Deﬁning mental health and
Sharon Leighton and Nisha Dogra
Key features • Discussion of the terminological confusion that exists in relation to issues
associated with mental health.
• The scale of individual suffering from mental health problems and illness
among young people.
• The worldwide phenomenon of the stigmatization of mental illness,
originating during childhood.
• Evidence regarding interventions to reduce stigma.
In this chapter we explore the concepts of mental health and mental illness from different
perspectives, including those relating to children, and of children. This is important as those
who work in mental health, or are familiar with the ﬁeld, often make the assumption that the
terms used are readily understood by others. The scale of the problem and access to services is
outlined. We then discuss stigma generally, explore the reasons for it and possible sequelae, and
then consider how this relates to children. Finally, interventions to reduce stigma are brieﬂy
presented. As mentioned in the Introduction, where possible we have referred speciﬁcally to the
literature relating to children but where this is limited we have drawn from the wider literature
to highlight key issues.
The chapter begins with an exercise which provides a practical context for the theoretical
content and should be borne in mind as you read, and answered once you have ﬁnished the
• What words or images do you associate with the following terms:
• Mental health
• Mental health problems
• Mental illness
• Mental disorder
• What sorts of problems do people experience that could be described as mental
health problems or mental illness?
• How would you be able to tell if someone was experiencing mental health prob-
lems or mental illness?
Case scenarios and associated questions
Please read each senario and then consider the following questions in relation to it:
• What do you think might be happening with the young person?
• Do you think the young person has a mental health problem or illness? If so, on
what grounds would you justify that decision?
• Do they need help?
• If so, who and/or what might be helpful?
• How might this be helpful?
Case scenario 1
Jack, aged 9, lives with his mother and younger brother. His father unexpectedly left the
family a year ago. Jack started a new school six months ago and is having difﬁculty
settling in. He complains of tummy ache each school morning and is increasingly
reluctant to attend.
Case scenario 2
Emily, aged 14, lives with her parents, who are both busy professionals. She works hard,
achieves A-grades and plans to be a lawyer. Recently she has been teased by her
friends about her weight and has decided to go on a strict diet. She is pleased with the
results so far and plans to continue eating little, making herself sick after meals and
exercising a lot.
Case scenario 3
Joshua, aged 15, lives with his dad and stepmother. He has little contact with his mum or
younger brother and sister. Recently he has been cautioned by the police for joy-riding
in stolen cars with his mates. He prefers to spend time smoking dope with older boys
rather than going to school.
Deﬁning mental health and mental illness
Clarity is essential when using the terms ‘mental health’ and ‘mental illness’. In all phases of a
recent small-scale research project, conceptual confusion was identiﬁed in the literature review
and among participants (Leighton 2008). Ironically, referring to mental illness in terms of
mental health originated in the 1960s in an attempt to reduce stigma (Rowling et al. 2002).
There is no widely agreed consensus on the meaning of these terms and their use. Mental health
and mental illness can be perceived as two separate, yet related, issues.
Ryff and Singer (1998) suggest that health is not a medical concept associated with absence
of illness, but rather a philosophical one that requires an explanation of a good life – being one
where an individual has a sense of purpose, is engaged in quality relationships with others, and
possesses self-respect and mastery. This is synonymous with the World Health Organization
(WHO) (2000, 2005b) deﬁnition of positive mental health.
However, such a deﬁnition is incomplete as individuals do not exist in isolation, but are
inﬂuenced by, and inﬂuence, their social and physical environments. Furthermore, people will
have their own individual interpretations of what a good life is. Rowling et al. (2002: 13) deﬁne
mental health as the
8 Nursing in child and adolescent mental health
capacity of individuals and groups to interact with one another and the environment in ways that
promote subjective wellbeing, the optimal development and use of cognitive, affective and relational
abilities, the achievement of individual and collective goals consistent with justice.
This is a more rounded deﬁnition, and one that can coexist alongside the WHO (1992) deﬁnition
of mental disorder.
Mental health – one of many factors
It is also important to recognize that neither physical nor mental health exist separately –
mental, physical and social functioning are interdependent (WHO 2004). Furthermore, all
health issues need to be considered within a cultural and developmental context, as do the
social constructs of childhood and adolescence (Walker 2005). The quality of a person’s mental
health is inﬂuenced by idiosyncratic factors and experiences, their family relationships and
circumstances and the wider community in which they live (WHO 2004). Additionally, each
culture inﬂuences people’s understanding of, and attitudes towards, mental health issues.
However, a culture-speciﬁc approach to understanding and improving mental health can be
unhelpful if it assumes homogeneity within cultures and ignores individual differences (WHO
2004). Culture is only one, albeit important, factor that inﬂuences individuals’ beliefs and
actions (Tomlinson 2001; Dogra 2003). Interaction between different factors may lead to differ-
ent outcomes for different individuals.
It can be argued that the above approaches are rooted in western perspectives. However, they
provide a useful starting point from which to discuss mental health issues with children and
Deﬁnitions of child mental health
Deﬁnitions of mental health as they relate speciﬁcally to children have been provided by the
Health Advisory Service (HAS) (1995) and the Mental Health Foundation (1999). These def-
initions bear similarities to those provided by Ryff and Singer (1998) and Rowling et al. (2002),
while recognizing the developmental context of childhood – i.e. the ability to develop psycho-
logically, emotionally, creatively, intellectually and spiritually; initiate, develop and sustain
mutually satisfying personal relationships; use and enjoy solitude; become aware of others and
empathize with them; play and learn; develop a sense of right and wrong; and resolve problems
and setbacks and learn from them (HAS 1995; Mental Health Foundation 1999). Such deﬁnitions
are useful as they relate to ‘societal’ expectations of children.
Different deﬁnitions are used to deﬁne mental ill health. The WHO uses the term ‘mental
disorders’ broadly, to include mental illness, intellectual disability, personality disorder, sub-
stance dependence and adjustment to adverse life events (WHO 1992). The WHO acknowledges
that the word ‘disorder’ is used to avoid perceived greater difﬁculties associated with ‘illness’ –
for example, stigma and the emphasis on a medical model. Meltzer et al. (2000) use the term
‘mental disorders’ in reference to emotional, conduct, hyperkinetic and less common disorders
as deﬁned by the ICD (International Classiﬁcation of Diseases) 10 and DSM (Diagnostic and
Statistical Manual of Mental Disorders) IV. Jorm (2000) focuses speciﬁcally on depression and
psychosis. Meanwhile, Rowling et al. (2002) use the terms ‘mental illness’ and ‘mental disorder’
interchangeably. Johns (2002) and the British Medical Association (BMA 2006) identify that
the term ‘mental health problems’ is used to cover a broad spectrum of conditions ranging
from diagnosable disorders such as anxiety and depression, through to acting out behaviours.
The BMA (2006) also distinguish between mental disorders and illness, with illness being severe
psychiatric disorders such as depression and psychosis.
Deﬁning mental health and mental illness 9
Others take a broader view. Rickwood et al. (2005) refer to ‘young people’s help-seeking for
mental health problems’ and proceed to use various terms including ‘psychological distress’,
‘mental health issues’, ‘mental health problems’ and ‘mental disorder’. The interchangeable use
of these terms in effect renders them meaningless, as their use may reﬂect an individual’s bias,
or political correctness, rather than indicating the extent or severity of the problem. However,
all identify alterations in mood, thinking and behaviour associated with distress or impaired
functioning across various domains.
Entity or dimension?
Kendall (1988) presents the relative merits of using categories and dimensions with respect
to mental disorders. Typically, medicine has used categories, given its roots in the biological
sciences. Categorization allows for easier deﬁnitions, recognition if someone ﬁts a particular
category and therefore conformity with a clinical concept. However, a dimensions approach
allows for greater ﬂexibility. Kendall (1988) concludes that where psychotic illness is concerned
a categorical approach may be preferable, whereas in other conditions the situation is more
likely to be changeable, and would perhaps beneﬁt from a dimensional perspective.
One way of distinguishing between distress associated with adverse life events and more
severe disorders which involve physiological symptoms and underlying biological changes is to
distinguish between mental health problems and mental illness, using a multi-dimensional
model. This has an additional advantage in enabling normal ‘distress’ (e.g. grief following
bereavement) to be recognized as part of the ‘human condition’, rather than being medicalized
and possibly classed as ‘depression’. It is suggested that a variety of normal human experiences
have become medicalized through an ever increasing range of psychological disorders with
virtually every type of behaviour eligible for a medical label (e.g. social phobia, over-eating
disorder, dependent personality disorder) (Illich 1977; WHO 1992; American Psychiatric
Rowling et al. (2002) propose that mental health and mental illness can be seen to exist as
part of a multi-dimensional model. An exemplar of mental health and mental illness being
two separate and yet related continua can be found in the vulnerability-stress working model
developed by Asarnow et al. (2001). This model suggests how the effects of ongoing stress on
mental health can lead to mental illness (depression) if left unchallenged.
Depression is classed as a diagnosable disorder which is reported to be on the increase (WHO
1996). However, the term ‘depression’ is also employed in everyday language for a variety of
states of distress: demoralization as a result of long-term suffering; living with chronic adversity
and stress; reaction to loss; low self-esteem; and pessimistic outlook. While there are similarities
between the feelings of unhappiness, despondency, frustration and sense of hopelessness
associated with a state of emotional stress and with depression, the latter involves pervasive
physical symptoms such as sleep and appetite disturbance, and, ultimately, changes in brain
chemistry. However, the cut-off between what is ‘normal’ stress and what is depression may
not always be clear. It is not just the presence of symptoms that deﬁnes a disorder but also its
severity and pervasiveness as well as its impact on everyday functioning.
Thus, from a dimensional perspective, many features of mental disorder (psychosis excepted)
can be viewed as part of the range of ‘normal’ human behaviour. For example, anxiety is
a normal human response to the perception of danger. Different types of anxiety are develop-
mentally appropriate during childhood – for example, separation is an issue for infants,
academic performance can cause anxiety during middle childhood and peer rejection concerns
adolescents (Moore and Carr 2000).
10 Nursing in child and adolescent mental health
Mental health literacy
Finally, in this section, it is also worth considering how the mental health ‘literacy’ of adults
and children in the general population varies from that of professionals. In all phases of a recent
research project, conceptual confusion was identiﬁed in the literature review and among ado-
lescent participants (Leighton 2006, 2008). Focus group participants did not ﬁnd the single
continuum model suggested by the WHO (2000) helpful (Leighton 2006). Furthermore, in the
focus group feedback session, participants suggested that labelling serious mental illnesses such
as schizophrenia and major depression, as ‘mental health problems’, diminishes the seriousness
of mental illness, with implications for attitudes towards, and treatment of, those with mental
illness (Leighton 2006). It is also evident that there is considerable confusion for young people
between the terms ‘mental health’, ‘mental illness’ and ‘learning disability’ (Dogra et al. 2007;
Rose et al. 2007).
However, whatever terminology is used, the scale of individual suffering from mental health
problems and illness is signiﬁcant, and this is now brieﬂy outlined.
The scale of the problem
The number of people experiencing mental health problems worldwide is reported to have risen
to nearly epidemic proportions, with depression identiﬁed as the leading cause of disability
among 15–44-year-olds (WHO 1996). In the UK the prevalence of mental health problems
among adolescents is high. One in 20 is reported to be experiencing mental health problems at
any given time (Mental Health Foundation 1999; Meltzer et al. 2000; Coleman and Schoﬁeld
2005). The Ofﬁce for National Statistics (ONS) survey carried out in 1999 identiﬁed the follow-
ing prevalence rates of diagnosable mental disorder among 11–15-year-olds: depression 1.8 per
cent; anxiety 4.6 per cent; conduct disorder 6.2 per cent (Meltzer et al. 2000). Moreover, the
prevalence of serious mental illness increases greatly during adolescence (Davidson and Manion
1996; Smith and Leon 2001; Rickwood et al. 2005). Such problems have a negative impact on an
individual’s development across all areas of their lives – i.e. self-esteem, relationships, academic
success, career options and lifestyle (Mental Health Foundation 1999; Meltzer et al. 2000).
Furthermore, the burden of adolescent mental health problems and illness involves enormous
ﬁnancial costs to individuals, families and society. These include loss of earnings for parents
and adolescents, and social care, health service, education and Home Ofﬁce costs (Appleton
and Hammond-Rowley 2000). Although the scale of the problem is vast, studies indicate that
less than a ﬁfth of young people who need mental health care actually receive any services and,
of those who do receive services, less than half obtain services appropriate to their need (Atkins
et al. 2003; Hinshaw 2005).
Stigma and mental illness
In this section the aim is to explore the concepts of, and the relationship between, stigma and
mental illness. One possible reason for both conceptual confusion and reluctance to seek help is
that the stigmatization of mental illness continues to be a worldwide phenomenon (Jorm et al.
1997; Crisp et al. 2000; Sartorius 2002; Gureje et al. 2005).
Deﬁnition of the concept of stigma
Stigma can be viewed as a social construct. Setting people apart from other members of society
has a long history. In ancient Greece members of tainted groups – for example, slaves and
Deﬁning mental health and mental illness 11
traitors – were branded with a mark (Goffman 1970; Hinshaw 2005). The concept is applied in
diverse circumstances, including with reference to the mentally ill (Link and Phelan 2001).
Additionally, stigmatization can be seen to depend on social, economic and political power and
can occur on a large and tragic scale – for example, the systematic and dreadful stigmatization
of the Jewish people by the Nazis (Link and Phelan 2001). Stigma was deﬁned by Goffman
(1970) as the position of the individual who is disqualiﬁed from full social acceptance. It is
perceived as the outcome of a process of social labelling which singles out difference, names this
difference inferiority, subsequently blames those who are different for their otherness and
contributes to the creation of a spoilt identity (Goffman 1970). Since that seminal develop-
ment, the concept has evolved. For example, stigma can be described with reference to the
relationships between a set of interrelated concepts, rather than focusing solely on personal
attributes – i.e. stigma exists when elements of labelling, stereotyping, separation, status loss
and discrimination occur together in a power situation that allows these processes to happen
(Link and Phelan 2001).
The nature and extent of stigmatization in adult mental illness
There are many factors involved in the formation of individuals’ beliefs about mental illness,
and their attitudes and behaviour towards those labelled as mentally ill. These include personal
experience of mental illness, either personally or in someone known to them; the impact of the
media; beliefs as to what causes mental illness (e.g. genetic, self-inﬂicted); and socio-cultural
inﬂuences (Hinshaw 2005).
Four possible explanations for the stigmatization of mental illness have been identiﬁed in
the research literature:
• attribution of responsibility;
• belief that mental illness is chronic with a poor prognosis;
• disruption of normal social interactions based on social rules (Hayward and Bright 1997).
These explanations can be elaborated as follows: people with mental illness are perceived as
dangerous and unpredictable; there is an implied belief that the mentally ill choose to behave
as they do and have only themselves to blame for their situation; people with mental illness
are believed to respond poorly to treatment, and outcomes are poor, therefore they are an
embarrassment and should be avoided; the mentally ill are seen as difﬁcult to communicate
with and this makes for unpredictable social intercourse. These are enduring themes, provoking
personal fear in others and threatening to upset the status quo (Hayward and Bright 1997;
Explanations for the stigmatization of the mentally ill include the following ideas.
• From a biological perspective, a person suffering from mental illness may be viewed as a poor
genetic choice in relation to reproductive potential and as a possible threat to the safety of
• The need to share understanding in order to survive as an individual and as a species means
that when a person’s way of perceiving the world is unfamiliar to us we can feel threatened
and uncertain as to how to respond to them (Eminson 2004).
Media, mental illness and stigma
There is a dearth of research which focuses speciﬁcally on how mental illness is depicted in the
children’s and young persons’ media (Wahl 2002). This is despite suggestions that such media
12 Nursing in child and adolescent mental health
provide the means by which young people will derive a preliminary understanding of mental
illness. Participants in a small-scale local study identiﬁed some positive and accurate represen-
tations in the media. These included the Jacqueline Wilson books, the ﬁlm A Beautiful Mind and
Channel 4 documentaries (Leighton 2006). Byrne (2003) discusses examples in soap operas
when television can perform a major public service where care is taken over how mental illness
is portrayed. One suspects that the converse is also true – that when care is not taken the
damage done to those suffering with mental illness can be immense.
Two large-scale literature reviews have suggested that the media can be regarded as an
important inﬂuence on community attitudes towards mental illness. It is considered that
there is a complex and circular relationship between mass media representation of mental
illness and public understanding, with negative media images promoting negative attitudes
and resultant media coverage feeding off an already negative public perception. It is also
thought that negative images will have a greater effect on public attitudes than positive por-
trayals (Francis et al. 2001; Edney 2004). Work by Wahl (2003) suggests that this is equally
applicable to children.
Consequences of stigma
Stigmatization of the mentally ill is understood to be prejudicial to them, injurious to all aspects
of their treatment in mental health services and damaging to their role as members of society
(Hinshaw 2005). Stigmatization leads to individual and social discrimination against the stig-
matized person. Several authors identify that the discriminatory behaviour displayed can be
hostile or avoidant and that it operates throughout personal and social relationships, pervading
the home, workplace, local community, health and social welfare systems. This can result in
increased feelings of shame, increased personal and social impairment and isolation, perpetu-
ation and worsening of an illness, reluctance to access health care and infringement of human
rights (Link and Phelan 2001; Crisp 2004; Hinshaw 2005).
Children, mental illness and stigma
There is also a scarcity of research examining the issue of stigma in relation to children and
mental illness (Wahl 2002; Hinshaw 2005). As described previously, the high prevalence of
mental health problems in young people and their reluctance to access specialist services gives
cause for concern. The indications are that children develop negative attitudes towards those
with mental illness early on (Gale 2007). Additionally, adolescents are the adults of the future
and therefore their beliefs and attitudes regarding mental health and illness will affect service
development, the quality of life of those experiencing mental health problems and the help-
seeking behaviour of individuals (Armstrong et al. 2000; Hinshaw 2005).
Box 1.2 highlights themes identiﬁed from work which focused on adolescents, mental illness
and stigma, albeit to varying degrees and using different methods.
Box 1.2 Themes associated with mental illness and stigma identiﬁed
• Negative attitudes towards groups described as deviant – for example, the mentally
ill – were apparent by kindergarten and increased with age (Weiss 1986, 1994;
Deﬁning mental health and mental illness 13
• Words and phrases used to describe people with mental health problems or
mental illness were largely derogatory, with the most common labels being
‘retarded’, ‘psycho(path)’, ‘spastic’, ‘mental’, ‘crazy’ and ‘nutter’ (Bailey 1999;
Pinfold et al. 2003).
• The most frequently cited causes of mental illness were stress, genetics and bad
childhood experiences (Bailey 1999).
• Young people with experience of mental health problems described being met
with negative attitudes and reactions from other people, including professionals
(Scottish Executive 2005).
• Although adolescents stigmatized peers with both physical and mental illness,
they had a greater tendency to stigmatize those experiencing a mental illness
(Sessa 2005a, 2005b).
• Adolescents presenting in school with either a physical or mental illness were
likely to be socially excluded, itself a risk factor for developing mental health
problems (Sessa 2005a, 2005b).
• Providing mental health education could lead to a positive change in reported
attitudes in the short term, especially among females and those reporting personal
contact with someone who had a mental illness (Pinfold et al. 2003).
• Although adolescents with less knowledge about mental health and illness had
more negative attitudes towards mental illness, this did not inﬂuence the willing-
ness to seek help for mental health problems as much as other factors – for
example, level of psychological distress, number of barriers to overcome in order
to access help, or adaptability (Shefﬁeld et al. 2004).
From the sparse literature available, it would appear that adolescents’ attitudes towards
mental illness tend to be negative and stigmatizing. The need for education among the public,
and adolescents in particular, in order to combat the stigma of mental illness is highlighted
in the literature (Davidson and Manion 1996; Armstrong et al. 1998; Esters et al. 1998;
Bailey 1999; Secker et al. 1999; Taylor 2001; Naylor et al. 2002; Pow 2003; Hinshaw 2005;
Early indicators from our own work in Nigeria are that such attitudes transcend culture
(Dogra 2009). However, there is evidence that stigma can be tackled. We will now examine
some of the interventions undertaken to reduce stigma among children.
Interventions to reduce stigma
Large-scale interventions, such as high proﬁle campaigns, are often difﬁcult to evaluate. In the
UK there have been several such campaigns – for example, The Royal College of Psychiatrists’
campaign, ‘Every Family in the Land’ (Crisp 2004) and the WHO ‘Dare to Care’ campaign
(WHO 2001). There is little evidence available to indicate that these have successfully changed
public or personal attitudes, although there is evidence that more targeted initiatives may reap
beneﬁts (WHO 2005a). While much of the work to date has focused on adults, there are increas-
ing efforts to address the issue among younger populations.
There is scope for joint working between schools and child and adolescent mental health
services (CAMHS) in order to provide mental health promotion and reduce stigma. However,
it is important that we do not attempt to reduce stigma by just changing the terminology used,
as there is no evidence that such strategies work.
One small-scale local study found that young people thought they might be helped by
14 Nursing in child and adolescent mental health
having more basic information about local services (Dogra et al. 2007). In another such study,
adolescents who lived with parental mental illness suggested that the best ways of providing
adolescents with information about mental health included real experience and focusing on
the issue in schools – i.e. existing sources of (mis)information. It was thought that those speak-
ing out should be adolescents who were conﬁdent to talk about their situation, but they should
not talk to people they knew for fear of being bullied and they should be pupils at other schools
Two school-based interventions reported promising results. Rahman et al. (1998) concluded
that the school programme they undertook was successful in improving mental health aware-
ness in the children and their community. Unfortunately, the intervention is only brieﬂy
described and it is difﬁcult to be clear whether attitudes towards mental health (and issues
about stigma) were addressed, or whether awareness of mental health (and therefore knowledge
and understanding) informed the intervention. More recently, Pinfold et al. (2003) undertook
short educational workshops with 472 secondary school children in the UK. Changes were
most marked for female students and those who had personal contact with people with mental
health problems. Further analysis of the labels used to stigmatize people with mental illness
found that of the 472 students sampled, 400 of them provided 250 words to describe a person
with mental illness. Nearly half were derogatory (Rose et al. 2007). The authors conclude that
there need to be interventions which address factual information about mental illness and
that reduce the strong negative emotional reactions to people with mental illness. Effective
evaluation is unlikely to be possible if there is no clarity about the purpose of the intervention
or too many aspects covered in one evaluation (Naylor et al. 2002).
Considerable terminological confusion exists in relation to issues associated with mental health
generally and among children and young people speciﬁcally. Furthermore, stigmatizing atti-
tudes towards mental illness and related issues continue to pose a challenge. Children, young
people and adults display similar negative attitudes towards both mental illness and individuals
experiencing mental health problems or illness. However, there is some evidence that these
might be amenable to interventions such as education.
You may now wish to reﬂect on the issues discussed in this chapter by returning to the
exercise in Box 1.1.
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