Adolescence and young adult mental health

IntroductionThis chapter will focus specifically on the mental health of adolescents and young adults, as well as considerhow it can impact on an individual in later life. It will introduce the reader to concepts and theoriesrelating to adolescent mental health and the development of services within the UK, over the latter partof the twentieth century, the behavioural, emotional and physiological changes that can occur during thisperiod and how they interact with one another will also be discussed. A section considering the role andinfluence of family, friends and peers on adolescent mental health is also presented. The chapter willconclude by exploring a number of mental health problems that may emerge during this stage.The reader will be introduced to contemporary research that seeks to evaluate and understand thenature of a young persons mental health. It will also aim to identify how health professionals, parents,educators and support workers can each play a role in promoting positive mental health in adolescence.Case scenarios have been selected to assist the reader in understanding the benefits of intervening andpromoting positive mental health during this stage. The terms adolescent, young adult and young personare used interchangeably and defining this stage is discussed within the text. Much of the research discussedis with reference to a UK setting, although other international research is specified accordingly.No adolescent ever wants to be understood, which is why they complain about being misunderstoodall the time. Adolescence and young adult mental healthAdolescence is derived from the Latin word adolescere, which means grow to maturity. It is astage of development that is defined by the pubertal transition into adulthood, involving biological,psychological and social changes (Alsaker, 1995). The period of adolescence is a fluid conceptand one which is known to change across time and culture (Coleman, 2011; Eveleth and Tanner,1976; Himes, 2006; Tanner, 1981). It is a period that is often associated with the teenage years,but its onset and duration can last anywhere between the ages of 7 to 25 years old (Johnson et al.,2011). Adolescence is often a time that is associated with affirming ones identity, the developmentof more complex social and sexual relationships, increased autonomy and independence, andincreased educational and occupational demands (Coleman, 2011; Goldin and Katz, 2009; Hill,1983). From a biological standpoint, the physiological changes that occur in both genders with theonset of puberty greatly alter individuals body shape and size, reproductive related physiologyand brain development. It is often a period that is characterised as the transition from childhood toadulthood and from school into work.The nature of adolescence has evolved over the last century, particularly in the Western world.Compulsory education, restrictions on child labour, the complexities of an industrialised and technologicallyadvancing state, increased prosperity, cultural migration, improved media and informationdistribution, as well as increased liberalisation and civil rights are just a handful of factors that haveall contributed in defining a change of what adolescence means (Gillibrand et al., 2011, p. 358).Goldin and Katz (2009) point out that the longer-term consequences of academic success in recenthistory means there is an added pressure at this stage to achieve, potentially leading to greater anxietyand stress. Disruptions during this stage, by way of poor mental health, could therefore haveconsiderable ramifications.Early theories and conceptsThe concept that adolescence is one of increased conflict and inner turmoil is as old as AncientGreek thinking (Coleman, 2011). Leading theories of adolescent development over the past centuryalso reflect this idea. Granville Stanley Hall proposed that the period of adolescence is one ofstorm and stress (Hall, 1904 as cited in Arnett, 1999). Arnett (2006) discusses how Halls viewof adolescence was generally one of increased behavioural and emotional turmoil brought about bydramatic and unpredictable growth spurts. Eriksons (1968) Theory of Psychosocial Developmentdescribes a crisis in identity at this stage due to a young persons emerging identity being at oddsand in conflict with the role expectations of others. Likewise, Anna Freud describes an imbalanceof the id and ego during adolescent development (Muss, 1988). One final theory worthy of note isDavid Elkinds (1967) Egocentrism in Adolescence. Elkind characterised adolescence by a numberof cognitive distortions that develop from the newfound ability to formulate a hypothetical perspective.He argued that an adolescent can be made to feel as though they are under constant scrutiny dueto perceiving themselves as being on a kind of social stage with an imaginary audience. Theymay also experience feelings of isolation, believing their abilities and experiences to be unique toeveryone elses, a concept which Elkind coined personal fable.Copyright 2016. Routledge. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. orapplicable copyright law.EBSCO Publishing : eBook Collection (EBSCOhost) printed on 5/3/2020 6:20 AM via SOUTHERN CROSS UNIVERSITYAN: 1077234 ; Thomas, Mike, Steen, Mary.; Mental Health Across the Lifespan : A HandbookAccount: s7109345Adolescence and young adult mental health 115The reason these theories have been selected and highlighted here is that they describe adolescenceas being a troubled and turbulent transition. However, developments in the latter partof the twentieth century served to challenge these concepts. During the 1960s and 1970s, empiricalevidence began to emerge that suggested the majority of adolescents coped with stressful lifeevents in a resilient way and that relationships with their family and peers were generally positive(Coleman, 2011, p. 15). From the 1960s to the 1980s, there was a demand for research that soughtto understand the aetiology of disorders in young people, attracting health professionals from variousspecialities (Hersov, 1986). In more recent decades, efforts have been made to prioritise theinvestigation and delivery of prevention and intervention programmes (Cottrell and Kraam, 2005).Today it is now generally recognised that many mental health problems originate in childhood andadolescence (Heginbotham and Williams, 2005).Service provision and developmentGovernment strategies within the UK and internationally have emphasised a multidisciplinaryapproach to caring and supporting young people (Department of Health, 2004; EC Directorate-General for Health and Consumer Protection, 2006; U.S. Department of Health and HumanServices, 1999). However, the fragmentation in services may serve as a barrier when accessingcare; a young persons mental healthcare needs are often dealt with in less well equipped settingssuch as schools, the home, primary care, youth justice and welfare services (Corcoran, 2011,p. 190). Nonetheless, many of the presenting issues that can occur during this stage can be managedin primary care without the need to refer to specialist services (Dogra et al., 2009, p. 31). The developmentin service provision for children and young people parallels many of the changes in adultmental healthcare, changes which seek to provide greater community-based services as opposedto inpatient care. Evidence from the US highlights this trend with hospitalisation length of staysfor young people falling significantly from 44.05 days to 10.7 days on average, from 1991 to 2008(Meagher et al., 2013).The UK Child and Adolescent Mental Health Services (CAMHS) is a specialist NHS service foryoung peoples mental healthcare. In an attempt to review and offer a strategic framework for theorganisation of CAMHS, the Together We Stand (Health Advisory Service, 1995) and The Healthof the Nation: Child and Adolescent Mental Health Services (Department of Health, 1995) policydocuments were developed in order to help audit and benchmark services. The policy split care intofour tiers, of universal, specialist, multidisciplinary and inpatient care, with each tier determined bythe severity of an individuals mental health condition. However this approach has been criticisedfor promoting a hierarchical system of care, when in fact it is argued that CAMHS professionalsshould be working across all tiers (Richardson et al., 2010). The number of nurses workingwithin CAMHS has increased rapidly over the last two decades and their roles have broadened. Thisbroadening of roles now means that nurses are increasingly involved in designing and managingservices as well as delivering them (Townley and Williams, 2009). CAMHS professionals providea range of psychotherapeutic interventions and deal in a range of multi-agency working. Howeverit is a specialism that is often little understood by service-users, professionals and commissionersalike (Richardson et al., 2010). Other European countries also tend to provide separate specialistCopyright 2016. Routledge. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. orapplicable copyright law.EBSCO Publishing : eBook Collection (EBSCOhost) printed on 5/3/2020 6:20 AM via SOUTHERN CROSS UNIVERSITYAN: 1077234 ; Thomas, Mike, Steen, Mary.; Mental Health Across the Lifespan : A HandbookAccount: s7109345116 S. Steenclinics for child and adolescent mental healthcare, but still place great emphasis on preventativeapproaches (Jan-Llopis and Anderson, 2006).We will now take a brief look at the changes that occur during adolescence in terms of developmentand its potential impact on young persons mental wellbeing.Brain and physiological developmentAs mentioned previously, one of the defining characteristics of adolescence is marked by the onsetand ongoing development in puberty. The factors that affect pubertal onset can be complex and multifaceted,determined by a persons genes, environment and lifestyle (Alsaker and Flammer, 2006).Physical and bodily changes that occur during this stage can have an impact on a young personsidentity, sociability and self-esteem (Bearman et al., 2006; Chen and Jackson, 2012; Dawson andDellavalle, 2013; Laursen and Hartl, 2013; Wertheim et al., 2009; Westwood and Pinzon, 2008).These will be explored in further detail in subsequent sections, but for now it is worth consideringthe development of the brain during adolescence.The development of the brain and connections between brain regions during adolescence can bedefined as being one of immense change (Dahl and Spear, 2004; Fair et al., 2009; Kelly et al., 2009;Lenroot and Giedd, 2010; Paus, 2010; Steinberg, 2008; Supekar et al., 2009). By way of synapticpruning, the brain facilitates the neural structure to develop more efficient, focused and specialisedsystems (Fair et al., 2008, 2009; Luna et al., 2010). Pruning refers to the overall reduction of theneuronal and synaptic connections within the brain. This process is important in facilitating topdownexecutive thinking over bottom-up reactive thinking (Casey et al., 2008; Ernst et al., 2005;Hwang et al., 2010). It is thought to be critical in the processes of learning and can be influenced byfactors in the environment (Craik and Bialystock, 2006).Changes in particular regions of the brain have also been found to develop at a different rate(Blakemore, 2012). These include the prefrontal cortex and limbic system, which have been foundto undergo developmental transformations across a range of species during the period of adolescence(Spear, 2000). The prefrontal cortex is thought to be critical in the processes of higher-order executivefunctioning and abstract thought, and therefore may play a role in harm-avoidant behaviours.This region has been found to mature more gradually than other areas of the brain in adolescence(Bava and Tapert, 2010). The difference in maturing rate of certain regions means that other moredeveloped regions, such as that of the limbic system, may dominate emotional processing. Theresult of this could manifest in impaired decision-making and a susceptibility for reward seeking(Dahl and Spear, 2004; Ernst et al., 2005; Eshel et al., 2007; Galvan et al., 2006; Steinberg, 2008).Reward seeking can be thought of as a motivated behaviour for pursuing exciting experiences andhas been shown to peak in the middle teenage years, between 13 and 16 years of age (Steinberg,2008). Ernst et al. (2009) suggest this may be based on an evolutionarily beneficial principle. Theypoint out that the process would allow adolescents to explore social contact beyond the family unitand thus help enhance genetic diversity. This may also help to explain the social behaviour seenduring adolescence, which aligns itself with an increase towards peer orientation (Forbes and Dahl,2010; Steinberg and Morris, 2001). Cognitive development in adolescence allows thought processingto become more abstract and analytical. The growing independence that emerges during thisstage aligns itself well with these ongoing brain developments.Copyright 2016. Routledge. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. orapplicable copyright law.EBSCO Publishing : eBook Collection (EBSCOhost) printed on 5/3/2020 6:20 AM via SOUTHERN CROSS UNIVERSITYAN: 1077234 ; Thomas, Mike, Steen, Mary.; Mental Health Across the Lifespan : A HandbookAccount: s7109345Adolescence and young adult mental health 117Changes to sleeping patternsIt is worth briefly considering the changes to sleeping patterns that are known to occur duringadolescence. The deregulation of circadian rhythms is common during this stage (Dahl and Lewin,2002; Hansen et al., 2005) and may result in potential maladaptive sleeping patterns such as daytimesleepiness (Feinberg and Campbell, 2010). When compared with children or adults, adolescentgroups appear to exhibit a shift in the release and levels of melatonin (a hormone linked with sleep)by as much as two hours (Carskadon et al., 2004; Taylor et al., 2005). Harris, Qualter and Robinson(2013) found that dysfunctional sleep in pre-adolescents (811 years) could lead to decreases insocial interaction, further impacting on sleep. This growing cycle may then lead to irritability andsocial withdrawal, potentially exacerbating feelings of social isolation. Less sleep in adolescencehas been associated with poorer academic performance and an increased likelihood of depressivesymptoms being reported, even when controlling for other socio-demographics (Gau et al., 2004;Ohida et al., 2004; Pagel et al., 2007; Roberts et al., 2009;). A possible explanation for this couldbe the ongoing developments in the brain discussed above that may also influence the complexinteraction of circadian, social and other factors (Feinberg and Campbell, 2010). Other exacerbatingfactors might include the modern availability of media such as television and the Internet (Cainand Gradisar, 2010; Punamki et al., 2007; Van den Bulck, 2004). Therefore, attitudes towardsthe sleeping patterns of adolescents are important and appreciating the impact of sleep deprivationon behaviour and cognition may be helpful in raising awareness of this. Reacting positively to thegeneral functioning and patterns of sleep in this age group is necessary to reduce stress and discordwith other age groups that may not share the same patterns.Recognising vulnerable adolescentsIt is important to recognise that many adolescents will have a positive mental health status duringthese years (Coleman, 2011). Although many adolescents can be resilient to the effects of mentalhealth problems and stressful life events, there are a number of young people who can go onto develop behavioural, emotional or neurodevelopmental disorders. The study of adolescencedemands research that integrates biology, context and psychological development (Steinberg andMorris, 2001). Additional stressors in the environment (family or illness-related) may have a noticeableimpact on adolescents whose brain development is still ongoing (Jehta and Segalowitz, 2012,p. 21). Moreover, genetic expression has been found to increase over time, between the ages of 13and 35 years, increasing the heritability impact of mental health problems (Bergen et al., 2007).The emergence of a lifetime risk for psychopathology has been found to peak at age 14, withover half of mental health disorders starting by this age (Kessler et al., 2005, 2007; Maughan andKim-Cohen, 2005). Current estimates within England suggest that around 1 per cent of 516 yearolds exhibit a clinically recognisable mental health problem (Green et al., 2005). A three-year follow-up survey to this study, conducted in 2007, involving 67 per cent of the original sample (5,364of 7,977), found that 30 per cent of those who had an emotional disorder in the original surveywere still experiencing it in the follow-up (Parry-Langdon, 2008). Estimates from the US for theprevalence of disorders causing severe impairment and/or distress in 1318 year olds (n=10,123) isapproximately 22.2 per cent (Merikangas et al., 2011). Epidemiological evidence from internationalCopyright 2016. Routledge. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. orapplicable copyright law.EBSCO Publishing : eBook Collection (EBSCOhost) printed on 5/3/2020 6:20 AM via SOUTHERN CROSS UNIVERSITYAN: 1077234 ; Thomas, Mike, Steen, Mary.; Mental Health Across the Lifespan : A HandbookAccount: s7109345118 S. Steensources suggests that longer periods of depressive and anxiety-related symptoms during adolescenceare associated with the emergence of a disorder in later life (Fergusson et al., 2005; Kessleret al., 2005, 2012; Maughan and Kim-Cohen, 2005; Patton et al., 2014).Untreated mental health problems during this period can lead to a number of poor outcomes suchas family conflict, poor physical health, anti-social behaviours including crime and a decline inacademic performance (Rutter and Smith, 1995). Estimates from national and international surveysreport low numbers of young people accessing treatment, with only around a quarter of those witha diagnosable mental health problem receiving treatment (Burnett-Zeigler et al., 2012; Green et al.,2005; Ma et al., 2005; Meltzer et al., 2003; Merikangas et al., 2011, 2103; Mojtabai, 2006; Patelet al., 2007). Despite a large proportion of mental health problems presenting in adolescence, treatmenttends not to occur until a number of years later (Kessler et al., 2007). Moreover, the costsassociated with untreated mental health problems in adolescence can be substantial for both theindividual and society (McCrone et al., 2008). The Kennedy Review (2010), on evaluating childrenand young peoples NHS services, pointed out that adolescents can often be thought of as theforgotten group in healthcare. The overriding stigma and common misunderstandings surroundingmental illness within this group may mean that cases often go unnoticed and consequentlyuntreated. Recognising vulnerable adolescents early is crucial in preventing these onsets, thereforemaking it a fundamental part of any health professionals work.On the individual level, risk factors for experiencing poor mental health during adolescencehave been found to include a low IQ, learning disability, shifts in pubertal timing, communicationdifficulties, a difficult temperament, physical or neurological illness, especially if chronic, pooreducational performance and low self-esteem (Dogra et al., 2009; Mental Health Foundation, 2004).It should also be noted that the opposite of these risk factors might serve as protective factors.Young people with a learning or physical disability, especially if severe, are at an increased risk ofreporting emotional distress, developing a mental health problem and attempting to commit suicide(Einfeld et al., 2011; Emerson, 2003; Emerson et al., 2009; Honey et al., 2011; Svetaz et al., 2000).In the UK, up to 10 per cent of children are affected by learning difficulties, which have an impacton their mental health and subsequent academic performance (Foresight, 2008). These are similar tolevels found in the US with a 9.7 per cent estimated prevalence rate (Altarac and Saroha, 2007).

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