Guidance

Early adolescence: applying All Our Health

Updated 16 December 2019

Introduction

Children and young people progress through a number of transition stages in their lives as part of the journey to adulthood. Early adolescence is widely recognised as a crucial period. During this transition, children and young people may experience changes or be exposed to situations which may positively or negatively impact on their health and wellbeing.

Evidence suggests that the outcomes for children and adults are strongly affected by experiences during this transition period, particularly as they take more control of their own health and wellbeing, including making diagnoses and choices about their health. There are major transition points between 10 to 14 years, including moving from primary to secondary school; this can also provide an opportunity to provide advice to support positive health choices and behaviour change.

School nurses are the lead professionals in delivering the Healthy Child Programme: 5 to 19 years old. Working in schools and within local communities, they have an important role in supporting children, young people, and families. School nursing teams work with other partners including schools, youth workers and wider community services to address a range of health and wellbeing needs affecting physical, emotional and social wellbeing.

Adolescence is a time of rapid change including:

• physical development, for example, growth spurt and sexual maturation
• cognitive development, for example, evidence suggests brain development continues up to age 25 (Association for Young People’s Health (AYPH), 2017)
• emotional development, for example, identity, self-esteem, and resilience
• social development, for example, peer influences, sexual identity
• behavioural development, for example, risk taking and the beginning of lifelong behaviours

Young people experience significant physical, psychological and behavioural changes as they progress to adulthood. Appropriate and timely support for young people on their journey to adulthood is essential to ensure future health and wellbeing.

Access the early adolescence e-learning session

An interactive e-learning version of this topic is now available to use.

Public Health England (PHE) and Health Education England’s ‘e-Learning for Healthcare’ have developed this content to increase the confidence and skills of health and care professionals, to embed prevention in their day-to-day practice.

Completing this session will count towards your continued professional development.

Start the early adolescence e-learning session.

Focusing on early adolescence in your professional practice

Substance misuse

Adolescent alcohol and substance use have been associated with lower academic attainment, reduced school attendance, changes in affect and behaviours leading to impairments in relationships with family and friends.^{[footnote 1][footnote 2][footnote 3]}

Recent surveys among 15 year olds in England^{[footnote 4]} have identified an increase in substance use with 29.8% reporting use in the last year and 17.8% in the last month. The results of the most recent survey of 15 year olds has also identified that 73% consumed alcohol in the last year and 24% in the last week with 23% reporting being drunk once or more in the last month.

The Chief Medical Officer has advised that young people should have an alcohol-free childhood, at least to the age of 15.

Being drunk is a major indicator of alcohol misuse. In the 2015 European School Survey Project on Alcohol and Other Drugs (ESPAD) involving 36 European countries, the UK compared poorly for rates of underage drunkenness (Hibell and others, 2012). Teenage girls in the UK aged 15 to 16 were in the top 3 countries where girls were most likely to have been drunk in the previous month, and 28% of girls and 24% of boys in the UK said they were drunk in the previous week.^{[footnote 5]}

It is for these reasons that local authorities are strongly encouraged to invest in substance-related service provision across the different levels of need from schools, targeted provision with groups vulnerable to drug use, and specialist services treating young people’s substance misuse.^{[footnote 6]}

Mental health and wellbeing

Adolescence is a critical period for young people’s mental health and wellbeing. The most recent data shows that one in seven 11 to 16 year olds have a diagnosable mental health disorder.^{[footnote 7]} Data also shows that over half of all mental health problems are established by age 14 and 75% by age 24.^{[footnote 8]}

The number of referrals by schools in England seeking mental health treatment for pupils has risen by more than one third in the last 3 years with more than half (55%) of referrals over the 4-year period coming from primary schools (NSPCC 2018).

In an average class of 30 students aged 15:

• 10 are likely to have witnessed their parents separate
• 7 are likely to have been bullied
• 6 may be self-harming
• one could have experienced the death of a parent

Source: Promoting children and young people’s emotional health and wellbeing, PHE 2015.

Particular groups of children have significantly worse outcomes linked, for example, to an increasing number of young carers, to gender, socioeconomic status, ethnicity, disability, sexual orientation, being a looked after child or being in the youth justice system.^{[footnote 9]}

Teenage mothers have higher rates of poor mental health for up to one year after the birth of their child (PHE, 2016). Children who have had an adverse childhood experience are more likely to have difficulties learning and engaging with others and are more likely to go on to experience mental health problems. And 18% of 11 to 15 year olds report having experienced some form of bullying via online platforms.^{[footnote 10]}

Supportive relationships and environments including within the family, amongst peers, in the context of school and the wider community, contribute to building protective factors and mitigating risk for adolescents mental health and wellbeing.^{[footnote 11]} Promoting resilience and mental health literacy amongst individuals, families and communities has also been identified as an important part of a public health approach.^{[footnote 12]} (UCL Institute of Health Equity 2014.

Government policy to improve young people’s mental health includes commitments set out in the NHS Long Term Plan. These build on a 5-year programme to develop children and young people’s mental health services which aims to ensure 70,000 more children and young people can access treatment each year by 2020 to 2021.

The Long Term Plan commits the NHS to continuing over the next 10 years to widen access to community-based mental health services, including new support in schools and colleges. By 2023 to 2024, at least an additional 345,000 children and young people aged 0 to 25 will be able to access support from NHS-funded mental health services and school or college-based mental health support teams.

As well as developing the new mental health support teams, some areas are also testing a 4-week waiting time to give quicker access to specialist mental health services to children and young people who need more expert support. Investment will continue into eating disorder services to deliver the waiting time standard.

As part of their commitment to children and young people’s mental health, the Department for Education are incentivising and supporting all schools and colleges to identify and train a designated senior lead for mental health that will oversee implementation of a whole school approach. In addition, the Department for Education is making relationships education compulsory for all primary pupils, relationships and sex education compulsory for secondary pupils and health education compulsory for all pupils in all primary and secondary state-funded schools. This includes a requirement for pupils to learn about mental health and wellbeing. Schools will be encouraged and supported to teach the new subjects from September 2019 and the requirement will become compulsory from September 2020. (Department for Education, 2019)

Homelessness

Becoming homeless can be a devastating emotional experience for a family. It may encompass feelings of loss, separation from friends and family, alienation from society, stigma, shame, and concerns about the future. It may involve feelings of helplessness, particularly if the experience happened suddenly, or if there is less support available to the family.

It is well evidenced that children and young people thrive in routines and environments they are familiar with. Homelessness takes children outside of familiar environments, can take them away from their home, and may involve moving schools which takes them away from friends. This insecurity, together with uncertainty about the length of time the family will be in temporary accommodation, can leave an emotional burden on children and young people at a time when their parents are less equipped to support them, as they are coping with numerous challenges themselves. Stress, anxiety, depression and other mental health problems are common of children, young people and families that are homeless. Some children and young people are homeless with their families, others are homeless on their own.

Research has found that homelessness places an enormous mental and physical stress on children, young people and families, which can have a negative impact upon their health.

Housing can be unsuitable, unsafe, or insecure with risks of higher accident rates and overcrowding. Families who have become homeless can also experience post-traumatic stress symptoms. Stress, anxiety, depression and other mental health problems are common AYPH 2018.

Vulnerabilities and adverse childhood experiences

Vulnerability and adverse childhood experiences increase the individual’s risk of health-harming behaviour. For every 100 adults in England, 48 have suffered at least one adverse childhood experience during their childhood and 9 have suffered 4 or more (Bellis, and others 2014)

Taking a preventative approach to vulnerability and adverse experiences can yield both individual and wider system benefits, contributing to outcomes such as educational attainment, workplace productivity, reduced crime and a reduction in the demand for mental health services (PHE, 2015). Early intervention during childhood can prevent problems from escalating and continuing into adulthood (PHE 2018).

Childhood obesity and physical activity

The childhood obesity plan recognises the role that health and social care professionals can play in supporting children with their weight and pledges to provide them with the latest tools so that they can help children, young people and families with their weight (PHE 2018).

For more information, read Childhood Obesity: All Our Health.

Oral health

Oral health is part of general health and wellbeing and contributes to the development of healthy children and young people.

For more information, read Child oral health: applying All Our Health.

School absence

Pupil absence in schools in England: autumn 2017 and spring 2018 reported that:

• the overall absence rate for pupils who are known to be eligible for and claiming free school meals (FSM) was 7.2%, compared to 4.2% for non FSM pupils
• the percentage of FSM eligible pupils that were persistent absentees was 23%, compared to 9.1% of pupils that were not eligible for FSM
• pupils with a statement of special educational needs (SEN) and pupils with an education healthcare plan (EHC) had an overall absence rate of 7.5%, compared to 4.4% for those with no identified SEN
• the overall absence rate for pupil referral units in autumn or spring 2017 to 2018 was 34.6%

Teenage pregnancy

Teenage pregnancy is often a cause and consequence of education and health inequality for young parents and their children. Teenagers have the highest rate of unplanned pregnancy and around 50% of under-18 conceptions and 60% of under-16 conceptions end in abortion.

Children born to teenage mothers have a 60% higher rate of infant mortality, a 30% higher rate of low birth weight and a 63% higher risk of living in poverty. Mothers under 20 have a 30% higher risk of mental illness 2 years after giving birth, with young mothers up to age 25 also experiencing poorer mental health. This can affect their own wellbeing and their ability to form a secure attachment with their baby, recognised as a key foundation stone for positive child outcomes.

An estimated 12% of the number of young women aged 16 to 17 who are not in education, employment or training, are teenage mothers; and by the age of 30, teenage mothers are 22% more likely to be living in poverty than mothers giving birth aged 24 or over. Young fathers are twice as likely to be unemployed aged 30, even after taking account of deprivation.

Through the implementation of an evidence based multi-agency programme, England has achieved a 62% reduction in the under-18 conception rate between 1998 to 2017, from 46.6 out of 1,000 15 to 17 year old females to 17.8; the under-18 and under-16 conception rates are now at the lowest level since 1969. However, inequalities persist. The teenage birth rate in England remains higher than comparable western European countries, there is a six-fold difference in rate between local authorities, and 60% have at least one ward with a significantly higher rate than England.

Child poverty and unemployment are the 2 area deprivation indicators with the strongest influence on under-18 conception rates. Free school meals eligibility and being a looked after child or care leaver are 2 of the strongest individual risk factors associated with pregnancy before 18. Other strongly associated risk factors are persistent school absence by year 9 and poorer than expected academic progress between key stage 2 and 3 (ages 11 to 14).

Maintaining a downward trend is a priority in the Department of Health and Social Care’s Framework for Sexual Health Improvement in England. The Public Health Outcomes Framework (PHOF) includes the under-18 conception rate and a number of other indicators disproportionately affecting young parents and their children. PHE has published evidence-based guidance on teenage pregnancy to help local areas sustain reductions, narrow inequalities and improve outcomes for young parents and their children.

Not in education, employment or training (NEET)

A report on young people not in education, employment or training reported that they are likely to be:

• eligible for free school meals
• those who have been excluded or suspended from school
• those with their own child
• those who have a disability

In January to March 2019, 11% of all young people aged 16 to 24 were NEET.

Immunisation

While uptake of infant and childhood immunisations is generally good in England, a proportion of children and young people may have missed opportunities to receive routine vaccines and remain vulnerable to preventable infectious diseases.

Early adolescence is an ideal opportunity to find out immunisation status, particularly as young people are becoming more aware of their own health and wellbeing. No opportunity to check immunisation history and offer missing immunisations should be missed. A young person’s immunisation status can be checked during contact with health and care professionals at any age. From April 2019, GPs in England can claim a fee for checking the MMR immunisation record of 10 and 11 year olds, confirm they are still in the area, actively invite and immunise those who lack 2 doses of MMR vaccine.

You can also check immunisation status before routine teenage vaccinations such as HPV, MenACWY and Td/IPV. These vaccines are usually offered in school settings and other vaccines which have been missed previously, such as MMR, can be given at the same time. From September 2019, boys in school year 8 (aged 12 and 13) will be offered the HPV vaccine as well as girls.

Cases and clusters of measles are still being seen in the UK. These can be prevented through unimmunised individuals receiving 2 doses of MMR vaccine. This will also provide protection against rubella which is important for females of childbearing age to protect unborn children from the potentially serious effects of rubella infection during pregnancy.

Road injury prevention

As children become more independent and start to travel on their own this corresponds to an increase in the casualty rate. Child pedestrian casualties increase rapidly between the ages of 9 to 12.^{[footnote 13]} Teenagers are also particularly at risk once they learn to drive, and travel as passengers with friends. The highest rates of hospital admissions and police reported serious and fatal casualties occur immediately after young people start legally using cars and motorcycles.

Evidence shows that taking a ‘whole school approach’ – one that develops a supportive culture, ethos and environment; focuses on learning and teaching and proactive engagement with families, outside agencies, and the wider community is more likely to have a positive impact in embedding and sustaining a positive impact across a range of outcomes.

Core principles for health and care professionals

Health and care professionals should:

• know the needs of individuals, communities and population and the services available for children and young people
• think about the resources to support healthy lifestyles available in the health and wellbeing system
• understand specific activities which can prevent, protect, and promote healthy lifestyles

Taking action

Frontline health and care professionals

Health and care professionals can have an impact on an individual level by:

• ensuring children, young people and families are aware of the services available to them and how to access them in a timely manner
• improving service access through technology and safe social media approaches which complement face to face delivery
• providing early help and access to local services for children, young people and families who may need additional support, at times when they need it most
• providing consistent evidence-based healthier weight, optimal nutrition and physical activity messages for young people - this includes explaining the principles of the Eatwell Guide, and directing to further information
• providing evidence based oral health advice and signposting to further information and dental care
• providing evidenced based drug and alcohol advice, targeted support to vulnerable groups of young people and signposting for specialist support where needed
• ensuring services are young people friendly and meet, or are working towards, You’re welcome quality criteria
• using supervision as a supportive tool to address emotive issues from practice
• keeping updated on policies and procedures for working in safeguarding or child protection

Team leaders and managers

Community health and care professionals and providers of specialist services can have an impact by:

• engaging with young people, ensuring their voice is embedded in service design, emphasising young people as local assets
• working collaboratively with key partners, for example, local authorities, primary and secondary schools and specialist services to address young people’s health inequalities and improve health and wellbeing outcomes
• working in partnership with local communities to build community capacity; demonstrating population value, utilising asset-based approaches, best use of resources and outcomes; and ensuring effective use of community-based assets
• developing integrated services between health, education providers, community and third sector organisations to ensure they are responsive to national and local needs and demonstrate improved public health outcomes

Senior or strategic leaders

Health and care professionals should be aware of the interventions at population level, which include:

• using national and local data to identify public health priorities for children and young people, focussing on important challenges they may experience in early adolescence, including the transition between primary and secondary school, and progression towards self-determination and decision-making
• promoting emotional wellbeing and health messages both in and out of school settings; seeing children and young people as community based assets who can support population health and wellbeing
• working collaboratively with partners including schools and local authorities to stimulate awareness of need and to develop collective solutions
• working with commissioners to ensure services are meeting local needs (PHE 2018)

Understanding local needs

Public Health Outcomes Framework (PHOF)

There are 4 indicators linked to children aged 10 to 14.

1. Excess weight in children aged 4 to 5 and 10 to 11 (2.06ii). In academic year 2017 to 2018, 22.4% of 4 to 5 year olds had excess weight and 34.3% of 10 to 11-year-olds.
2. Hospital admissions caused by unintentional and deliberate injuries in children aged 0 to 14 years (2.07i). In 2017 to 2018 the admission rate was 96.4 per 10,000 resident population aged under 15 years.
3. Average difficulties score for all looked after children aged 5 to 16 who have been in care for at least 12 months on 31 March (2.08i). In 2016 to 2017 this was 14.1.
4. Percentage of children where there is a cause for concern (2.08ii). In 2016 to 2017 this was 38.1%.

An alternative indicator may be the percentage of school pupils with social, emotional and mental health needs. In 2018 there were 2.4% of school pupils with social, emotional and mental health needs.

There are 2 further indicators linked to children under 16:

1. under 18 conceptions: conceptions in those aged under 16 (2.04). In 2017 the under-16 conception rate was 2.7 conceptions per thousand women aged 13 to 15 years.
2. population vaccination coverage HPV in girls aged 12 to 13 years (3.03xii). In 2017 to 2018 the percentage of girls vaccinated was 86.9%.

NHS Outcomes Framework

Tooth extractions due to decay in children admitted as inpatients to hospital, aged 10 years and under (3.7.ii).

Oral health

The National Child Dental Health Survey is a useful reference of changes in the oral health of children. It includes children aged 12 and 15 years and reports on dental examination and questionnaires.

Episodes of children being admitted to hospital for tooth extractions from 2011 to 2018 includes data for hospital extractions 0 to 19 years.

School absence statistics

Statistics are available on overall authorised and unauthorised pupil absences by school type, including persistent absentees and pupil characteristics on GOV.UK.

Statistics on NEET and participation

The Department of Education provide statistics on young people’s participation in education, employment and training and those not in education, employment or training. These are also available on PHE’s Fingertips platform in the Child Health Profiles.

Measuring impact

As a health and care professional there are a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people, or help you with your professional development.

The Everyday Interactions measuring impact toolkit provides an easy way for health and care professionals (HCPs) to record and measure their public health impact in a uniform and comparable way.

The childhood obesity impact pathway is recommended for health and care professionals and the wider public health workforce to record and measure actions undertaken as part of routine care which impact on childhood obesity.

Professional resources and tools

The 4-5-6 model is an evidence-based approach to provide the healthy child programme. It encompasses the reach and impact of health visiting and school nursing services.

‘Supporting public health: children, young people and families’ provides guidance to support local authorities and providers in commissioning and delivering children’s public health services aged 0 to 19 years.

The ‘Healthy child programme 0 to 19: health visitor and school nurse commissioning’ service specification is for local authorities commissioning health visitors and school nurses, for public health services for children aged 0 to 19.

‘Promoting emotional wellbeing and positive mental health of children and young people’ guidance supports effective commissioning of school nursing services to provide public health for school aged children.

The ‘School Nurse Toolkit: improving young people’s health literacy toolkit’ has been designed by the Association for Young People’s Health and PHE to support school nurses to improve young people’s health literacy.

The ‘Addressing health inequalities in homeless children, young people and families’ learning resource is designed as a self-study tool to help public health nurses to engage effectively with this important group, in order to reduce health inequalities and lead to better outcomes.

‘Young people commissioning support 2019 to 2020: principles and indicators’ is guidance to help commissioners and local authorities develop joint strategic needs assessment and health and wellbeing strategies to reduce the harm caused by smoking, drinking, substance use and misuse in young people.

Getting it right for children, young people and families: maximising the contribution of the school nursing team - vision and call to action provides best practice guidance for school nurses.

School nursing: public health services includes advice on promoting emotional wellbeing and positive mental health of children and young people.

Supporting children, young people and families and communities to be safer, healthier and to reduce youth crime is guidance to support school nurses and youth justice professionals working with young people who are in the youth justice system or at risk of being involved.

Maximising the school nursing team contribution to the public health of school aged children is guidance for putting in place public health services for children and young people from 5 to 19 years.

Supporting the health and wellbeing of young carers sets out important messages for services and professionals to meet the needs of young carers. It is of interest to all professionals providing on-going care where a child or young person may be involved in caring duties.

Supporting the health and wellbeing of military families supports health visitors and school nurses to improve outcomes and outlines aspirations for service provision.

Quality criteria for young people friendly health services sets out principles to help commissioners and service providers to improve the suitability of NHS and non-NHS health services for young people.

Promoting a healthier weight for children, young people and families offers consistent messaging support for health and care professionals to be consistent and provides a core set of evidence-based healthier weight, nutrition and physical activity messages throughout the life course.

Promoting children and young people’s emotional health and wellbeing is guidance describing principles, informed by evidence and practice, to promote emotional health and wellbeing in schools and colleges.

Health behaviour in school age children (HBSC) is data analysis of the HBSC survey data to explore the rising trend in poorer emotional wellbeing of young people.

Improving young people’s health and wellbeing is a framework for national and local action to address and promote health outcomes of young people.

A public health approach to promoting young people’s resilience is a resource focusing on public health approaches to supporting young people’s resilience.

Road injury prevention: resources to support schools highlights important data, signposts support, resources and shares practice examples.

The Marmot Review proposed the most effective evidence-based strategies for reducing health inequalities in England from 2010. It includes 2 specific policy areas for children:

• give every child the best start in life
• enable all children, young people and adults to maximise their capabilities and have control over their lives

Measles: the green book, chapter 21 provides measles immunisation information, including updates, for public health professionals.

Health Matters blog on child dental health outlines how health professionals can help prevent tooth decay in children under 5.

NICE guidance

Behaviour change: general approaches (PH6) provides the principles for effective interventions and is aimed at those responsible for helping people to change their behaviour to improve their health.

Behaviour change: individual approaches (PH49) also makes recommendations on individual-level interventions, aimed at health-damaging behaviour in over 16s.

Alcohol and drugs

NICE ‘Alcohol: school-based interventions, Public health guideline PH7 covers school-based interventions to prevent and reduce alcohol use among children and young people. It aims to encourage children and young people not to drink, delay the age at which they start drinking and reduce the harm to those who do drink.

NICE ‘Drug misuse prevention: targeted interventions, guideline NG64’ covers targeted interventions to prevent misuse of drugs, including illegal drugs, ‘legal highs’ and prescription-only medicines.

NICE ‘Alcohol-use disorders:diagnosis, assessment and management of harmful drinking and alcohol dependence, clinical guideline CG115 covers identifying, assessing and managing alcohol-use disorders (harmful drinking and alcohol dependence) in adults and young people aged 10 to 17 years.

NICE ‘Co-existing severe mental illness and substance misuse: community health and social care services, guideline NG58 covers how to improve services for people aged 14 and above who have been diagnosed as having co-existing severe mental illness and substance misuse.

Weight management

Obesity prevention (CG43) guidance on the prevention of overweight and obesity in adults and children and is the first national guidance on the prevention of overweight and obesity in adults and children in England and Wales.

Obesity: identification, assessment and management (CG189) covers identifying, assessing and managing obesity in children, young people and adults.

Physical activity for children and young people (PH17) also provides guidance for all those who are involved in promoting physical activity among children and young people, including parents and carers.

Preventing unintentional injuries

‘Unintentional injuries: prevention strategies for under-15s’ (PH29) gives advice and guidance on preventing unintentional injuries in the home, on the road and during outdoor play and leisure.

‘Unintentional injuries on the road: interventions for under-15s’ (PH31) gives advice on how health and care professionals and local highways authorities can make the roads safer.

In addition, ‘Unintentional injuries in the home: interventions for under-15s’ (PH30) aims to prevent unintentional injuries among all children and young people but, in particular, those living in disadvantaged circumstances as they are at increased risk compared to the general population.

Social and emotional wellbeing

Depression in children and young people: identification and management (CG28), in primary, community and secondary care, covers the care children and young people can expect from their doctor, nurse or counsellor.

Social and emotional wellbeing in primary education (PH12) is guidance is for teachers and school governors, and for staff in local authority children’s services, primary care and child and adolescent mental health services.

Social and emotional wellbeing in secondary education (PH20) focuses on interventions to support all young people aged 11 to 19 who attend any educational establishment.

Substance misuse among vulnerable children and young people (PH4) outlines the paths for reducing substance misuse.

Smoking: preventing uptake in children and young people (PH14) is aimed at teachers, school governors and practitioners with health and wellbeing as part of their remit.

Alcohol interventions in secondary and further education (NG135) is aimed at teachers, school governors and practitioners with health and wellbeing as part of their remit.

Oral Health

Public Health England and NICE have published Delivering better oral health. This is an evidence-based guide to prevention in dental practice which describes the preventive advice and actions required to improve oral health.

Oral health promotion: general dental practice (NG30) describes how dental teams can best convey such advice.

Improving oral health: an evidence-informed toolkit for local authorities aims to support local authorities (LAs) to commission oral health improvement programmes for children and young people aged up to 19 years.

Oral health improvement: local authorities and partners (PH55) recommends that oral health is promoted and protected by improving diet; reducing consumption of sugary food and drinks, alcohol and tobacco; improving oral hygiene; increasing the availability of fluoride; encouraging regular dental attendance; increasing access to dental services.

Looked-after children

Looked-after children and young people (PH28) focuses on how organisations, professionals and carers can work to help looked-after children and young people reach their full potential.

Advice for patients and the public

The NHS website and Change4Life have a range of information and resources to support people to eat well, get fit and manage their weight.

Rise Above is a social marketing programme which aims to equip 11 to 16 year olds with the skills they need to withstand social pressures and build their resilience.

MindEd is a free educational resource about children and young people’s mental health for all adults.

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2. Pedrelli, P., and others, Alcohol use and depression during adolescence and young adulthood: a summary and interpretation of mixed findings. Current addiction reports, 2016. 3(1): p. 91 to 97. ↩

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4. NHS Digital, Smoking, Drinking and Drug Use Among Young People in England - 2016, in NHS Digital. 2017. ↩

5. Hibell B, Guttormsson U and Ahlström S (2012) The 2011 ESPAD Report - Substance use among students in 36 countries. The Swedish Council for Information on Alcohol and Other Drugs (CAN). ↩

6. Young people - substance misuse commissioning support pack 2018 to 2019: principles and indicators. ↩

7. NHS Digital, 2017 Mental Health of Children and Young People in England ↩

8. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62 (6) pp. 593 to 602. doi:10.1001/archpsyc.62.6.593. ↩

9. DHSC and DfE Transforming children and young people’s mental health, 2017. ↩

10. PHE (2017) Cyberbullying - an analysis of data from the Health Behaviour in School Age Children survey for England 2014. ↩

11. Mental health of children in England. ↩

12. A public health approach to promoting young people’s resilience ↩

13. PHE (2016) Road injury prevention - resources to support schools promote safe active travel ↩