This chapter is set within the context of both the ‘National Service Framework for children, standards for hospital services’ (Department of Health (DoH) 2003), the ‘National Service Framework for children, young people and maternity services’ (DoH 2004) and the CAMHS Review (DoH 2008). The earlier NSF advocates child-centred services that consider the whole child, not simply the illness. Seeing the whole child also means recognising that health protection and promotion, and disease prevention are integral to the young person’s care in any setting. In exploring child-centred care it is recognised that the child exists within the context of a family, school, friends and local community. Further, children and young people have rights, and their treatment is a partnership. Respecting the role of parents is seen as a significant part of providing services for children.

Prevention and health promotion are also seen as a fundamental question of attitude that looks beyond the immediate treatment of the presenting problem. This chapter seeks to explore those strategies involved in the promotion of mental health and opportunities for the prevention of health risk behaviours. The ‘National Service Framework for children, young people and maternity services’ (DoH 2004) builds and develops the earlier work seeking to ensure that all children and young people get services that are age appropriate, accessible and that recognise that their needs are different. It is a national blueprint to ensure personalised child-centred health and social care services. It recommends that all staff working with children are able to recognise the contribution they can make to children’s emotional well-being and that they understand their responsibilities for supporting children in difficulty.

The CAMHS review (2008) stresses the need to integrate CAMHS into all spheres of child health care, therefore emphasising the need for sick children’s nurses and other allied disciplines to be aware of the mental health needs of children. This review highlights that these needs not only exist for children with predominant mental health problems but also for children who present with a primary physical problem and associated mental health needs. This report highlights how a child with a physical disorder or condition is twice as likely to develop mental health problems as the child without such difficulties (Shooter 2005). Thus emphasising the need for sick children’s nurses to be sensitive to and aware of the needs of children to maintain a sense of psychological well-being.

This term ‘psychological well-being’ is thought to be the most useful description of mental health needs of children and adolescents as too often we limit ourselves to viewing mental health problems as diagnosable, symptom-apparent mental illnesses. There is a shift in mental health now to move away from the predominantly medical models, but not towards a polarised social model. Rather the aim is to view the child or adolescent as psychosocial beings with both psychological and social contributing factors to both their difficulties and possible solutions. The term psychological well-being also incorporates emotional, cognitive and behavioural attributes of well-being (CAMHS Review 2008).

There is also a move to fine tune the general public’s view of mental health where incompatible extremes exist. Like the assumption that one needs the criteria of symptoms to be mentally unwell, on the contrary, our view of mental wellness is equally important. Recent refreshing insights into young people’s views of mental health indicated that young people realistically do not view being mentally healthy as being happy all the time but rather view it as being able to cope with the potential happiness that accompanies living (CAMHS Review 2008).

Working with adolescents is a task many groups find challenging. In the foreword to the report ‘Bridging the gaps’ (RCPCH 2003), David Hall reminds us that the British stand accused of ‘not liking children’; he suggests perhaps we like adolescents even less. Generally, adolescents are considered to have needs that differ from both adults and children yet they are often nursed in environments that also contain either adults or children. If we add to this issues of emotional distress/mental health, things seem to move beyond the perceived areas of expertise or competence of many children’s nurses (Norwich Union 2001). The picture may be complicated further by the nurse having to move quickly from the parents of a child who is seriously physically ill to an emotionally distressed, abusive, swearing, adolescent whose physical health may or may not appear to be seriously compromised. It is these dilemmas that this chapter wishes to address by providing information and educational resources, but more importantly some practical guidance on the interpersonal skills that might be helpful with this client group.

It is commonly accepted that there are some dominant ideas about adolescence. It can be defined as a period in human development linked to biological markers, involving transitions (that can be seen as stages), in which the central task is establishing identity. It is suggested that universal definitions of adolescence should at best be restricted to describing adolescence as a ‘period of transition’ in which, although no longer seen as a child, the young person is not yet considered an adult. The World Health Organization’s (WHO 1995) definition of adolescence states that the stage is commonly associated with physiological changes occurring with the progression from the appearance of secondary sexual characteristics (puberty) to sexual and reproductive maturity. Dehne & Riedner (2001) suggest that these biological markers create problems because the falling age of onset of the menarche attributed to improved health means there is now a widening gap between the age of sexual maturity and the age at which sexual relations become legitimate. A central dilemma of the adolescent experience is that in some cultures physical maturity comes well before legal definitions of adulthood in terms of legal sexual behaviour, the right to vote, join the military, etc.

The combination of young people’s relative inexperience in sexual matters and the social stigma attached to them being sexually active creates vulnerability that is only now being recognised and addressed (Dehne & Riedner 2001). However, adolescence is not characterised just a sexual dilemma, there is also vulnerability in relationships with peers, with adults and with organisations. It seems that adults don’t know how to take adolescents seriously because they do not find it easy to understand their experience.

There is, however, a view that the dilemma of adolescence has been overplayed, in terms of a life stage that, by its very nature involves serious conflict and upheaval. More recent thinking suggests much less necessary difficulty and much more continuity between the child that was, through adolescence to the adult that will be. It is considered that normal adolescents negotiate this period of life transition with relatively little major disruption or sustained high-risk behaviour (Offer 1987, cited in Burt 2002).

Even if the more optimistic view of adolescence is taken, healthcare settings are likely to see more of those children involved in high-risk behaviours. These high-risk behaviours are also linked to the precursors of mental health problems, low self-esteem and dysfunctional families (British Medical Association (BMA) 2003).

A simple definition for adolescence, which acknowledges the developmental stages, is offered by the Registered Nurses Association of Ontario (RNAO) in its guidelines for nursing practice entitled ‘Enhancing healthy adolescence’:

Individuals will negotiate these stages in their own time but, as a general principle, it is helpful to view adolescence in this way. There seems to be a significant degree of agreement that the stage models of the adolescent journey see personal identity as the focal concern (Kroger 1989, cited in La Voie 1994). These models take a stage approach, starting with the preadolescent, and continue the process of change through to post adolescence (La Voie 1994).

It is helpful to see the key adolescent task as a search for identity, that is, a sense of separate self but, as always, the self in relation to others. Adolescents are in search of an identity that will lead them to adulthood, they make a strong effort to answer the question ‘Who am I?’.

Of the stage models, Erickson’s psychosocial model is perhaps the best known. Erickson (1963) describes the adolescent task/crisis as identity versus confusion. He notes that the healthy resolution of earlier conflicts can now serve as a foundation for the search for an identity. If an individual has developed a sense of trust and a strong sense of industry then the search for identity will be easier. The adolescent must make a conscious search for identity. This is built on the outcome and resolution to conflict in earlier stages. If the adolescent cannot make deliberate decisions and choices, especially about vocation, sexual orientation and life in general, role confusion becomes a threat.

Jacobs (1998) looks at adolescence in three stages:

In this model, early adolescence is linked to puberty and reinitiates issues of sexual identity and attitudes as part of the overall quest for personal identity. The young person may become very self-conscious and also very preoccupied with appearance and dress. The young person’s changing physical appearance matters a great deal. This might evoke feelings of pleasure and confidence or strangeness and shame. Rivalry and competition are often important elements at this time as part of the adjustments within peer groups. However, rivalry is not confined to peer groups: just at the time the children are finding their sexual identity, their parents are conscious of imminent or present changes in themselves.

Jacobs talks of how a mother may be entering her menopause at the same time as the daughter achieves her menarche or a father may be aware of his spreading midriff and lack of muscular tone just as his son is reaching his peak of physical fitness. Even if that is not the case, parents in the UK will be made aware of their changing life position in what is a very youth-oriented culture. These changes in life positions for all family members are the context in which the young person’s ambivalence towards his or her parents is acted out. On the one hand, the parent is still needed as an object of love and a protector but on the other there is a strong desire to push the parent away to find their own confidence and object of love. To both love and hate parents, who then may respond by being hurt or angry, can be a difficult conflict for the young person to contain and manage.

There is also the consideration of current changes to the adolescent landscape. One must consider that the cultural advances in technology and exposure via mobile technology and the internet mean that our adolescent population is bombarded with dialogue and imagery far beyond their developmental capacity. They are exposed to sexual images and sexual discourse that their emotional development has not the capacity to cope with. This can contribute to the high octane mood swings and outbursts that are understood by an increasing pressure to cope. This mismatch between cultural demand and emotional maturity means that sometimes adolescents resort to toddler-like coping strategies of tantrums, sulking and verbal and physical ‘meltdowns’. This can be understood by proposing that this behaviour is symbolic to the return to a primitive manner of coping or regression in a time of increased stress and an inability to cope. The lack of expressive ability inherent in the adolescent means that their feelings are expressed through acting out behaviours like outbursts, rebellious dress sense and/or periods of withdrawal or refusal to communicate.

An understanding of the adolescent’s developmental tasks will allow the nurse to focus caregiving in the most effective manner. The most important nursing intervention might be for the nurse to spend time with the young person’s key friends, helping them accommodate the changed circumstances of the illness so that supportive peer relationships can be maintained (not sure about this?). This in turn will enhance the young person’s self-concept and self-esteem, which will be needed in facing the difficult adjustments ahead. This strategy will also serve as a protective factor against emotional distress and the risk of mental ill health. This would support the idea of moving beyond pure medical thinking and embrace the concept of adolescent health (Bennett & Tonkin 2003).

Lifespan developmental theories tend to support these important ideas (Goosens & Marcoen 1999):

When thinking of a holistic assessment process, it might be helpful to reflect on the interplay between the young person’s illness and their transition through the adolescent developmental tasks. You might want to think of some questions you could ask during the assessment phase that might help you locate where the young person is in terms of their adolescent transition.

Sexuality might be seen as a taboo subject in that it is often an overlooked issue for those working with children and adolescents. Clearly, the reality is that children are exposed to issues of sexuality extensively within the popular media. Children and adolescents are aware of changes in their own bodies and those of their family and friends. There is a need to be sensitive to the young person’s accommodation of his or her own sexuality in earlier adolescence, and their possible uneasiness with themselves in terms of sexuality. In middle adolescence we need to be aware of how younger nurses may be drawn by the young person into their peer network. They may want to see the nurse as a friend or identify with them, compete with them, or even reject them as a peer. The young person might develop intense feelings about individual nurses that may involve love and/or sexual attraction. It is worth noting that the changing attitudes in society to the expression of sexuality mean that we need to be aware of issues of primary sexual orientation, heterosexuality, homosexuality and/or bisexuality.

Being ill can be a significantly challenge to the individuals confidence about their sexuality, personal appearance and thus self-worth. Studies show that awareness of sexuality and physical attractiveness significantly influenced females’ and males’ sense of self-worth (Hay & Ashman 2003).

Key documents in this area (CAMHS Review 2008) are:

The factors that contribute towards health risk behaviours in children and young people are closely related to the factors that contribute to emotional distress and mental health problems.

There is strong and growing evidence for the fundamental inter-relationship between physical, mental and social health. Problems in any of these areas indicate the likelihood of long-term adverse health and social consequences (RCPCH 2003). These links mean that young people with health problems are likely to have a greater risk of presenting with mental health problems. It is important to note that most adolescents negotiate this period of life transition with relatively little major disruption or sustained high health-risk behaviour. Those who do experience major disruptions and who persistently engage in problem behaviours now have a significantly higher risk of health problems in later life. Thus successful intervention now has important payoffs in terms of future health problems prevented and future satisfying and productive lifetimes promoted (Burt 2002). There is a strong relationship between adolescent health and other aspects of adolescent life such as education, employment and housing. Interventions therefore should be multiprofessional and involve cooperation between health, education and social services (BMA 2003).

Most reports on adolescent health focus on health interventions in terms of health risks and protective factors. Key health risk factors identified by the BMA report ‘Adolescent health’ (BMA 2003) include nutrition, exercise and obesity, smoking, drinking and drug use, mental health and sexual health. Similar health outcomes were selected for study in an Australian report, ‘Evidence-based health promotion no. 2: adolescent health’ (Department of Human Services Victorian Government 2000). This systematic review identified six health outcomes: tobacco use, alcohol and drug use, sexual risk-taking behaviour, crime and antisocial behaviour, depression, and suicidal behaviour. There will be similar patterns in other industrially developed countries, although Australia has not identified obesity. Perhaps with sport and outdoors activity so embedded in the culture, the effects of overeating are mitigated by attitude, activity and exercise.

Research has shown that certain factors mitigate against health-risk behaviours:

The more positive the young person’s self-esteem, the greater his or her sense of self-efficacy. Negative self-efficacy is linked with general unhappiness and past worries. The links are stronger for girls than boys but are significant for both. Negative self-efficacy and low self-esteem increase the possibility of health-risk behaviours. Poverty, family dysfunction or lack of parental involvement and support are the risk factors that consistently differentiate the youths most likely to get into serious trouble from those who don’t (Burt 2002).

Common antecedents to health-risk behaviours (Catalano & Hawkins 1995, cited in Burt 2002) are:

According to the CAMHS Review (2008) mental health problems are likely to occur in the presence of three or more stressful events. The most common (Audit Commission 1999) are:

It can be seen that the contemporary health problems of young people occur within the context of the physical, social, cultural and political realities within which they live. Recognition by self-report that most adolescent health concerns were actually social and psychological in nature suggests that the time has come to throw off pure medical thinking and embrace the notion of adolescent health. What is needed is a holistic model of health care highlighting the multiplicity of human needs that may exist beyond and yet create the context of the presenting complaint (Bennett & Tonkin 2003).

The idea that our early experiences shape our later lives is not new. The work of Freud and the psychoanalysis movement highlighted the importance of early life, and Bowlby (1988) and others made the link between problems in adolescence and childhood experiences. In early childhood our mental health is mediated in large part by our relationship with our primary caregivers. Recent neurological research is commented on in the CAMHS Review (2008) and reinforces the importance of early intervention to reduce the impact of stress in pregnancy and to promote attachment and acknowledge the long-term effects of attachment disturbances. This is particularly referred to in the case of children from disadvantaged circumstances

Illness can be seen as easier to define than health and is often described in diagnostic manuals. However, the question needs to be asked: what is mental health? The definition in ‘Bright futures: promoting children and young people’s mental health’ (The Mental Health Foundation 1999) offers some indicators. This definition states that a mentally healthy child or young person is one who has the ability to:

It is as difficult to define mental health as it is health in general, but it is widely agreed that in children, mental health is indicated by (NHS Health Advisory Service 1995 p 15):

A useful definition of mental health (or psychiatric) disorder was given by Rutter & Graham (1968) as:

In making a child psychiatric assessment five key questions are asked (Goodman & Scott 1997):

Strengths can often be seen in terms of protective factors that increase resilience in the face of stressors. Generally the interplay of risk and protective factors determines whether the child overcomes the stressors they face. In some situations the stressors can be so great or so many that they cannot be defended against.