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20% of adolescents may experience a mental health problem in any given year. |
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50% of mental health problems are established by age 14 and 75% by age 24 |
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10% of children and young people (aged 5-16 years) have a clinically diagnosable mental health problem , yet 70% of children and adolescents who experience mental health problems have not had appropriate interventions at a sufficiently early age. (Mental Health Foundation) |
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Children who have been bullied at age 13 are more than twice as likely to have depression at age 18. (Office for National Statistics). |
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Data from Understanding Society shows that around 1 in 10 children aged 10 to 15 years old are unhappy with their appearance (11% in 2011 to 2012 and 10% in 2012 to 2013). The proportion of girls reporting that they are unhappy with their appearance is around double that of boys (14% of girls compared with 7% of boys in 2012 to 2013). (Office for National Statistics). |
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Of the well-being measures available from the Understanding Society survey, bullying and quarreling with mothers had the strongest associations with mental ill-health. These results are consistent with findings from academic research and previous national surveys of children’s mental ill-health. |
Mental Health
Children and young people who are mentally healthy will have the ability to
develop psychologically, emotionally, creatively, intellectually and spiritually
initiate, develop and sustain mutually satisfying personal relationships
use and enjoy solitude
become aware of others and empathise with them
play and learn
develop a sense of right and wrong
faceproblems and setbacks and learn from them, in ways appropriate for that child's age.
This includes strengthening individuals (such as through enhancing parenting, self esteem, psychosocial competence etc.), strengthening communities (e.g. though social inclusion, anti bullying school policies etc) and reducing barriers to inequalities in access to housing, education, employment etc).
Mental health promotion improves physical health, reduces behavioural and learning problems and risk taking behaviour .
Depressive Disorders
Depressive disorder is sometimes a reaction to a single or severe stressor but depression in young people is more likely to arise from an accumulation and interaction over years of biological, psychological, and social factors. These factors combine:
Genetic influences (static factors): These are probably less important in uni-polar depressive conditions than in bipolar depressive conditions accounting for about 50% of the variation in depressive symptomatology in adolescents. Studies have suggested that genetic factors are often indirect, acting through temperamental traits that increase vulnerability to stress. They may also increase the risk of psychiatric disorders e.g. anxiety and conduct disorders which are in themselves risk factors for depression.
Chronic Adversity Factors (stable dynamic factors): Includes both intra-familial and extra-familial factors. The most important familial factors are parental depression and other psychiatric disorders, family discord, and parenting problems including abuse. The most important extra-familial factors are peer relationship problems (including bullying) and substance abuse.
Precipitating Stressful Events (acute dynamic factors): These most commonly arise from the chronic stressors that occur with adversity and include family problems (e.g. parental separation), breakdown in a friendship or relationship with a peer, episodes of parental mental illness. The effects of acute stressful events depends to an important extent upon their context and the degree of threat that they represent to the child and their well being e.g. the death of a grandparent has much more impact on a child if the grandparent was the primary carer or an important source of support for the child.
These factors act through psychological and biochemical processes to produce the depressive syndrome which, once established is often prolonged by maintaining factors e.g.
any of the risk factors cited above
psychological or biological "scarring" arising from the first depressive episode
the symptoms of depression itself (such as sleep disturbances which leads to poor concentration, which in turn worsens negative thinking)
Activity: Listen to this Podcast from the Mental Health Foundation.
About this Podcast: "A recent study looking at the mental health of medical students found that over 27% of medical students in 47 countries showed symptoms of depression. Why is this? Does it translate to the rest of the student population? What can we do to prevent it? How can we support students who experience mental ill health?
In this latest podcast with the British Journal of Psychiatry, Lauren Chakkalackal is joined by Derek Tracy of the British Journal and the Mental Health Foundation's Anna Hoang and Linda Liao - themselves relatively recent university graduates".
What insights does this programme offer in terms of understanding the aetiology and effects of depression?
Are any of the experiences and vulnerabilities of these medical students similar to those of young people that you work with?
Disorders of Attachment
Adolescence is a critical period for the development of self reliance, and negotiation between adolescent and caregiver of age appropriate autonomy. Difficulties in attachment relationships can cause difficulties for adolescents with the process of individuation. Other behaviours noted in adolescents with attachment disorders include addictive symptoms, antisocial behaviour, delinquency, eating disorders, psychosomatic illness and self harm.
An important cognitive ability that emerges during adolescence is the 'reflective function' or 'mentalising'- the ability to evaluate oneself and the environment and construct a meaningful account of social interactions and life events (Fonagy 2000). Reflective function enables adolescents to develop the ability to interpret their own actions and the actions of others in a comprehensible and purposeful way, thus facilitating social reciprocity.
Adolescents that have a history of severe dysfunction in the parent child-relationship may never develop a reflective function which results in an inability to develop a psychologically stable sense of self and trust in others. Such adolescents tend to focus on their own distress and aspects of the environment that they feel that they can manipulate and control. They will have difficulty with the development of reflective processes and hence the ability to think flexibly and understand the mental states and intentions of others.
Adolescents that have experienced severe maltreatment internalise a sense of badness: this will interfere with their sense of control, sense of self, and the ability to regulate emotional distress. They may also have developed dysfucntional beliefs about the self and others that could lead to distorted relationship patterns and sense of agency rendering them vulnerable to the development of personality difficulties in adulthood.
Activity: Watch this video from the Anna Freud Centre in which Peter Fonagy explains the concept of "Mentalising".
About the Video: "Mentalising refers to our ability to attend to mental states in ourselves and in others as we attempt to understand our own actions and those of others on the basis of intentional mental states. A focus on this very human activity as a therapeutic intervention forms the core of Mentalisation Based Treatment (MBT). MBT was initially developed for the treatment of borderline personality disorder (BPD) although it is now being used on a wide range of disorders."
How can you use your knowledge and understanding of attachment theory to help reduce the impact of children's pre-existing distorted beliefs about themselves and others and the consequent effects on social, emotional and interpersonal functioning?
It is crucial that practitioners working with vulnerable adolescents apply attachment principles to their work by encouraging openness, the provision of choices, sensitivity and responsiveness.
Professionals need to provide vulnerable adolescents with consistency e.g. following through on an agreed action as well as being honest about difficulties that may be encountered.
Emotional Disorders
A common term that has often been used is "emotional disorer of childhood" - a broad cataegory of disorder by any measure. Possible reasons for such a rag-bag term include:
The fact that presentations vary so much by age and development
Young people often present with a mixture of symptoms that include significant changes in the young person's mood, changes in behaviour, and physical symptoms.
There may be a complex mixture of symptoms that vary greatly between young people making further categorisation too complicated to be helpful.
Despite these issues, nowadays some specific types of emotional problems have been more clearly distinguished and largely relate to substantial changes in mood, or "affect" e.g. anxiety, worry, fear, sadness, misery, depression and anger. It's important to note that anger in and of itself is not a mental disorder but difficulties in coping with or regulating anger are frequent targets for intervention with young people to assist healthy emotional and social development.
This leads to the question "At what point does an emotional problem become a mental health problem?" Two useful repsonses to this are to first evaluate whether the symptoms cause the young person or others a significant degree of distress, and second, whether the symptoms have an adverse effect on social or educational function.
A third factor may be assessed in longer term issues: that of the effect on the young person's psychological or physical development.
Activity: View the "Emotional Disorders in Childhood" presentation
Severe challenging behaviourthat persists accross domains and over time may constitute a conduct dissorder: Oppositional Defiant Disorder(ODD) and Conduct Disorder (CD).
ODD: Characterised by irritability, temper outbursts, disobedience, and negativity.
CD: Characterised by rule breaking, verbal and physical aggression, lying and stealing, and violation of other people's rights.
There are obvious overlaps between both conditions. The oppositional young child often develops delinquent behaviour over time. They are the most common disorders in childhood and adolescence. UK data suggests that rates of oppositionality remain relatively constant across childhood and adolescence but conduct problems increase with age, especially in the teens.
Classification
Conduct disorders are classified as either unsocialised or socialised.
Unsocialised Conduct Disorders: The young person usually presents with a pervasive difficulty in relating to their peer group
Socialised Conduct Disorder: The young person usually is well integrated with their peers
Conduct disorders often co-exists with depression.
Common Behaviours in Young People with CD
Excessive levels of bullying or fighting
Stealing and repeated lying
Firesetting
Aggression
Repeated truancy
Running away from home
Cruelty to other people and animals
Unusually frequent and severe bad temper tantrums
Defiant and provicative behaviour
Severe and persistent disobedience
Risk Factors
Socio-economically disadvantaged communities
Familial discord and large families
Poor parenting and modelling
Poor educational attainment or opportunities (especially specific reading and writing problems)
Genetic factors
Poor physical health
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD is a condition charcterised by three main features:
Inattention : Poor concentration with a reduced ability to maintain attention without distraction.
Hyperactivity: Difficulty in controlling the amount of physical activity appropriate to the situation.
Impulsivity: Lack of appropriate forethought and consequential thinking.
Onset can occur in the preschool years. it is more common in boys than in giorls and is said to have an approximate prevalence rate of 0.06% in all school age children. The true figure may be higher as some children remain undiagnosed.
