Racial-Ethnic and Gender Inequalities in Mental Health-related SEND and Hospital Contacts among Children and Adolescents: A Population-based Linked Data Cohort in England

Background: Racial-ethnic and gender inequalities exist in England’s Special Educational Needs and Disability (SEND) system, with identification of Social, Emotional and Mental Health (SEMH) needs particularly vulnerable to bias. Systematic differences in mental health-related referrals, hospital admissions and treatment experiences also indicate potential bias in identifying need and response. Objective: Developed in partnership with peer researchers and community stakeholders, we examined intersectional differences based on racial-ethnic group and gender in school and hospital system responses to mental health needs identifying opportunities for equitable provision and access.Design: Population-level analysis of linked school and hospital administrative data for 1.7m children aged 5-16 years attending state schools in England (2005-2018). We examined rates, age distributions and timing (Kaplan-Meier Curves) of SEND-for-SEMH and mental health-related hospital contacts, including in-patient and out-patient contacts. Results: Findings confirm higher rates of SEND-for-SEMH Black Caribbean, Mixed White-Black Caribbean and Irish Traveller pupils, with schools faster to record boys from these groups, and lower rates among Asian and White Other pupils (from 16 per 1,000 Indian girls to 240 per 1,000 Black Caribbean boys). Boys access mental health-related hospital-based services earlier and more steadily across school years, primarily through out-patient appointments. Girls are consistently older when first recorded with SEND-for-SEMH, simultaneously experiencing increases in mental health-related hospital contacts, with higher rates of in-patient admissions. Conclusions: Findings indicate systematic differences in mental health-related SEND and hospital contacts emphasising the need for standardised mental health guidance and equity-oriented frameworks to address persistent simultaneous over-pathologisation and under-recognition of mental health needs.