What are the risk factors for suicide for Children and Young People?

Risk factors for suicide in children and young people are broad and far reaching. Suicide is often driven by experiencing distressing events, which influences how a person thinks and feels about themselves and the world around them. Reaching this point of crisis can be the result of a sudden decline in psychological well-being, with this being more likely in those living with a mental health disorder.

Mental health disorders are characterised as significantly impacting a person’s functioning in their daily lives (ICD-11),[1] this can include ‘common mental health disorders’ such as depression and anxiety (NICE, 2011),[2] as well as a range of other disorders such as schizophrenia, psychosis, bipolar and eating disorders.

Childhood and adolescent represents a “period of physical, emotion, social and psychological development” (CQC, 2017).[3] Therefore children and young people who do experience mental health difficulties can also experience considerable challenges with their social and emotional functioning and behaviour.

For example, a young person suffering with depression may become socially isolated or become aggressive to others. These associated problems are otherwise known in educational settings as ‘Social, Emotion and Mental Health’ (SEMH) needs (Department for Education & Department for Health, 2015).[4]

The development of 'mental disorders' in childhood and early adulthood (ICD-10 diagnosic classification) is also a potential risk factor for suicide. Even though they are distinct (include emotional, behavioural, hyperactivity and other types of mental disorders), characteristics of these and the combination of biological, behavioural, psychosocial and cultural factors sitting behind these disorders often overlap with each other, usually resulting in mental health issues (Clark et al., 2017).[5}

Why are they important to consider in suicide prevalence?

Paying close attention to the psychological wellbeing and mental health of children and young people is vital as experiencing a mental health crisis in response to distressing events (or worsening of mental health disorder symptoms) significantly increases risk of suicide; this being one of the three leading causes of death among young people (WHO, 2020).[6]

Data published in 2017 showed that there were 922 suicides and probable suicides by people aged under 25 in England in Wales from January 2014 to December 2015 (University of Manchester, 2017).[7] Poor mental health is additionally associated with a range of other harmful behaviours which can have severe implications, these being self-harm, substance use, risky sexual behaviours and exposure to abuse and violence.

How prevalent are they?  

10 to 20% of children and young people worldwide experience mental health conditions, with half of these developing before the age of 14 and one in five young persons experiencing a mental health condition each year (WHO, 2020).[6]

The likelihood of children (both boys and girls) aged 5 to 16 years old developing a mental disorder has increased since 2017, with 11% children in 2017 to 16% in 2020. As children get older the likelihood of developing a mental disorder has found to be higher, with 27% of young women being likely to develop one compared to 13% of young men (NHS Digital, 2020).[8]

ZSA Suicide Prevention Resource Map – Key Takeaways

The Suicide Prevention Resource Map includes a series of indicators that are of interest in exploring risk factors of suicide for children and young people. Examples of these include:

  • Percentage of school pupils with social, emotional and mental health needs – highest in local authorities of Torbay, the City of London and Plymouth (>4 %), with the lowest percent in Havering (1.2%)
  • Income Deprivation Affecting Children Index (IDACI) for ages 0 to 15 – highest in selected North West and North East Clinical Commissioning Groups (~30%)
  • Children who started to be looked after due to abuse or neglect (aged under 18) – highest in the local authority of Blackpool (61 per 10,000) and the lowest in Windsor and Maidenhead (4 per 10,000) with an average median of 17 per 10,000
  • Percentage of looked after children with a substance misuse problem – highest in the local authority of Bournemouth (27%) and the Lowest in Leeds (1%), with an average median of 4%

For more suggested data indictors to explore in the map, please refer to the list provided at the bottom of this page.

How do they occur?

Childhood and adolescence can be challenging. These crucial formative years are when children and young people gain vital knowledge and social-emotional skills that will shape their future wellbeing and mental health as adults. It is not only important to teach young people how to cope with life’s stresses, but also to protect them from traumatic events which may have significant effects for those who are already vulnerable.[9]

These traumatic events early in life are otherwise known as Adverse Childhood Experiences (ACEs). These have been found to significantly increase a child’s risk of developing a range of mental and physical health conditions in later life (Annual Report of the Director of Public Health, 2018).[10] 

ACEs includes any detrimental experiences which could impact a child or young person and have implications on their wellbeing as they grow into adulthood (Public Health England, 2018).[11] These range from direct forms of harm (such as emotional, physical and sexual abuse, or neglect) to indirect forms influenced by the environment a child grows up in (including domestic violence in the home, parental separation, mental illness, substance misuse and a family member in prison). Income deprivation is also important to consider here as is an indicator of poverty and socioeconomic position. Research has linked the two with a lower socioeconomic position found to be associated with a greater risk of ACEs (Walsh et al., 2019; Lewer et al., 2020).[12][13]

ACEs are thought to be a prominent factor of influence for health and wellbeing throughout the lifespan. ACEs have also been found to hinder childhood development, including the development of coping mechanisms which are relied upon to manage distressing emotions in later life. Not having a range of cognitive and behavioural skills to hand leaves a person less able to manage their emotions, and therefore, more likely to experience crisis in the face of challenging situations. 

Additionally, exposure to ACEs increases the likelihood of adopting health risk behaviours leading to psychological and physical health consequences, including likelihood of developing mental illness (Education Policy Institute, 2019). ACEs have also been found to play a pivotal role in the development of serious mental illnesses (SMIs) in early adulthood, including psychosis, schizophrenia and bipolar disorder (Garno et al., 2005; Varese et al., 2012).[14][15] 

ACEs are unlikely to be limited to one type, but instead co-occur alongside others (Felitti et al., 1998).[16] This has significant consequences with research finding that more ACEs a child experiences, the higher their risk of reaching crisis and attempting suicide in their lifetime (Choi et al., 2017).[17]

Young people also experience other sources of stress, these of which may vary in comparison to other age groups (such as adults and older adults). Some examples of stressors young people may face could include:

  • Living circumstances – living in an area of high socio-economic deprivation has been found to have a detrimental effect on young people’s mental health and wellbeing, likely to be linked with heightened social stress (Visser et al., 2021).[18] Strained family relationships, involvement of social services, living in care and homelessness are all additional factors that increase stress, and as a consequence increase risk for developing a mental heath problem (Narendorf, 2017)[19]
  • Periods of transition – these represent a significant time of change to independent living, involving forming new habits, meeting new people and learning to manage competing demands (Mind, 2019).[20] Examples include leaving school and going to university or for those receiving mental health support, transitioning from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) at the age of 18. Many of these transitions occur between the ages of 16 and 18 which coincide with a key development stage. This adds further complexity to the challenges likely to be experienced during that time (Singh, 2009)[21]
  • Social Media – research has found that high levels of social media usage amongst young people is a likely source of stress within this population group (Meier et al., 2016[22])
  • Bullying - this has been linked to poorer wellbeing and higher risk of self harm and suicidal behaviours (John et al., 2018).[23] Some demographic groups have found to be particularly impacted by bullying, including young people that identify as part of the LGBT+ community (Kelleher, 2009)[24]
  • School exclusion – being excluded from school has been found to not only be associated with psychological distress and poor mental health as a result, but can also contribute to reasons behind the exclusion (Ford et al., 2017).[25] Other factors that were associated with exclusion include poor general health, learning disabilities and poor parental mental health. This was also found to be more common amongst boys, secondary school students and those living in deprivation.

If you require further information, visit our original Facts for Action series: bullying, child abuse and neglect and being a child in care.

This is not to say that all children and young people who experience stress at a young age, including ACEs, will go on to develop mental health problems, but instead this heightens their risk. This vulnerability is thought to be likely contributed to by a combination of social and biological factors, with research finding a 30 to 40% likelihood due to genetic predisposition, and 60 to 70% due to environmental factors (BPS, 2018).[26] 

Below is a brief summary of the range of contributing factors to the development of poor psychological wellbeing and mental health:

  • The persons internal state and aptitude – the resilience and capacity a person has to handle the challenges, and handle the emotional difficulties they face (Schultze-Lutter, Schimmelmann and Schmidt, 2016)[27]
  • The societal and demographic factors they are subject to – pre-disposing factors such as poverty or social isolation (Mental Health Foundation, 2016)[28] as well as factors related to their genetics, race and culture (Mental Health Foundation, 2019).[29]
  • Situational factors – the likelihood and severity of the inciting incidents, presence of protective factors and access to support (Schneiderman, Irsonson and Siegel, 2005).[30]

What are the consequences?

The consequences of not addressing the risk factors of poor psychological well-being and mental health in childhood, is that they leave children and young adults more at risk of not only a mental health crisis (which earlier was established as a risk factor for suicide), but makes it much more likely to lead to poorer health outcomes in adulthood (Otto et al., 2020).[31]

Young people can also turn to substance misuse, such as excessive drinking and taking drugs. Substance misuse is often relied upon as a coping mechanism to manage social stress and distressing thoughts and feelings experienced as a result. Using substances can perpetuate the cycle of precipitating and being a consequence of poor mental health. Substance misuse can also worsen mental health and act to reinforce negative thoughts and feelings. Young people who use substances are also more at risk of becoming homeless (Mallett, Rosenthal & Keys, 2005)[32], with this previously being identified as being linked to poorer mental health (Narendorf, 2017).[18]

Poor mental health, specifically depression, is estimated to be the second greatest contributor to disability-adjusted life years (DALYs), a measure of the overall burden of disease (NICE, 2011).[3] Major stressful experiences early in life or ACEs are not only likely to contribute to a young person’s wellbeing, but also is a key risk factor in the development of serious mental illness (SMIs) such as schizophrenia, psychoses or bipolar disorder in adulthood. Living with an SMI has significant and enduring consequences in quality of life and early mortality, including a heightened risk of suicide, due to the stark health and social inequalities these individuals face.[33]

To find out more about SMI in adulthood, see our ZSA Facts for Action for Serious Mental Illness.

Impact of COVID-19

Research found that over the COVID-19 lockdown there was an increase in poorer mental health across the general population (Understanding Society, 2020).[34] Young people have experienced numerous disruptions in their education (e.g. home schooling, online learning, exam cancellation), limited contact with friends and support networks, limited opportunities to enjoy every day activities, loss of part time jobs and difficulty entering the job market after leaving school (Lee, 2020[35]; Children’s Commissioner, 2021[36]; Das et al., 2020[37]). Children from poorer backgrounds have been particularly impacted by school disruptions, with limited access to digital based learning resources. 

The consequences of the pandemic have severely impacted the well-being of young people, putting them at higher risk of developing other mental health problems, substance misuse and dying by suicide (WHO, 2020).[6]

54 to 59% of children and young people aged 11 to 22 years old who were likely to be experiencing mental health problems before the start of the pandemic reported that lockdown had made their life worse, compared to 37 to 39% of their counterparts that were unlikely to be experiencing mental health problems prior to lockdown (NHS Digital, 2020).[8] It has been forecasted that 1.5 million children and young people will need new or additional support for their mental health needs as a result of the COVID-19 pandemic (Centre of Mental Health, 2020).[38]

For more information about the impact of COVID-19, see Facts for Action for Children and Young People’s Services.

Children and young people are also spending more time at home which has found to worsen relationships within families and leave young people exposed to incidences of domestic violence (Centre for Mental Health, 2020).[38] In addition to major disruption to routine and social isolation, these relationship strains and exposure to ACEs (i.e. domestic violence, abuse) contribute to explaining why children have experienced an increase in suicidal thoughts and incidences of self-harm during the pandemic (XenZone, 2020).[39]

Research by NHS England and NHS Improvement estimate that despite the increase in demand for children and young people’s services during lockdown, referrals have dropped by 30 to 40% (Health and Social Care Committee, 2020).[40] The reported increase in distressing experiences as a result of the COVID-19 lockdowns and the lack accessible support during this time, leaves children at a higher risk of developing significant and long lasting mental health issues. This includes increasing the risk of developing an SMI in adulthood, especially within families already struggling with other social stressors (Varese et al., 2012; Garno et al., 2005).[15][14]

National Guidelines for practice

Broad picture

The Five Year Forward View for Mental Health published by the NHS in 2016 outlined a long-term transformation of mental health services (NHS, 2016).[41] The plan detailed a new commitment to funding to expand Children and Adolescent Mental Health Services (CAMHS) to improve the mental health outcomes for young people.

For more information on these changes, see Facts for Action for Children and Young People Services.

NICE guidelines

NICE have produced a series of guidelines, public health guidelines, quality standards and clinical standards are relevant to the prevention recognition and evidence-based management of a range of children and young people’s mental health and emotional wellbeing needs. The easiest way to find this guidance is to use NICE pathways.

Treatment for mental health illnesses are primarily delivered by primary care services such as IAPT or secondary care services including Children and Young People Mental Health Services (CAMHS) which provide inpatient and community based interventions.

BPS guidelines

The British Psychological Society (BPS) provide a series of guidelines to help clinicians work in a psychologically informed way.  As part of this, the BPS work alongside NICE in developing guidelines for the treatment of mental health disorders in children and young people.

The BPS have a range of resources and publications in relation to working with children, young people and their families (CYPF), for more information please visit the BPS’ CYPF faculty website.

Key approaches 

The BPS advocates for an evidence-based preventative approach which puts emphasis on introducing effective interventions early on and incorporating them through children’s lives, with a broader focus on wider issues around children’s development and psychological wellbeing (BPS, 2021).[50] By putting preventative measures in place, this will in turn reduce the demand on primary and secondary mental health services for children and young people, as well as adults.

This systemic population based approach presents countless opportunities to support children and their families, creating integrated formal and more cultural based care systems within the community. Schools present one of these key opportunities whereby school staff and parents can be supported to understand challenges to mental health and wellbeing, and learn what they can do to help. The introduction of NHS-led Mental Health Support Teams in schools whereby children and young people are offered counselling services will also contribute to this movement. As described in the NHS’ Long Term Plan for Mental Health, the aim is to achieve 20 to 25% national coverage by 2023, with 100% coverage by 2027 (NHS, 2016).[41] However, this may not capture the needs of every young person, including those who have been excluded from school, or those who themselves or their family have a poor relationship with their educators and so lack the opportunity and the support to be included.

Another development called for by the BPS is the formation of community peer support structures which focus upon building community resilience, benefiting children and young people and their families (BPS, 2021.[50]

The BPS also call for trained assessors to be able to identify and understand early social and emotional needs of individual young people prior to implementing interventions. Additionally, the inclusion of applied psychologists such as Clinical and Educational Psychologists would be the most appropriate trained professionals to undertake leadership of preventative and reactive measures.

Lastly, a family-focused community-based approach is also needed in order to address increasing levels of family conflict and relationship breakdown. A cross-departmental strategy would be required to lead effective change in these areas, bringing together the Department for Health and Social Care (and the Department for Education), Department for Work and Pensions and Ministry of Housing, Communities and Local Government (BPS, 2021).[50]

This particular approach would also go far in helping to address Adverse Childhood Experiences (ACEs), with helping support families that are in distress and specific identifying risk factors for trauma (e.g. bereavement, relationship breakdown, abuse). It would also go towards addressing the concern of missing children and young people that have been excluded from school or caught in-between a breakdown of the partnership between families and schools.

Case studies

Case studies listed below are good examples whereby a population approach to reducing the prevalence and the impact of poor mental health for children and young people. Some of these case studies form part of our original Facts for Action work which provide additional contextual information within these themes. For more information about each of them, please follow the individual links.

ZSA Suicide Prevention Resource Map - Related Indicators 

Direct

Child abuse and neglect/safeguarding

Looked after children

Indirect

Referrals

Waiting times

Contacts

Hospital Admissions

References

[1] ICD-11 (2020). Mental, behavioural or neurodevelopmental disorders. Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054 ( accessed 21/01/2021)

[2]  NICE (2011). Common mental health problems: identification and pathways to care, clinical guideline [CG123]. Available at: https://www.nice.org.uk/guidance/cg123/chapter/Introduction (accessed 18/03/2021)

[3] Care Quality Commission (2017). Review of children and young people’s mental health services. Phase one report. Available at: https://www.cqc.org.uk/publications/major-report/review-children-young-peoples-mental-health-services-phase-one-report (accessed 09/03/2021)

[4] Department for Education & Department of Health (2015). Special educational needs and disability code of practice: 0 to 25 years. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.pdf (accessed 18/03/2021)

[5] Clark, L., Cuthbert, B., Lewis-Ferdandez, R., Narrow, W. & Reed, G. (2017). Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health's Research Domain Criteria (RDoC). Psychological Science in the Public Interest, 18(2). Available at: https://doi.org/10.1177/1529100617727266 (accessed 16/09/2021). 

[6] World Health Organisation (2020). Guidelines on mental health promotive and preventive interventions for adolescents. Available at: https://apps.who.int/iris/bitstream/handle/10665/336864/9789240011854-eng.pdf (accessed 11/03/2021)

[7] The University of Manchester (2017). National Confidential Inquiry Into Suicide and Homicide by People with Mental Illness. Suicide by Children and Young People. Available at: https://sites.manchester.ac.uk/ncish/reports/suicide-by-children-and-young-people/ (accessed 09/03/2021)

 [8] NHS Digital (2020). Mental Health of Children and Young People in England, 2020: wave 1 follow up to the 2017 survey. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2020-wave-1-follow-up (accessed 11/03/2021)

[9] Mental Health Foundation (2016). Children and young people. Available at: https://www.mentalhealth.org.uk/a-to-z/c/children-and-young-people (accessed 11/03/2021)

[10] Annual Report of the Director of Public Health (2018). Adverse Childhood Experiences, Resilience and Trauma Informed Care: A Public Health Approach to Understanding and Responding to Adversity. Available at: https://www.nhshighland.scot.nhs.uk/Publications/Documents/DPH-Annual-Report-2018_(web-version).pdf (accessed 31/12/2020)

[11] Public Health England (2018). Introduction to Adverse Childhood Experiences. Available at: https://www.towerhamlets.gov.uk/Documents/Children-and-families-services/Early-Years/ACES_and_social_injustice_DCP_SW.pdf (accessed 21/01/2021)

[12] Walsh, D., McCartney, G., Smith, M. & Armour, G. (2019). Relationship between childhood socioeconomic position and adverse childhood experiences (ACES): a systematic review. Journal of Epidemiology & Community Health, 73(12). Available at: https://jech.bmj.com/content/73/12/1087 (accessed 06/04/2021)

[13] Lewer, D., King, E., Bramley, G., Fitzpatrick, S., Treanor, M., Maguire, N., Bullock, M., Hayward, A. & Story, A. (2020). The ACE Index: mapping childhood adversity in England. Journal of Public Health, 42(4), e487-e495. Available at: https://doi.org/10.1093/pubmed/fdz158 (accessed 06/04/2021)

[14] Garno, J., Goldberg, J., Ramirez, P. et al. (2005). Impact of childhood abuse on the clinical course of bipolar disorder. British Journal of Psychiatry, 186, 121-125. Available at: https://pubmed.ncbi.nlm.nih.gov/15684234/ (accessed 26/01/2021)

[15] Varese, F, Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., Read, J., van Os, J. & Bentall, R. (2012). Childhood Adversities Increase the Risk of Psychosis: A Meta-analysis of Patient-Control, Prospective- and Cross-sectional Cohort Studies. Schizophrenia Bulletin, 38(4), 661-671. Available at: https://pubmed.ncbi.nlm.nih.gov/22461484/ (accessed 26/01/2021)

[16] Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14, 245–258. Available at: https://pubmed.ncbi.nlm.nih.gov/9635069/ (accessed 11/01/2021)

[17] Choi, N. G., Dinitto, D. M., Marti, C. N., & Segal, S. P. (2017). Adverse childhood experiences and suicide attempts among those with mental and substance use disorders. Child Abuse & Neglect, 69, 252-262. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/cch.12617 (accessed 11/01/2021)

[18] Visser, K., Bolt, G., Finkenauer, C., Jonker, M., Weinberg, D. & Stevens, G. (2021). Neighbourhood deprivation effects on young people’s mental health and well-being: A systematic review of the literature. Social Science & Medicine, 270. Available at: https://doi.org/10.1016/j.socscimed.2020.113542. (accessed 17/03/2021)

[19] Narendorf, S. (2017). Intersection of homelessness and mental health: A mixed methods study of young adults who accessed psychiatric emergency services. Children and Youth Services Review, 81, 54-62. Available at: https://doi.org/10.1016/j.childyouth.2017.07.024 (accessed 17/03/2021)

[20] Mind (2019). Moving from child to adult mental health services. Available at: https://www.mind.org.uk/information-support/for-children-and-young-people/moving-to-adult-services/ (accessed 21/01/2021)

[21] Singh, S.P. (2009). Transition of care from child to adult mental health services: The great divide. Current Opinion in Psychiatry, 22, 386-390. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20266 (accessed 11/01/2021)

[22] Meier, A., Reinecke, L., & Meltzer, C. E. (2016). Facebocrastination? Predictors of using Facebook for procrastination and its effects on students’ well-being. Computers in Human Behavior, 64, 65-76. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0747563216304411 (accessed 11/01/2021)

[23] John, A., Glendenning, A., Marchant. A. et al. (2018). Self-harm, suicidal behaviors, and cyberbullying in children and young people: systematic review. Journal of Medical Internet Research, 20(4), 129. Available at: https://pubmed.ncbi.nlm.nih.gov/29674305/ (accessed 11/01/2021)

[24] Kelleher, C. (2009). Minority stress and health: Implications for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people. Counselling Psychology Quarterly, 22(4). Available at: https://www.tandfonline.com/doi/abs/10.1080/09515070903334995 (accessed 17/03/2021)

[25] Ford, T., Parker, C., Salim, J., Goodman, R., Logan, S. & Henley, W. (2017). The relationship between exclusion from school and mental health: a secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007. Psychological Medicine, 48(4), 629-641. Available at: https://doi.org/10.1017/S003329171700215X (accessed 17/03/21)

[26] BPS (2018). BPS Supports new GLAD study of depression and anxiety. Available at: 30-40% of the risk for both depression and anxiety is genetic and 60-70% due to environmental factors. Available at: https://www.bps.org.uk/news-and-policy/bps-supports-new-glad-study-depression-and-anxiety (accessed 18/03/2021)

[27] Schultze-Lutter, F., Schimmelmann, B. G., & Schmidt, S. J. (2016). Resilience, risk, mental health and well-being: associations and conceptual differences. European Child and Adolescent Journal of Psychiatry, 25(5), 459-466. Available at: https://www.researchgate.net/publication/301598267_Resilience_risk_mental_health_and_well-being_associations_and_conceptual_differences (accessed 21/01/2021)

[28] Mental Health Foundation (2016). Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy. London: Mental Health Foundation. Available at: https://www.mentalhealth.org.uk/sites/default/files/Poverty%20and%20Mental%20Health.pdf (accessed 21/01/2021)

[29] Mental Health Foundation (2019). Black, Asian and Minority Ethnic (BAME) communities. Available at: https://www.mentalhealth.org.uk/a-to-z/b/black-asian-and-minority-ethnic-bame-communities (accessed 21/01/2021)

[30] Schneiderman, N., Ironson, G. & Siegel, S. (2005). Stress and Health: Psychological, Behavioral, and Biological Determinants. Annual Review of Clinical Psychology, 1, 607-628. Available at: https://www.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.1.102803.144141 (accessed 21/01/2021)

[31] Otto, C., Reiss, F., Voss, C., Wüstner, A., Meyrose, A., Hölling, H. & Ravens-Sieberer, U. (2020). Mental health and well-being from childhood to adulthood: design, methods and results of the 11-year follow-up of the BELLA study. European Child & Adolescent Psychiatry. Available at: https://link.springer.com/article/10.1007/s00787-020-01630-4 (accessed 06/04/2021)

[32] Mallett, S., Rosenthal, D. & Keys, D. (2005). Young people, drug abuse and family conflict: Pathways into homelessness. Journal of Adolescence, 28(2), 185-199. Available at: https://doi.org/10.1016/j.adolescence.2005.02.002 (accessed 17/03/2021)

[33] Public Health England (2018). Severe mental illness (SMI) and physical health inequalities: briefing. Available at: https://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing (accessed 19/10/2020)

[34] Understanding Society (2020). Understanding Society Working paper Series.  Available at: https://www.understandingsociety.ac.uk/research/working-papers (accessed 22/10/20).

[35] Lee, C., Cadigan, J. & Rhew, I. (2020). Increases in loneliness amongst young adults during the Covid-19 pandemic and association with the increase in mental health problems. Journal of Adolescent Health, 67(5), 714-717. Available at: https://www.sciencedirect.com/science/article/abs/pii/S1054139X20304924 (accessed 21/01/2021)

[36] Children’s Commissioner (2021). The state of children’s mental health services 2020/21. Available at: https://www.childrenscommissioner.gov.uk/report/mental-health-services-2020-21/ (accessed 11/03/2021)

[37] Das, S. Kim, A. & Karmakar, S. (2020). Change-Point Analysis of Cyberbullying-Related Twitter Discussions During COVID-19. 16th Annual Social Informatics Research Symposium (ASIS&T). Available at: https://arxiv.org/abs/2008.13613 (accessed 11/01/2021)

[38] Centre for Mental Health (2020).  Covid-19 and the nation’s mental health: October 2020. Available at: https://www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-october-2020 (accessed 14/12/2020)

[39] XenZone (2020). How Covid-19 is Affecting the Mental Health of Young People in the BAME Community. Available at: https://xenzone.com/wp-content/uploads/2020/07/Week16ADULTv2.pdf (accessed 04/12/2020)

[40] Health and Social Care Committee (2020). Oral evidence: Delivering Core NHS and Care Services during the Pandemic and Beyond, HC 320. Available at: https://committees.parliament.uk/oralevidence/331/pdf/ (accessed 16/12/2020)

[41] NHS (2016). The Five Year Forward View for Mental Health: A report from the independent Mental Health Taskforce to the NHS in England. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf (accessed 09/02/2021)

[42] NICE (2015). Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care, NICE guideline [NH26]. Available at: https://www.nice.org.uk/guidance/ng26 (accessed 11/03/2021)

[43] NICE (2015). Looked-after children and young people, public health guideline [PH28]. Available at: https://www.nice.org.uk/guidance/ph28 (accessed 11/03/2021)

[44] NICE (2016). Children’s attachment, quality standard [QS133]. Available at: https://www.nice.org.uk/guidance/qs133 (accessed 11/03/2021)

[45] NICE (2016). Early years: promoting health and wellbeing in under 5s, quality standard [QS128]. Available at: https://www.nice.org.uk/guidance/qs128 (accessed 11/03/2021)

[46] NICE (2008). Social and emotional wellbeing in primary education, public health guideline [PH12]. Available at: https://www.nice.org.uk/guidance/ph12 (accessed 11/03/2021)

[47] NICE (2016). Transition from children’s to adults’ services for young people using health or social care services, NICE guideline [NG43]. Available at: https://www.nice.org.uk/guidance/ng43 (accessed 11/03/2021)

[48] NICE (2018). Drug misuse prevention, quality standard [QS165]. Available at: https://www.nice.org.uk/guidance/qs165 (accessed 11/03/2021)

[49] Alcohol: preventing harmful use in the community, quality standard [QS83]. Available at: https://www.nice.org.uk/guidance/qs83 (accessed 11/03/2021)

[50] BPS (2021). British Psychological Society briefing: Children and Young People’s Mental Health and Psychological Wellbeing. Available at: https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/BPS%20Briefing%20-%20Children%20and%20Young%20Peoples%20Mental%20Health%20and%20Wellbeing.pdf (accessed 11/03/2021)