Educational attainment of adolescents treated in psychiatric inpatient care: a register study over 3 decades

Adolescence is a crucial time for establishing personal values or ethical systems, adopting socially responsible behavior and making choices regarding one’s educational pathway [1]. Education affects subsequent employment, social life and even health and mortality [2‐7]. Adolescents dropping out of secondary school are at markedly increased risk for sickness and disability in young adulthood [3] and are more likely to smoke or take drugs, to report suicide attempts in the preceding year and to have been arrested on suspicion for crimes [8]. Higher education is associated with healthier behavior and overall health [2, 5, 9]. Formal education has an ever-increasing role in working life [10, 11] accompanied by pressure to shorten the time needed to qualify and enter working life [12]. These developments may exacerbate the negative impact of adolescent mental disorders on ultimate educational level and position in working life.

This is a register-based follow-up study, the study population comprising all Finnish citizens admitted between 1980 and 2010 for their first ever psychiatric inpatient treatment at age 13–17 in Finland. Information on inpatient care in psychiatric hospital was obtained from the Patient Discharge Register (used between 1969 and 1993) and the Care Register for Health Care (from 1994). Altogether 17,112 adolescents aged 13–17 were admitted to psychiatric inpatient care for the first time (in their lives) in 1980–2010. The subjects were followed up in registers until 2014.

The study data contains diagnostic information from three versions of the International Classification of Diseases (ICD). The WHO conversion tables were used to recode ICD-8 and ICD-9 diagnoses as ICD-10 diagnoses [35]. In the analyses, primary diagnoses according to ICD-10 were classified into organic, intellectual disability and developmental (diagnostic groups F00–09, F70–79, F80–89, G-diagnoses), Schizophrenia group (F20–29), mood disorders (F30–39) anxiety disorders (F40–48), behavioral syndromes associated with physiological disturbances and physical factors (F50–59), externalizing disorder (F10–19, F60–69, F90–92), emotional disorders of childhood (F93–99) and social reasons (Z-codes). Age at index admission was classified to early (13–14 years) and middle (15–17 years) adolescence.

Information on highest attained post-comprehensive school education was obtained from the Statistics Finland Register of Completed Education and Degrees. The statistics include all upper secondary and tertiary education options with harmonized concepts and classifications. In the analyses, highest education obtained was classified as comprehensive school only, upper secondary education (general upper secondary school and vocational qualifications and tertiary education (university of applied sciences, university). Data on enrollment in post-comprehensive school studies in 2014 were obtained from the Statistics Finland Progress of Studies register.

For the present study, we included those aged 20–49 years who were alive and who had received psychiatric diagnoses or organic, neurological (G-group), intellectual disability or developmental diagnosis or social reasons (Z-code) diagnosis as the primary diagnosis at index admission. On 1.3% of these (197/14,632; demographic information in Supplementary Table 1), no education information was available in 2014 and they were excluded from the study. The lower age limit was chosen assuming that the vast majority would have completed upper secondary education by age 20 in Finland [12, 36]. This upper age limit was chosen to ensure equal age groups. Because subjects had different follow-up times and, therefore, different amounts of time to attain education, the study population was categorized into age groups based on subjects’ age at the end of 2014. These age groups were 20–29, 30–39 and 40–49 years. To compare the educational attainment of the study population to that in sex- and age-matched general population, information on the educational attainment of Finnish population was gathered from the Official Statistics of Finland: Educational Structure of Population [14].

Of the study population (n = 14,435), 38.8% (n = 5603) were males and 61.2% (n = 8832) females. Information on the age of the study population age at first admission to inpatient treatment and in 2014 and primary diagnoses in first psychiatric inpatient care are presented in Table 1.

Highest educational attainment among former adolescent psychiatric inpatients across age groups was considerably lower than among Finnish general population. The study population included an especially high proportion of those who had only completed comprehensive school education, with a significantly large difference from general population, especially in males. Except for behavioral syndromes group (F50–59), every diagnostic group had a two- to threefold greater proportion of those who had completed only comprehensive school education when compared to general population. Especially in males, those with externalizing disorder (F10–19, F60–79, F90–92) diagnoses differed from those with other diagnoses. These findings are more noticeable when compared to studies on general psychiatric problems or general population [18, 19, 37‐49]. While mental health problems predispose to lower educational attainment, those with psychiatric symptoms severe enough to require inpatient care are at greater risk. The failure of former adolescent psychiatric inpatients to attain educational levels comparable to same-aged general population could be related to the nature of the disorders themselves or to the stigma related to psychiatric morbidity, but may also signify that, despite increases in the availability and variety of adolescent psychiatric services and welfare services in school and special education and other support for learning, society has failed to adequately promote the integration of adolescents with mental disorders into education, with long-term negative implications for their integration into working life.

With the exception of those with organic, intellectual disability and developmental group diagnoses (F00–09, F70–79, F80–89, G-diagnoses), those with externalizing disorders were at highest risk of having no post-comprehensive school education. This concurs with the findings of earlier studies [15, 16, 39] and may reflect the impact of neurocognitive and motivational deficits associated with externalizing disorders [16, 40, 41]. These deficits may also characterize those whose index admissions were due to diagnoses in the emotional disorders of childhood group (F93–99) and the social reasons group (z-codes) as these diagnoses are often set in the absence of other obvious psychiatric problems. The risk persisted in the youngest age groups even though the pharmacological treatment of attention deficits and hyperactivity, for example, improved vastly during the 2000s [42].

In addition to the well-known impairments caused by cognitive deficits found, for example, in schizophrenia group (F20–29) diagnoses, impaired social functioning, seen in many mental disorders, may also have a negative effect on the skills needed for education [21, 43‐45]. Adolescents with anxiety disorders (F40–48), especially social phobia, face many academic and social difficulties and experience higher levels of peer victimization, which may lead to refusal to attend school, slow academic progress or failure to enter higher education [46, 47]. Adolescence is a stage of life associated with the rapid acquisition of new information and making far-reaching choices, for example, in education. Mood disorders (F30–39) are often associated with cognitive dysfunctions persisting beyond symptom recovery [48, 49], and this may have particularly damaging and long-lasting effects on education. It has been proposed that the impact of mood disorders on educational attainment may be to delay, rather than to prevent, completion of higher education [24]. However, in this study, the risk of exclusion from higher education was present in every age group. In this case, lower educational attainment compared with same-aged general population might well no longer be seen in the oldest age groups, which was not the case in the present study.

In addition to the negative effect of the symptoms, mental disorders may also have a negative impact on educational attainment due to the accompanying stigma. Stigma may reduce willingness to seek help and impair treatment adherence, undermine treatment outcome, impair well-being and, especially during adolescence, influence personal identity and independence in the long term [50‐53]. Adolescents with mental disorders are deemed more stigmatized than peers with other health problems [52]. Stigma may manifest in general devaluation, bullying, being underestimated by others or outright social rejection, which may impair adolescents’ willingness to pursue education [50]. In addition, adolescents with mental disorders may be branded as having a disability, which may lead to lower educational expectations on the part of parents and teachers. For example, Schifrer [54] found that among similarly achieving and behaving adolescents the odds of teachers expecting a bachelor’s degree education or higher for adolescents labeled as having a learning disability were 82% lower than for adolescents without this and that adolescents’ educational expectations are partially mechanized through parents’ and particularly teachers’ lower expectations. Therefore, while learning difficulties associated with many mental disorders may require support from special education services, those services may, while improving students’ opportunities to learn, engender stigma.

This study represents 3 decades of development of adolescents’ mental health services and the education system. Subjects aged 40–49 years in 2014 were in adolescent psychiatric inpatient care mainly in the 1980s, those aged 30–39 in the 1990s and those aged 20–29 in the 2000s. In spite of considerable improvement in support services for those in need in both education and mental health services [13, 30, 33] those adolescents with psychiatric disorders requiring psychiatric inpatient treatment in the 2000s were nevertheless at similar risk for not pursuing higher education to those in inpatient care in the 1980s. This may be because psychiatric disorders impair academic performance so profoundly that even if support is arranged at school, it does not suffice to alleviate the effects of psychiatric symptoms. Another possibility is that the focus on adolescents’ social environments and skills and the kind of support needed is still inadequate. Third, stigma related to mental disorders may hinder functioning at school and the readiness to offer and accept support. Systematically lowered educational attainment across diagnostic categories and across decades is not only a matter of persistent inequality. Given the importance of education today, lack of post-comprehensive school education may impair employment prospects, lead to lower socioeconomic status and so to poorer physical and mental health [3, 4, 55].

Adolescents with psychiatric disorders requiring inpatient care are at considerable risk for not continuing their education beyond compulsory comprehensive school or of attaining lower educational levels than their age-peers in general population. This has not changed over time despite improvements in adolescent psychiatric care, school welfare services and pedagogical support. The risk for low educational attainment among former adolescent psychiatric inpatients is particularly pronounced among males. Greater effort in psychiatric treatment, school welfare and pedagogical effort are needed to tackle this severe inequality. Psychiatric symptoms, cognition, social integration and stigma all need to be considered.