Children’s and Adolescents Views of Health and Mental Health Concepts - A Qualitative Group Discussion Study

doi:10.21203/rs.3.rs-4676436/v1

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Children’s and Adolescents Views of Health and Mental Health Concepts - A Qualitative Group Discussion Study

https://doi.org/10.21203/rs.3.rs-4676436/v1

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Background To explore children’s conceptualizations and perceptions of health and more specifically mental health.

Methods: Open semi-structured group discussions with 44 Swedish children and adolescents (10–14 years old) recruited from four schools were conducted. The interviews were conducted between April 2022 and January 2023. Data were analyzed using qualitative content analysis.

Results: Children’s and adolescents' conceptualizing of health included aspects of both the body and the mind, with a focus on the latter. Mental health was expressed as a state of being, illustrated by various lived experiences of emotions, moods, and thoughts. The social world was ever present in their understanding of health, e.g., through the lenses of social and gender norms.

Conclusions: This study reveals young children’s recognition of health terms, showing their ability to observe nuances between mental health problems and everyday struggles. The children discussed mental health problems to a greater extent than mental health promotion. An implication of the study is the highlighted need to focus more on mental health promotion in future preventive programs. These findings might also potentially influence how school staff and student health team communicate with secondary children and adolescents about these concepts.

Health promotion

School nursing

Content analysis

Mental health

Perceptions

Adolescents

Focus groups

Qualitative interviews

Public Health

Health literacy

Mental health among children and adolescents in Western countries, including Sweden, has declined since the 1980s (1-2), and the proportion of young people reporting recurrent psychosomatic symptoms — a key indicator of mental health problems— has doubled. Now, almost half of Swedish 15-year-olds report experiencing this type of issue (2-3).

Common mental health problems among school-age children include anxiety, worry, sleeping problems, and low mood. A high percentage of school children also express feeling stressed by schoolwork, with 15-year-old girls reporting the highest percentage (78 percent) compared to boys of the same age (51 percent). Additionally, the proportion of students who enjoy

school a lot continues to decrease, as does perceived classmate support. Furthermore, more children are being bullied at school compared to previous years (2). Despite these mental health challenges, the majority of school-aged children in Sweden report good life satisfaction, a trend that has remained relatively stable since the early 2000s. Thus, while young people generally seem to feel well, they also experience stress and report psychological problems, painting a complex and elusive picture of their health and well-being (2).

Throughout the 2000s, visits to Child and Adolescent Psychiatry (CAMHS) in Sweden have dramatically increased. However, whether this reflects an actual increase in illness or a shift in demand, diagnostic criteria, and school dynamics remains inconclusive. Many professionals note that “crises” once considered normal aspects of maturation and development in children and young people are increasingly being categorized as mental illness (4). Life crises are becoming “medicalized”, leading more individuals to seek assistance from CAMHS for issues that were previously addressed within family or social circles, such as relationship breakups. At the same time, a growing number of children and young people present with challenging and complex needs, indicating a diverse demand for assistance (5). In a comparative study on child psychiatry involving 13 other countries, Sweden ranks highest in terms of the proportion of children in the population registered for CAMHS (6.4 percent) (6).

Thus the medicalization of everyday challenges has expanded the scope of mental health. This development reflects a changing society and a new coping mechanism for emerging realities. Definitions and understandings of mental health has not remained static, leading to uncertainty on both ends. One end represents individual capacity and the ability to adapt and self-manage, while the other represents the community, society, and academia. Manwell et al. (7) suggest that the widespread use of the term 'mental health' serves as a euphemism for ' mental illness' and that the lack of agreement on the subcomponents and factors encompassed by the concept underscores the need for distinct definitions for individual and societal understanding.

A mapping by Manwell et al. (7) of how mental health experts determine core concepts illustrates how different empirical discourses shape mental health definitions. There is the definition proposed in the spirit of health promotion, emphasizing the positive aspects of the concept. Mental health is seen as the capacity for individuals to feel, think, and act in ways that enhance their ability to enjoy life and cope with the challenges, respecting cultural, equity, social justice, interconnections, and personal dignity (8). The World Health Organization’s (WHO) definition echoes similar positive dimensions: '... a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” (9). Criticism of such broad definitions highlights their contributes to the medicalization of society, as they exclude many individuals (10), thereby viewing everyday problems within the scope of mental health.

A previous scoping review (11) on this matter shows some uncertainty in understanding mental health. A shared mental health language would help children clarify distinctions between everyday challenges and issues requiring specialist attention. According to Beckman et al. (11), it is also evident that highlighting the positive aspects of mental health can increase the understanding that mental health can be improved. Similar conclusions are drawn by Hermann et al., (12), emphasizing the importance of clear terminology in mental health discussions. They further demonstrate that older adolescents (15-18 years) discuss mental health in holistic terms, indicating their understanding of its complexity despite using simplified language.

But how can we expect children to understand and communicate 'real' mental illness when various discourses around the concept exist? Empirically investigating perceptions of mental health among children and adolescents needs to consider researchers’ presumptions of the concepts. However, as a response to the biomedical approach, Antonovsky (13) introduced the salutogenic approach to health, which views health as more than just the absence of risk factors. It focuses on human strengths, viewing health as a continuum rather than a dichotomy. Consequently, there is a pressing need for more studies involving children and adolescents to gather their perspectives on the health concept and mental health.

Understanding how health and mental health is perceived and communicated among children and adolescents is crucial in planning interventions and strategies for health and mental health care and support. Therefore, this study aims to explore children’ conceptualizations and perceptions of health and mental health.

We opted for group discussions, rather than focus groups to gather in-depth information from the participants, foster comfort within their peer groups, facilitate the exchange of experiences, and enable them to comment on each other’s viewpoints. While focus groups originally were used for generating hypotheses, and for evaluating the effectiveness of statistical instruments and to explore participants’ insights (14), it is still used to emphasize the interaction among group participants in order to generate data and insights that would not otherwise be discernible. Group discussions were originally used mainly for research conducted with children and young people. The main objective of group discussion is to capture the issue being studied related to, for example, the social and school environment, and to the generational context. The interview guide for a group discussion is not followed strictly and should not be presented as a questionnaire. However, it is important that the initial question is the same for all groups, since the goal is to analyze them comparatively. Group discussions, as a research method, are an important tool in the reconstruction of milieux, both group milieux (e.g., family, neighborhood) and milieux characterized as spaces of expanded conjunctive experiences (e.g., generational, educational, gender, ethno-racial origin). Group discussions attempt to reconstruct collective orientations and the models that guide the actions of subjects in these spaces. The analysis of subjects’ discourse, both from an organizational and dramaturgical point of view, is key and helps to identify the collective importance of a given topic that emerges in a group discussion.

Data and participants

This study involved 44 participants (26 girls and 18 boys) aged 10–14 from four different schools in Värmland County, Sweden. This age range was chosen because it comprises grades 4 to 9 in Swedish schools, and that children in that age could be considered old enough to discuss these questions and understand what they comply with. Eight mixed-gender group interviews were conducted from April 2022 to January 2023 (see Table 1 for the gender and grade distribution). The interviews took place at the participants’ respective schools.

Table 1. Participants by gender and grade in each school area respectively.

Schools

Total (n = 44)

Girls (n = 26)

Boys (n = 18)

North school

Group 1

Group 2

n = 9

grade 8 n = 4

grade 8 n = 5

n = 5

grade 8 n = 2

grade 8 n = 3

n = 4

grade 8 n = 2

East school

Group 1

Group 2

Group 3

n = 17

grade 6 n = 6

grade 5 n = 6

grade 4 n = 5

n = 10

grade 6 n = 5

grade 5 n = 1

grade 4 n = 4

n = 7

grade 6 n = 1

grade 5 n = 5

grade 4 n = 1

South school

Group 1

Group 2

n = 10

grade 5 n = 6

grade 4+5 n = 4

n =7

grade 5 n = 4

grade 4+5 n = 3

n = 3

grade 5 n = 2

grade 4+5 n = 1

West school

Group 1

n = 8

grade 8 n = 8

n = 4

grade 8 n = 4

n = 4

grade 8 n = 4

Procedure and interview guide

The study received approval from the Swedish Ethical Review Authority (No: 2021-06168-01). The central Student Health Services (SHS) assisted in selecting schools and recruiting participants from grades 4-8 at four different schools. Subsequently, schools were contacted and provided with documents and project information. Participants were recruited from classes through school personnel (principals, school nurses, and school social workers). No specific selection criteria were outlined, except that the participants were required to have their parents’ signed consent at the time of the interview. Children interested in participating in a group discussion were eligible for the study. Some schools opted to inform the entire class about participation, while in other cases, teachers approached specific children. Participating children received both oral and written information about the study, emphasizing its voluntary nature, their right to terminate participation at any time, and the assurance that their responses would remain anonymous. Written and oral consent was obtained simultaneously with the interviews, which took place approximately two weeks after the first information session. The group interviews were conducted using open to semi-structured interview techniques, with an interview guide developed based on previous literature, such as Beckman et al. (11), focusing on amplifying children’s voices on health matters. Slightly different questions were tailored for different age groups (refer to the supplementary material for the interview guides).

The interviews were conducted by all authors, with two authors present for each interview, alternating between being the roles of preceptor and co-preceptor. Ibáñez (15-16) argues that the preceptor in the group discussion should not direct the group’s conversations, but rather provide an “open structure” so that all the participants can reproduce through their discourses “relevant relations” while allowing the participants themselves to decide what they want to talk about and in what order (15). The task of the preceptor involves “provoking the emergence of a theme and catalyzing its discussion” (15). The preceptor posed the questions and followed up with probes such as “Can you elaborate on what you just said?” and “Can you provide an example.” Before concluding each group discussion, participants were invited to share any additional thoughts or highlight any overlooked topics. The discussions lasted between from 30 and 59 minutes. Participants were not requested to review the transcripts before analysis due to the potential embarrassment or confusion in distinguishing their statements from others in the group (17). As the schools were chosen by the school health team manager, the sample could be considered a convenience sample. The socioeconomic status of the schools was assessed as middle to high based on grade points and average income for the district where the school is located.

Data Analysis

Data analysis was conducted using qualitative content analysis described by Graneheim and Lundman (18). In the first step, each group discussion was transcribed verbatim, and all authors read the transcription of each group discussion numerous times. Descriptions of health and mental health constituted the unit of analysis. Next, meaning-carrying units were condensed and abstracted into codes. These codes were then compared and sorted into categories. As the analysis progressed, categories and subcategories were further clarified and adjusted, resulting in the creation of three main categories (Table 2). The initial coding of the transcripts were performed by SH, SJS, and LB, each coding different interviews. The coded data were then collectively examined to construct categories. Throughout the analysis, comparisons were made with the context in each step to verify the empirical basis of the data.

Tentative codes and categories were discussed by all authors and revised until consensus was reached. In cases of disagreements, we revisited the meaning-carrying unit to ensure the fit with the category or reconsidered the preliminary coding. Reflection and discussion led to agreement on sorting the codes. By including quotations from the transcribed text, similarities within the differences between categories were illustrated (18). The quotations were translated from Swedish to English with the help from a native English speaker. Quotations cited in the results are labeled based on school and grade. The current study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (19). In conducting qualitative studies, it is important to acknowledge an awareness of one’s pre-understanding to minimize its influence on results and analysis. However, it is neither possible nor desirable to entirely eliminate it. According to Alvesson and Sandberg (20), pre-understanding can broaden the empirical base, generate ideas, formulate research questions, and evaluate the relevance and novelty of knowledge. The authors of this article have diverse backgrounds in social science, public health sciences, and psychology, contributing to - as well as constraining - the understanding and interpretation of the results.

Trustworthiness

To enhance trustworthiness, each step of the study included discussions concerning credibility, dependability, and transferability (18). Credibility was bolstered by including a variety of participants from various schools, striving for diversity in ages and genders. Our research team also comprised members with different backgrounds, allowing for a multifaceted examination of the data. We believe that the choice of group interviews further enhanced the credibility since children may feel a sense of imbalance in power dynamics when meeting an unknown person alone and discussing health and mental health (21). Additionally, we developed an interview guide ensuring that the same questions were addressed in all interviews, further bolstering credibility. To reinforce credibility, we included representative quotations from the interviews, and thoroughly discussed the codes and preliminary categories. One team member, a licensed psychologist specialized in clinical child and adolescent psychology (PsyD), contributed to maintaining a safe environment, particularly in preventing discussions of sensitive topics such as suicide (18). Dependability refers to the stability of data over time (18). Seven of eight group interviews were conducted during late spring and after the summer holiday, with one conducted the following winter. We believe that the gap between the seventh and the eighth interviews likely did not affect the result significantly. While new follow-up questions may have emerged during the later interviews, we did not review the transcripts beforehand. However, we do not consider this a factor contributing to inconsistencies in results but rather a source of greater variation in answers. The description of culture and context, characteristics, and selection process enables readers to assess the transferability of findings to other groups and contexts (18). Due to the nature of the sampling, which partly adapted to school circumstances and availability of time and willing teachers, transferability is open to discussion. Nonetheless, by selecting schools from different socio-economic districts and including boys and girls across grades 4 to 8, we believe that the sample can be considered transferable within a cultural context comparable to Sweden.

Table 2. Categories and sub-categories

	Perceptions of health - with focus on mental health
Categories	Conceptualizations of health	Experienced-based manifestations of being	Social norms
Sub-categories	Health - body and mind	Health as a state of being	Fitting in and being affirmed
	The meaning and value of the word	Negative mental health as an elusive emotion	Complexion and self-image
	Overlapping concepts	Health affected by sources of worries	Social life in school and on social media platforms
			Tell, show, ask

Conceptualizations of health

Children’s conceptualizations of health included the sub-categories Health - body and mind; The meaning and value of the word and Overlapping concepts. In conceptualizations of health, the participants gave their view of what health, mental health, and similar concepts meant to them.

Health - body and mind

When asked to describe what “health” is, the children discussed diet and exercise – especially among the younger ones. Good health was associated with eating nutritious food and essential vitamins, and to generally avoid eating junk food. Staying “fit”, i.e., maintaining a stable weight was also considered an important aspect of good health. It was evident that some children’s conceptualization of health encompassed mental well-being, and that these children recognized an interconnectedness of the body and the mind:

They affect each other. So, if you have positive thoughts and feel good mentally, it might be easier for you to be active and eat well. For some, it could also be that staying active and sleeping well may lead to better thoughts and such. (North school, grade 8b)

I would say that they are two completely separate things: one is about how your body feels, and the other is about how you feel mentally. (East school, grade 5)

Although some younger students in grade 4 were unsure of the meaning of mental health, it was described as “how you feel in your brain”, “that you are happy and energetic,” how you are treated by others, and how you enjoy your surroundings. Mental health was also associated with academic performance and peer relationships. However, understanding someone’s true emotional state was acknowledged as challenging:

For some people, you might think that they're doing really well, but deep down, they may not always be feeling great. Mental health can encompass many things because a lot is happening under the surface. (South school, grade 5)

One pupil in grade 6 described mental illness as unwell in the mind, emphasizing that it involves prolonged feelings of sadness rather than transient emotions. There was a perception that mental health was more important than physical health. Taking care of one’s body through exercise was seen to positively impact mental well-being, and that the two are intricately linked. A fifth-grader illustrated this by emphasizing that you need to work harder to get rid of a state of mental illness than being physically sick:

I think there's more weight when it comes to the mental aspect because when you're feeling mentally unwell, you have to put in extra effort to overcome it. Whereas, if you're physically unwell, it often tends to pass after a while, such as when you're sick. (East school, grade 5)

The meaning and value of the word

A call for greater caution was evident in how the concepts related to mental health should be used. The children expressed concern that mental illness was often trivialized through humor, risking its significance being undermined. Referring to mental health concepts, the children stated: "One must know what the word means". One fifth-grader gave an example of a non-sarcastically use of a loaded expression:

Sometimes people may joke about being depressed, like saying, "Oh, the game got canceled today; I'm so depressed now."(East school, grade 5)

The more general expression "feel bad" was described as a collective term that could carry varying degrees of seriousness:

You don't necessarily have to use it (feel bad) for mental problems; if you have a stomachache, you feel unwell. The weight of the term varies depending on the context in which it's used. (East school, grade 6)

The multiple views of what constitutes mental health indicates the complexity of mental health-related concepts, highlighting the challenges in their usage and understanding across different contexts.

Overlapping concepts

In reasoning about the concepts related to mental health, the children showed that their perceptions of these concepts frequently overlapped. Concepts such as sadness appeared to be perceived as easier to cope with by the children and worry were perceived as different yet interconnected. It was seen as easier to feel worried than sad and more challenging to feel worried than sad. One reason for this was, “When you are sad, you can cry, but when you are worried, you have to talk.” (East school, grade 6). Dealing with sadness could be perceived as i.e. "easier". Worry, on the other hand, could be experienced as stressful, with stress being described, among other things, as a mixture of feeling sad and worried. Stress was characterized as a sensation that “took over,” but it was acknowledged there could be both positive and negative forms of stress. Anxiety was seen as an extension of stress, where individuals tend to “overthink” various situations and events:

Anxiety is a combination of stress and feeling a bit down. Homework, negative social circles, exams, and things that weigh you down can lead to a point where you can't handle it anymore, resulting in a panic attack or something similar. (North school, grade 8a)

Anxiety was described as a sudden and intense feeling that could cause difficulty in breathing. However, older children believed that anxiety was not a term commonly used and was considered "harsher." Panic attacks were viewed as an escalation of anxiety: “Stress is more common; a panic attack is the peak of anxiety.” (North school grade 8a). During a panic attack, everything could seem to freeze, and there could be a sense of darkness for a while.

Yes, I believe there's a difference between anxiety and panic attacks. It seems like anxiety is something that lasts for a longer period, maybe transitioning from stress to anxiety. There are many different factors that can trigger this anxiety. However, when it becomes a panic attack, I think it's more intense and happens closely together. That's what I think. (North school, grade 8a)

When asked to define depression, it was described as feeling unhappy, very low, lacking the motivation to take care of oneself, and struggling to get out of bed. It could involve overthinking, “worrying,” and burying oneself. There could also be different versions of depression, where some deny it and go around smiling all day, but then when they get home, they dive into bed and are “completely destroyed.” The children said that everyone feels bad sometimes, but depression is being down for a longer period of time and that it was important to get help.

Experienced-based manifestations of being

In contrast to the perhaps more knowledge-driven conceptualizations of health, experienced-based manifestations of being represent answers relating to the inner self and one’s own experience of ill- and well-being. Experienced-based manifestations of being include the sub-categories Health as a state of being; Negative mental health as an elusive emotion; Health affected by sources of worries.

Health as a state of being

Health is expressed by the young respondents as consisting of various expressions of emotions, moods, thoughts, and overall well-being. If conceptualizations of health represent explicit descriptions of concepts, Health as a state of being represents hints of ideas originating from one's own experiences, implicitly relating to health through aspects of being. The spectrum on which these expressions move stretches from concrete expressions regarding physical health and sedentary lifestyles to vague and elusive expressions of being. The former is more often a response to physical health. Feeling fit and alert, being physically active, and sleeping properly were seen as expressions of well-being, while inactivity represents mental illness. A fourth grader gives this example:

I think bad health is mostly when you sit all the time and don't do much. (South school, grade 4)

Negative mental health as an elusive emotion

There is an elusiveness that characterizes these perceptions, mostly related to the negative aspects of being or moods, where the young respondents seemingly do not quite grasp the word that rightly describes the feeling or state of being. When asked to describe mental health, answers partly presented clear illustrations such as being happy, in good spirits, or enjoying oneself. However, negative perceptions of mental health manifested as a form of ill- being, often more vaguely expressed as a certain emotion, thought, mood, or gut feeling. Something they carry with them, sometimes for longer periods, as a state of being of the inner self.

It kind of doesn’t feel good. (East school, grade 5)

I think it means psychologically, it’s inside, that is when you kind of don't feel good inside and that it's like, it's like that thing with stress, that you don't feel so good inside. (East school, grade 4)

Health affected by sources of worries and stress

Worries were also perceived as something that triggers mental illness and stress and expressed in different forms and distances from oneself. Worries about the war in Ukraine and Syria or worries that a family member will die or get hurt. But worries about school and schoolwork was also quite extensively expressed. These worries as expressions of mental illness resemble what was also perceived as stress. When asked how they would describe stress, associations with thoughts were quite common, that they think of something that makes them stressed. Some describe it as overthinking or as a feeling that ends up in the stomach and creates anxiety. School seems to be the source of much anxiety and stress. Stress about tests, grades, and not learning enough or as a general feeling of being chased and unable to make it. A feeling apparently tangible and overwhelming to the young respondents but seldom concretized or further described. A sixth grader emphasizes stress when it’s too much.

One becomes overwhelmed, you know. You might think, for example, that you have a lot of things to do, like studying, exercising, and many other things, and it can become a bit too much. (East school, grade 6)

Social norms

The social world was ever-present in children' understanding of health, either implicitly or explicitly. Social norms included Fitting in and being affirmed, Complexion and self-image, Social life in school and on social media platforms, and Tell, ask, show. The children viewed fun activities with friends as having beneficial health effects because you do something enjoyable (and hence good) for yourself in a shared experience with close ones. However, social relationships were also associated with potential disadvantageous health consequences.

‘Being normal’ was considered vital for health, and it was also evident that beauty standards and gender norms were related to mental health and showing emotions.

Fitting in and being affirmed

Being normal and fitting in were considered essential to health – it is important to look and act like everyone else. If you do not fit in, you are left out:

And it can also be that you feel like, 'I don't fit in here; everyone else is so cool, and I just come in here suddenly like a little...'. Yeah, it's probably mostly feeling a bit excluded or left out. (South school, grade 5)

Mental health was, in this context, described as being affected by how people view you, what you do, and whether you are liked or not. On the same note, being socially awkward or prone to over-analyzing social situations can be stressful and depressing. Conforming to the group may lead to a sense of belonging, but chasing social affirmation may be compromising your health, e.g., doing things you do not want to do through peer pressure:

You do things you don't want to, as others want it, and so you want to be with them. So instead of saying, 'No, I don't want to do this, can't we do anything else?', you do it anyway, so you don't exactly take care of yourself. And then you sit there feeling sad because you did something that made you feel sick or bad. (South school, grade 5)

Complexion and self-image

Mental health is also described with reference to how one feels about how one looks and appears in the eyes of others. There seems to be a definitive link between physical appearance and mental health, and it goes both ways. To desire something you don’t have, a look or appearance, was one way of describing hope mental health could be affected by complexions or one’s self-image. Trends in looks and body shapes were also examples of what could affect mental well-being.

So it could also be that you feel bad, for example, about your appearance or you feel that you are not enough, so then you can- So you can think that you are mean even though you are not satisfied with yourself, and then it becomes psychological. (South school, grade 5)

Body trends reflected in social media were considered unhealthy, and these beauty standards mostly affected girls - and made them feel worse.

Social life in school and on social media platforms

Well- and ill-being as a signifier of health was also expressed in social terms, such as how

things are going at school and how one handles life. Well- and ill-being becomes extensive in the descriptions of young people; it can be about not feeling as usual, feeling scared, or not being good enough. It’s perceived as part of life and an everyday occurrence, appearing to many of the respondents as a consequence of social situations and encounters in real life, but certainly also on social media platforms where the young participants express concerns about the ongoing talk but also incitement around trends and behaviors. It's expressed as positive and negative experiences of being seen and sharing community, but also comparing oneself to others and how that can create bad feelings. However, at the same time, respondents refer to social media and the cell phone as a place to take a break and escape from stress at school, thus facilitating well-being. Social media was considered both fantastic and a terrible place. The children describe how they try to act like everyone else on social media. Social media sets standards for how one should look, which can lead to stress and depression:

Social media sort of raises the standard of how one should look, one's clothing style; for example, a lot of people Photoshop and tinker with the pictures, whether they want to get a smaller waist or bigger biceps or, yes, to make it look better and: This is how a body should look - even if it's not supposed to look like that. (North school, grade 8a)

Many have gone through stress or depression because they want to look like those who have been Photoshopped. Yes, so there are also many disadvantages. (North school, grade 8a)

The children also spoke about the role social media has in spreading so-called fake news and, by that, spreading anxiety.

Tell, show, ask

The children perceived it to be more of a taboo for boys to cry compared to girls. They expressed that boys often abstain from crying to avoid being perceived as weird or non-masculine, even though they emphasized that everyone cries sometimes and that it’s necessary to cry occasionally. Girls were described as having more reasons to be sad because they hurt each other more:

But I also think, I'm not a girl myself, but it seems like girls get more hurt by their friends as well, so it feels like it's quite difficult to be, well if there are three of them, two might hang out together, it can be quite difficult to be the third wheel. But we guys can be a group of several without, well, without any issues, and it works really well. (North school, grade 8b)

The children attributed these gender differences to society, with one explaining that there's just this feeling in his head that it's how things work. Additionally, there’s an age difference to consider, where it was believed that it’s acceptable for young children to cry, whereas teens need to maintain a cool image to a greater extent. Crying in front of others would make you feel weak.

The children emphasized a responsibility for others and the importance of asking friends how

they are. They value the support of others but noted that it’s “not something they usually do in their spare time.” There is also a risk of rejection when one opens up about how one really feels, and friends may also recoil when asked about their feelings. It’s also a matter of integrity; you do not have to share everything, and you cannot force another person to share how they are feeling:

It's difficult to share because you don't need to disclose everything that has happened. You only need to share if you're really worried about something, like "This is what I'm most concerned about how they will react and what they will think." In that case, they can skip that part and share everything they feel comfortable sharing. (South school, grade 4)

Result discussion

Analyzing the stories of school children views on health and mental health revealed several

important information about how they understand these concepts. The results are first discussed in relation to each of the inductive coding categories: Conceptualizations of health, Experienced-based manifestations of being, and Social norms. After that, the findings are discussed in relation to implications in practice and future research.

Conceptualizations of health – the children are well aware

Our main findings reveal that mental health is not an unfamiliar concept to school-aged children, although the youngest ones in grade 4 struggled with it, consistent with findings from a recent scoping review (11). When we inquired about health in general, there was a significant emphasis on eating well and doing physical activity, mirroring the findings of another Swedish study that interviewed children between the ages of 9 - 11 (22). However, mental health was also included in these discussions, and the two concepts - health and mental health – were seen as interconnected, reflecting the relationship between body and mind. Mental health was sometimes perceived to be even more crucial than physical health.

Mental health was described by the youngest children as how “one feels in the brain,” which

encompasses feelings such as mood, emotions, and overall well-being experienced in the mind. It includes feelings of happiness and energy, findings consistent with other qualitative studies with children and adolescents (12, 23-24). The children also included social relationships and surroundings in the descriptions of mental health, a finding echoed elsewhere (23, 25-26). Mental health was also described as when nothing goes against you, akin to the feeling of harmony, as reported by Landstedt et al. (27).

However, mental health is also intertwined with general health, which risks further conceptual ambiguities. Manwell et al. (7) propose that the integration of mental and physical health can be defined by the level of autonomy (i.e., the capacity for control over one’s self), whereas integration of mental and social health can be defined by a sense of ‘us’ (i.e., capacity for relating to others).

Depression, as part of mental health, was understood somewhat distinctly, characterized by not being happy and feeling very bad. The children emphasized that everyone feels bad sometimes, but that depression is feeling down for a longer period of time and that it was important to seek help. Similar findings were seen in Hermann et al. (12), where depression was viewed as a severe mental health problem and an illness, and in Perre et al. (24), where the length of time feeling depressed determined the difference between feeling down and diagnosed depression. We further found that “depression” could be used in many situations, although not meant to be “real,” clinical depression, and some participants underlined that it is important to use the word right; otherwise, the word will not be taken seriously. In Hermann et al. (12), it appeared that the adolescents’ thought peers commonly “self-diagnosed” depression without knowing what the condition really entails (11-12).

However, there seems to be a lack of agreement on what strengths are most associated with mental health (28). In his critical discussion on positive mental health, Vaillant (28) argues that positive mental health represents the presence of human strengths rather than the absence of weaknesses, maturity, the dominance of positive emotions, high socio-emotional intelligence, subjective well-being or resilience (28).

Experienced-based manifestations of being – two sides of the same coin

The children and adolescents struggle to link their cognitive understanding of negative mental health concepts with their limited experiences of mental health issues. At the same time, they partly make use of these concepts when describing experiences of feeling down or low. An approach to distinguish young persons' perceptions and articulations of mental health that has been suggested in several studies is the social constructionist perspective on knowledge. A perspective of the history of psychiatry demonstrates that the talk of “lighter mental symptoms” has changed over time. The analysis shows how the young people's descriptions of mental illness are characterized by a free use of psychological and psychiatric expert language and a “normalization” of different emotions, such as in contrast to the norms and demands of adult (expert) society (11, 29). The elusiveness of the descriptions of being could very well relate to a constructivist merge of more advanced psychological expressions picked up by the adolescents from their immediate environment and from society at large with a self-reflective understanding of one's feelings and moods. A perception of mental health that finds similarities with the dual-factor model (30). A model that suggests a conceptualization of mental health consisting of two separate but still related constructs; a merge of symptoms of psychological distress with subjective well-being and social-emotional strengths (30). This sense of doubled awareness of internalizing and externalizing distress could be what is represented by the vague and trying expressions of being that our study recognized among the adolescents (31).

Worries were perceived as triggers of ill-being. Worries, manifested as stress about school and schoolwork, were also quite extensively expressed. It is clear that school seems to be the source of much anxiety and stress, which was confirmed in our interviews and elsewhere (2, 12). In navigating around expressions of positive and negative mental health in a school environment, it is interesting to note how Putwain et al. (32), in their network analysis, identified school-related well-being to be distinct from test anxiety and more serious conditions as generalized anxiety disorder and panic disorder. Again, the dual-factor model suggests a way of separating but not disconnecting subjective, lighter expressions of mental health with psychological distress (30, 32).

At the same time, school is the most common arena for promoting mental health and the most important because there is a possibility to reach children that would not have been reached otherwise. An arena for promoting positive mental health but where stigma and negative attitudes are also addressed to encourage appropriate help‐seeking for mental health problems. The latter represents more of a deficit approach although meta‐analyses show that multicomponent mental health promotion interventions are more effective when adopting a positive mental health stance rather than focusing exclusively on illness prevention (33).

The range from concrete expressions regarding physical health and sedentary lifestyles to vague and elusive expressions of being that is shown by the children should also be understood from the perspective of the professional. To what extent are we as researchers the cause of this vagueness? A question raised and discussed by Manwell et al. (7) from the perspective that mental health has both a descriptive (“What is”) and a prescriptive (“What should be”) function. Manwell et al. (7) argues that the differences in how these functions are perceived must be empirically determined. In such an investigation which we believe has been undertaken in this study, Huber et al. (10) emphasize the we must be aware of the risk of mixing scientific evidence with moral argument. A thought in line with the argument of the early criticisms of the health-promoting perspectives, viewing health in positive, normative terms, avoiding a focus on risk and deficit (34). That the children struggle with sorting out the meaning of mental health might just reflect this academic uncertainty.

Social norms – body image, mental health and social media linked

The concept of normality is ubiquitous in the debate on mental illness and mental health. Horowitz (35) argues that it is impossible to determine what constitutes a mental disorder without delineating what constitutes normal functioning. If everyday challenges increasingly are being medicalized and, as such, represent deviance from normality according to Aneshensel (36), it raises the question of whether psychopathology constitutes a disjuncture with normality or is on the same continuum as normality, but at the opposite pole. But Vaillant (28) contests the idea of the average being equal to healthy, meaning that at the community level the healthy always mixes in with various forms of psychopathological presence (28). The centrality and normativity of normality have been the subject of critical research (37). From being an expression for the “probable,” it has become burdened with a discriminating power and its usage, therefore scrutinized in medicine as well as in the fields of disability studies, gender studies, anthropology, psychiatry, cultural studies, sociology, and critical race studies (37).

Departing from these definitions, factors relating to the individual and one’s capacity and ability for choice in interacting with society can be identified, stressing concepts of agency, autonomy, and control. The mapping by Manwell et al. (7) was commonly mentioned, suggesting that mental participation in valued roles such as family and work becomes important in understanding mental health. For children, this would represent social role-taking in a school environment, but also social aspects such as being able to disconnect by choice, as opposed to being excluded. It is widely recognized that socially excluded adolescents are at increased risk of depression and anxiety (38). The participants further expressed a link between mental health, body image, and social media. The appearance was thought to influence one’s mental health, and this was exaggerated by photoshopped influencers on social media. According to Choukas-Bradley et al., (39), social media constructs a “perfect storm” where idealized images of peers and quantifiable feedback, together with developmental factors and sociocultural gender socialization processes, amplify adolescent girls’ body image concerns. This can later develop depressive symptoms and disordered eating. The importance of social media for children and mental health cannot be emphasized enough, and adults need to raise awareness and be educated on this matter.

Limitations

In this study, we interviewed a small sample of children; therefore, the results may not be directly transferable to other countries or age groups, although our findings are in line with previous research. Although the participants were recruited from different schools, we did not reach the most vulnerable areas; thus, transferability to multicultural settings and rural areas is limited. Despite employing a nonclinical sample, several participants expressed personal interactions with counselors, doctors, and psychologists regarding mental health concerns, which may have influenced their views. We attempted to steer the discussion away from personal disclosures when these situations arose. Furthermore, the global COVID-19 pandemic and its associated restrictions and isolation for this target group may have affected their views on mental health. However, compared with other countries, Sweden faced fewer restrictions in closing compulsory schools, which might have positively influenced their mental health. Another consideration applies to the recruitment process; in some cases, the schools asked a few selected pupils if they wanted to participate rather than informing the whole class. More verbal and outwardly directed pupils were likely recruited over others, which might have influenced the richness and nuances of the interviews.

We used group interviews to encourage active discussions and enhance interactions by talking to one another, exchanging experiences, and commenting on each other’s points of view. However, the composition of the groups might have contributed to more or less interaction. For example, some participants might not have been comfortable talking in groups with the other sex, as the groups included both boys and girls. There is also a risk of personal negative emotions toward other children in the group, influencing the dynamics of the discussions. Choosing girls and boys from different schools and ages may have enhanced the credibility of the data, as it might have offered a richer variation and understanding of mental health among children with different backgrounds. However, logistical constraints prevented this option from being feasible. Finally, we were two researchers at each interview, which could imply both pros and cons. It is possible that some children felt intimidated by having two adults asking them questions, but this was nothing we sensed was a problem.

Health and mental health might be among the most important concerns for young people today. In an unstable and rapidly changing world where uncertainty dominates the global landscape, it is natural for individuals to feel worried. Transitioning from childhood to adolescence involves navigating various challenges, including friendships, social media, conformity to societal norms, and self-image, all of which significantly contribute to participants’ mental health, as articulated by them. The pervasive influence of social media and gender norms in adolescents' lives have, according to the children in our study, profound effects on their mental well-being. It is imperative for adults to raise awareness and become educated on this matter. The participants’ familiarity with mental health concepts indicates a strong recognition of the terms, albeit not always fully comprehended. They demonstrate an ability to differentiate between mental health problems and everyday struggles more effectively than anticipated. However, how can we expect children to rightly understand and express mental health and mental illness when several discourses and presumptions around the concept exist? When definitions and understandings of mental health have not remained stable, we, as researchers, have a great responsibility in finding that common language. Further, it seems like children and adolescents are more aware of the negative side of mental health problems than mental health-promoting; thus, there is a need for more focus on positive mental health. We hope our results will be used in schools by teachers, student health teams, and pupils in the ongoing health and mental health discussion and health promotion. Our results can contribute to a common language between adults and children. Future research should make use of this knowledge when creating health and mental health-promoting interventions and continue to ask children and adolescents about their views on their lives, and a specific focus should be on social media and how that affects their mental health.

CAMHS Child and Adolescent Psychiatry

WHO The World Health Organization

SHS Student Health Services

SH Sven Hassler (Author)

SJS Siri Jakobsson Støre (Author)

LP Louise Persson (Author)

LB Linda Beckman (Author)

COREQ Consolidated Criteria for Reporting Qualitative Research

PsyD Child and adolescent psychology

Ethics approval and consent to participate

The study has been performed in accordance with the Declaration of Helsinki and has received approval from the Swedish Ethical Review Authority (No: 2021-06168-01). Participating children (oral and written) and their caregivers (written) received information about the study, emphasizing its voluntary nature, their right to terminate participation at any time, and the assurance that their responses would remain anonymous. Written consent was collected from the caregivers beforehand and written and oral consent from the children was obtained simultaneously with the interviews, which took place approximately two weeks after the first information session.

Consent for publication

The manuscript contains no individual person’s data. All responses from the group discussions are kept anonymous. A general consent to publish articles based on the material have been collected from the children and their caregivers. All authors have approved the manuscript for submission.

Availability of data and materials

The collected data have been processed by personal data assistants. Audio files and printouts are stored so that no unauthorized person has access to them. All information about the informants is encrypted and data will be saved for at least 10 years. Karlstad University is the responsible research principal and personal data controller.

Competing interests

The authors declares that they have no competing interests.

Confirmation of manuscript not previously being published

The content of the manuscript has not been published, or submitted for publication elsewhere.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Authors' contributions

Sven Hassler (SH), Siri Jakobsson Støre (SJS), Louise Persson (LP), Linda Beckman (LB)

Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; (SH, SJS, LP, LB)
Involved in drafting the manuscript or revising it critically for important intellectual content; (SH, SJS, LP, LB)
Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; (SH, SJS, LP, LB)
Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. (SH, SJS, LP, LB)

Acknowledgements

We thank all focus group participants for their time. Data and the materials necessary to reproduce the analyses presented here are not publicly accessible, but the analytic code is available from the first author upon reasonable request. The analyses presented here were not preregistered.

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No competing interests reported.

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Children’s and Adolescents Views of Health and Mental Health Concepts - A Qualitative Group Discussion Study

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