a study by Santhya et al. based on survey data collected from five Indian states between 2006 and 2008 found that child marriage did increase the likelihood of ever experiencing sexual violence [ 66 ]. Studies from Bangladesh and Ghana reported that women who married as children were no more or less likely to experience sexual violence than those who married at later ages [ 60 , 71 ]. Two studies that pooled DHS data across multiple countries also found mixed results [ 22 , 53 ]. Olamijuwon used data from 18 African countries and found that child marriage increased the odds of experiencing sexual violence in Central, East, and Southern Africa, but there was no evidence of a statistical relationship in West Africa [ 53 ]. Kidman used DHS data from 34 countries across the globe and reported that child marriage seemed to increase the odds of experiencing sexual violence in the year prior to the surveys in all included geographic regions except Europe and Central Asia [ 22 ]. Erulkar found that women who married as children in Ethiopia were more likely to report that their first sexual experience was forced [ 35 ].

Only two studies, one from Pakistan and one from Ghana, considered emotional violence as a stand-alone outcome. Both concluded the child marriage led to an increase in the likelihood of ever experiencing emotional violence from an intimate partner [ 51 , 71 ].

Five studies considered only combined outcomes that mixed indicators of physical and sexual violence [ 62 , 70 ], or physical, sexual, and emotional violence [ 23 , 29 , 42 ]. All of these found that child marriage was associated with increased reporting of these composite measures of violence, but some results were sensitive to the sample used and were inconsistent across locations [ 70 ]. Hong Le et al. considered whether child marriage affected the likelihood of violence among boys but was underpowered to detect any effect [ 42 ].

Child marriage and mental health

Five of the studies included in our review estimated the effect of child marriage on various aspects of mental health. These studies relied on cross-sectional data collected from Ghana, Iran, Ethiopia, Niger and the United States [ 21 , 32 , 36 , 44 , 45 ]. Women in the United States who married before the age of 18 were more likely to report experiencing a wide range of mood, anxiety, and other psychiatric disorders in adulthood when compared to those who married at later ages [ 21 ]. The authors of a small study from a single county in Iran found that women who married as children reported more depressive symptoms than those who married at the age of 18 or older [ 36 ]. John, Edmeades, and Murithi examined the relationship between child marriage and multiple domains of psychological well-being in Niger and Ethiopia [ 44 ]. The authors found that marriage before the age of 16 was correlated with poorer overall psychological well-being, but no evidence that marriage between the ages of 16 and 17 was associated with poorer outcomes when compared to women who married at the age of 18 or later [ 44 ]. In Ghana, child marriage seemed to protect against measures of stress. The Ghanaian study also found no indication of differences in levels of social support between women who married before the age of 18 and those who married after their 18th birthdays, though these odds ratio estimates were very imprecise [ 32 ].

Child marriage and nutritional status

Six studies included in our review estimated the effect of child marriage on indicators of nutritional status [ 28 , 34 , 52 , 61 , 76 , 78 ]. Four focused exclusively on pregnant women. Two studies from Ethiopia examined the relationship between child marriage and mid-upper arm circumference (MUAC) [ 52 , 76 ]. One reported that pregnant women who married before the age of 18 were more likely to have an MUAC less than 22 cm, often interpreted as a marker of undernutrition [ 84 , 85 ], compared to those who married later on [ 52 ]. The other found that marrying before the age of 15 increased the likelihood of MUAC <22 cm but no evidence that marrying between the ages of 15 and 17 affected this outcome [ 76 ]. A third study from Ethiopia reported that child marriage led to an increase in the prevalence of Vitamin A deficiency among pregnant or recently post-partum women [ 28 ].

Two other studies focused on women who were not pregnant and used body mass index (BMI) as the indicator of nutritional status [ 34 , 78 ]. Their results diverge. Yusuf et al. found that women in Nigeria who married as children were more likely to have a BMI less than 18.5, frequently interpreted as underweight among adults. However, in a study of 35 African countries, Efevbera et al. reported that child marriage was protective against being underweight (BMI<18.5) [ 44 ]. Interestingly, the authors of these studies offered plausible explanations for effects in either direction. Efevbera et al. hypothesize that girls who marry as children may gain access to more plentiful food at an earlier age and that repeated pregnancies during adolescence might result in greater weight gain relative to those who marry at later ages [ 34 ]. In contrast, Nigatu et al. note that repeat pregnancies in quick succession may have a detrimental impact on cumulative nutritional status [ 52 ]. This suggests that the mechanisms through which age at marriage may affect subsequent nutritional status have not been thoroughly considered.

Other health consequences of child marriage

A few of the studies included in our review examined outcomes other than those discussed above. We note them briefly here. A case-control study from India reported that women diagnosed with cervical cancer were more likely to have been married before the age of 18 [ 72 ]. A large, pooled analysis of DHS data from 47 countries reported that child marriage was associated with symptoms of sexually transmitted infections [ 23 ]. A small, cross-sectional study from a single Indian state found no evidence that child marriage led to an increase in the odds of obstetric fistula [ 68 ]. A third study from India examined the effect of child marriage on the odds of experiencing at least one complication during pregnancy, delivery, or within two months after delivery [ 57 ]. Marriage before the age of 15 seemed to increase the likelihood of pregnancy complications, but there was no evidence of an effect for marriage between 15 and 17 years. Child marriage was not associated with delivery complications, but was associated with postnatal complications [ 57 ]. A study from Ghana found no indication that child marriage influenced the likelihood of self-reported poor health, of being ill in the two weeks prior to the survey, or of having a health insurance card but did report that child marriage increased the odds of having difficulty with activities of daily living, such as bending or walking [ 32 ].

Our systematic review synthesized research on the health consequences of marrying before the age of 18. Studies almost uniformly found that women who married before the age of 18 began having children of their own at earlier ages and gave birth to more children over the course of their reproductive lives when compared to those who married at the age of 18 or later. Whether these outcomes, considered alone, are harmful to health is not clear. Though there are many reasons to be concerned about adolescent childbearing, none of the studies of the effect of child marriage on the timing of births considered whether those pregnancies were planned or desired or whether they resulted in obstetric complications or maternal morbidity or mortality [ 23 , 26 , 31 , 32 , 34 , 39 , 46 , 50 , 63 , 75 ]. Similarly, having multiple births, especially at short intervals, may increase the risk of obstetric complications and subsequent morbidity or mortality. However, studies that compared the number of children born to women who married before the age of 18 with the number born to those who married at later ages also did not measure whether those pregnancies were planned or whether they led to harm [ 24 , 25 , 30 , 34 , 37 , 46 , 50 , 54 , 63 , 69 , 75 ]. Rather, studies seemed to assume that these are negative outcomes without directly measuring intentions or harms.

A separate set of studies that estimated the effect of child marriage on the experience of mistimed or unwanted pregnancies came to divergent conclusions: some found that child marriage increased the likelihood of these outcomes but others found that child marriage protected against them or had no effect. Studies of whether child marriage affected the likelihood of obstetric complications, miscarriage or stillbirth did not consider maternal age when those events occurred [ 39 , 47 , 48 , 50 , 57 , 63 , 66 , 75 ]. Moreover, the fact that child marriage corresponds with a larger number of pregnancies means that girls who married prior to the age of 18 had more opportunities to experience these events compared to those who married later; this was not discussed in any of the studies we identified.

The results of studies in other outcome domains are very mixed and challenge some common narratives regarding child marriage. To illustrate, studies included in this review came to conflicting conclusions regarding whether child marriage increases or decreases the use of modern contraception, the likelihood of giving birth within the first year of marriage, and the likelihood of repeated childbirth within two years. Conclusions regarding mistimed and unwanted pregnancies were also mixed, as noted above. Collectively, these results suggest that child marriage is not uniformly characterized by an inability to control the number or timing of births and suggests that a more cautious approach to discussions of agency within these marriages is warranted, at least regarding fertility and fertility control.

Across studies, women who married as children were less likely to give birth in a health care facility or with assistance from a skilled health care provider. These findings raise concerns about access to emergency obstetric care and subsequent birth outcomes for both mother and child. However, we found only one study that estimated the effect of child marriage on the likelihood of complications during pregnancy, delivery, and the postpartum period [ 57 ] and consideration of the consequences for the infants born was beyond the scope of this review. This statistical relationship could be confounded by lack of access due to geographic distance. Child marriage is more common in rural areas, where health care facilities and skilled health care providers may be more spread out. It may also be a function of gender inequality, which may manifest as an inability to seek care without permission. Future research should consider the potential for confounding by these and other variables and investigate whether place modifies this relationship.

Child marriage could plausibly affect many aspects of maternal and reproductive health through complex causal pathways. However, most of the studies included in our review did not discuss causal mechanisms in detail, which may have hindered their ability to identify and account for various sources of bias. More thorough consideration and discussion of these mechanisms would strengthen the theoretical underpinnings of this body of literature and help mitigate biases. For example, use of Directed Acyclic Graphs to illustrate assumed causal relationships would help to clarify the causal pathways being studied and identify sources of bias [ 86 ].

The effects of child marriage among boys have been almost entirely overlooked. Only 2 of the 58 studies included in this review considered boys or men and one of them was underpowered to generate informative estimates [ 42 ]. This intense focus on child marriage among girls reflects the gendered nature of the practice. However, a substantial proportion of boys also marry before the age of 18 in some countries [ 7 , 24 ] and further inquiry into the health consequences among boys is warranted.

The geographic distribution of research on child marriage and health is highly skewed. The focus on South Asia and sub-Saharan Africa may be justified since these regions have some of the highest rates of child marriage in the world. However, it is unclear why just three countries, India, Bangladesh, and Ethiopia, have received such focused attention while other countries in these regions have received very little. Child marriage is certainly ongoing in many other regions of the world that have received little or no research attention, including high-income countries [ 9 , 87 , 88 ].

The geographic distribution of these studies and the range of outcomes considered is clearly reflective of heavy reliance on the DHS. The DHS is appealing because it collects information on age at marriage that is comparable across settings and over time, data are readily accessible and of high quality, and samples are typically nationally representative. However, defaulting to this data source may also have restricted the range of outcomes studied. The DHS focuses primarily on reproductive health and our review included many studies of the effect of child marriage on fertility, contraceptive use, and intimate partner violence. Far less attention has been paid to other potential harms of child marriage that are not included in the surveys, such as indicators of mental health. Importantly, the DHS does not collect information on some of the strongest confounders of many relationships between child marriage and health, including childhood socioeconomic conditions and measures of gender equality. Other data sources will be necessary to increase the geographic scope of this body of research and to overcome some of the limitations inherent in the use of cross-sectional data to estimate causal effects.

All studies included in our review were at serious to critical risk of bias. Quantification of the net magnitude of different biases on the results of each study would have made the project untenable. Considering pervasive bias, we avoided interpreting the magnitude of reported estimates from individual studies and instead took only the directionality of the estimates at face value. This allowed us to assess the (in)consistency of conclusions within domains of health. However, it is entirely possible that bias could lead to a reversal of effects, i.e., estimating a positive effect when the true effect is negative or vice versa. The bias in these studies means that it is unclear whether any of the relationships described are causal.

Nearly all studies included in our review relied on cross-sectional data. There are severe limitations to using cross-sectional research designs to estimate causal effects, and more rigorous designs are needed to further our understanding of the consequences of child marriage. Quasi-experimental designs that more effectively mitigate confounding would strengthen this body of literature and have already been used to study the effect of child marriage on educational attainment and literacy. For example, Field and Ambrus and Sunder used age at menarche as an instrumental variable to study the effect of child marriage on these outcomes [ 3 , 4 ]. Encouragement trials that randomly assign exposure to interventions meant to prevent child marriage could also be used to estimate the effects of child marriage on health outcomes, though such trials are more resource intensive to conduct [ 89 ]. However, given that the DHS and other cross-sectional data sources will likely continue to be used to investigate these relationships, the use of quantitative bias analyses to examine how sensitive estimates are to various sources of bias would be an improvement [ 90 ].

There are several limitations to this systematic review. First, to capture as wide a range of health outcomes as possible, we searched databases focused on human health and biomedicine. Relevant studies from other academic disciplines such as economics and sociology may have been missed using this approach. Second, our search was conducted in English and all included studies were published in English. Eligible studies published in other languages may have been missed, which could influence our conclusions regarding the geographic distribution of research. Finally, as noted in the introduction, child marriage may have consequences beyond the domain of health. We focused our systematic review on the health consequences of child marriage in response to growing rhetoric regarding child marriage as a population health concern. Rigorous systematic reviews of the effect of child marriage on educational and economic outcomes would be a valuable addition to the literature.

Availability of data and materials

The PROSPERO protocol and the data extraction form are publicly available through the Open Science Foundation at https://osf.io/32mu7/ .

Abbreviations

Body Mass Index

Cross-Sectional

Directed Acyclic Graph

Demographic and Health Surveys

Mid-Upper Arm Circumference

Risk Of Bias In Non-randomised Studies - of Interventions tool

Socio-Economic Status

United Nations Population Fund

United Nations Children’s Fund

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Acknowledgements

We thank Genevieve Gore at the McGill University Library for her assistance in developing the search terms used in this review.

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SF and AK were responsible for the study conception and design. SF conducted database searches. SF and AK screened eligible studies and extracted data from included studies. SF and AK conducted the analysis, interpreted the results, and collaboratively wrote the manuscript. SF prepared the tables and figures. AK supervised the study. The author(s) read and approved the final manuscript.

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Fan, S., Koski, A. The health consequences of child marriage: a systematic review of the evidence. BMC Public Health 22 , 309 (2022). https://doi.org/10.1186/s12889-022-12707-x

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DOI : https://doi.org/10.1186/s12889-022-12707-x

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What it’s like to be the mom of a neurodivergent child

• I am the mom who wishes some things may be different for her child, but never wishes for a different child.

By Jane Kim September 2, 2024

Being a parent of a neurodivergent child can be incredibly isolating . Your friends have similar motherhood journeys but you can’t relate. If you share your experience, they can’t identify and it gets uncomfortable. You don’t see much of what you go through represented in the media, and you long to find your village.  

But you’re not alone. It’s estimated that more than 1 in 5 children in the United States are neurodiverse . As moms of these children, own your story—because it’s uniquely yours . Besides, what’s the alternative? The more we share, the more awareness, acceptance, kindness and community we create.

Related: I’m the mom of a child with autism. Here are 3 things I want people to know

So, here’s my story, which is likely a part of your story. Wherever you are, I see you—and I’m in your corner.

• I am the mom with the only child, for fear that having another will divert my time, energy, resources and devotion from my first.
• I am the mom who sometimes wonders if my spouse or partner will one day wake up, freak out and realize it’s all too much .
• I am the mom who can be found sitting alone at the preschool/kindergarten/middle school concert/talent show/picnic.
• I am the mom who has endless patience, then loses it, is overcome with guilt and starts over—again and again.
• I am the mom who never fully shared my early motherhood journey. But not many people asked, either.
• I am the mom who may be blamed and judged for my child’s differences—from family and friends, to random people at restaurants and stores.
• I am the mom who considered tapping into my HELOC (or taking a second mortgage on the house) to build a state-of-the-art sensory room, pay for therapists, private schools and anything else that may help my child thrive.

Related: Your motherhood journey might look different than what you expected—and that’s OK

• I am the mom who hears words like “annoying,” “not normal,” “strange” or “atypical” to describe my child and other children with diagnoses, disabilities or differences.
• I am the mom who is given extra time at doctor and dentist appointments and parent-teacher meetings.
• I am the mom who has more doctors, specialists and therapists for my child than I have had in my entire life. 
• I am the mom that knows the difference between an IEP and a 504 plan.
• I am the mom who has 10+ people at my child’s IEP meeting and starts each meeting with, “What do you see as his greatest strengths?”
• I am the mom who uses words like proprioception, motor planning, sensory-seeking behavior and bilateral coordination.
• I am the mom who celebrates the inchstones, milestones and everything in between.
• I am the mom who has difficulty advocating for herself, but advocates for her child like a boss.

Related: 5 smart steps for parenting neurodivergent kids

• I am the mom who isn’t sure how much money I need for my child’s future—and have made great strides in navigating and living in the unknown.
• I am the mom who can discern between a choice or something biochemical; that is, until my child changes and then I’m back to square one.
• I am the mom who has Caesar salad dressing in the refrigerator that probably expired two years ago.
• I am the mom who is also a daughter, sister, partner, friend, manager, co-worker, writer, neighbor, doubles tennis partner, and maker of killer nachos and Arancini balls. 
• I am the mom who cheerfully says my son’s name whenever he returns from school, throws a football, plays video games and basketball with him, and gives him as many goodnight kisses as the month’s date.
• I am a mom who is hopeful and fearful for the future.

Author's Note

Jane Kim writes a weekly newsletter about learning to connect the dots, gaining comfortability in uncertainty, and her experiences parenting a neurodivergent child. To see a sample newsletter and subscribe: https://conta.cc/46YaeXu

This story is a part of The Motherly Collective contributor network where we showcase the stories, experiences and advice from brands, writers and experts who want to share their perspective with our community. We believe that there is no single story of motherhood, and that every mother's journey is unique. By amplifying each mother's experience and offering expert-driven content, we can support, inform and inspire each other on this incredible journey. If you're interested in contributing to The Motherly Collective please click here .

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Child, adolescent, and psychological therapies national dataset (CAPTND) Child and Adolescent Mental Health Services Report

• Mental health

About this release

This release by Public Health Scotland (PHS) provides an update on information relating to activity in Child and Adolescent Mental Health Services (CAMHS) from the Child, Adolescent, and Psychological Therapies National Dataset (CAPTND) in NHSScotland, for the quarter ending June 2024.

Main points

CAPTND is a dataset in development that collates information for mental health services at patient-level and records each individual’s journey through the service. CAPTND data are still under development therefore any inferences or conclusions from this analysis must be treated with caution.

For CAMHS in the quarter ending June 2024:

• There were a total of 8,724 children and young people referred to CAMHS and recorded in CAPTND. This was a decrease of 1,038 (10.6%) compared with the 9,762 referrals in the previous quarter, and a decrease of 221 (2.5%) compared with the 8,945 referrals in the same quarter ending June 2023.
• CAMHS across NHSScotland received 4,875 (55.9%) referrals for females and 3,846 (44.1%) for males.
• Of the 8,724 referrals to CAMHS, 6,316 (72.4%) were accepted.
• There were a total of 45,876 CAMHS appointments recorded in CAPTND across NHS Scotland. This is an increase of 5,221 (12.8%) recorded appointments since the previous quarter, and an increase of 11,098 (31.9%) recorded appointments since the same quarter in the previous year.

Waiting times information for Child and Adolescent Mental Health Services (CAMHS) and psychological therapies using CAPTND is still being developed. NHS health boards are working with PHS and the Scottish Government to improve the consistency and completeness of the information.

CAMHS are multi-disciplinary teams that provide treatment and/or interventions for children and young people experiencing mental health problems. Where a child or young person is waiting for an assessment for a neurodevelopmental condition such as ASD, or ADHD, they may not be appropriate for CAMHS. This release does not report on the neurodevelopmental (ND) pathway including those children and young people on the neurodevelopmental waiting list.

Further information

The next release of this publication will be 4 March 2025.

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Summary pdf | 159.9kb, report pdf | 1.4mb, data tables xlsx | 139.5kb, general enquiries.

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They are tired or out of breath quickly