MENTAL HEALTH CONCERNS REGARDING ADOLESCENTS
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Discuss the major concepts associated with adolescent development
2. Identify normative versus nonnormative behavioral patterns in terms of developmental milestones for an adolescent
3. Describe the major areas to address when assessing an adolescent
4. Identify the common mental health problems found in the adolescent population
5. Apply the nursing process from an interpersonal perspective that addresses the care of adolescents with mental health problems
Adolescence is characterized by a period of transition from childhood through puberty and on into adulthood. This transition brings with it physical and emotional challenges and is part of normal growth and development. During this period, the social world begins to have a greater influence and the importance of peers becomes evident. This transition period is taking longer than it did 50 years ago, with some suggesting that adolescence now extends into the mid- or late-20s (Steinberg, 2011). When problems occur in adolescence, particularly mental health problems, they often can be dismissed as part of normal development. Thus, appropriate intervention may not be offered. There is a perception that time will heal mental health problems in adolescents and they will “grow out” of the problem as they proceed into adulthood. However, it is important to highlight that many difficulties experienced by adolescents transcend into adulthood without appropriate intervention.
In the United States, up to 22% of children and adolescents are experiencing a mental illness (Merikangas et al., 2010). Furthermore, studies reveal that approximately 58.1% of those between the ages of 12 and 17 years in the United States have screened positive for at least one cluster of symptoms related to a psychiatric disorder (Chen, Killeya-Jones, & Vega, 2005). Adolescents in other countries are also at high risk of mental health problems. For example, in Australia the prevalence of mental health problems is greater among 16- to 24-year-olds than any other group across the life span (Australian Bureau of Statistics, 2007).
When problems in adolescence are not identified and treated, lifelong problems that may have serious consequences often result. In addition, stigma still surrounds the issue of mental health. This is particularly evident in adolescents, as they are searching for self-identity and trying to feel accepted by their peers. This commonly results in many adolescents failing to seek professional help.
This chapter reviews adolescent growth and development, including the important role of peer relationships, and describes important areas to be included in the assessment. The chapter addresses the most common disorders associated with this population and concludes with a discussion of the nursing process from an interpersonal perspective related to the care of an adolescent with a mental health problem.
The beginning of adolescence is unclear; however, it is generally associated with the onset of puberty. Adolescence is characterized emotionally as a period of searching for self-identity, finding meaning in life, and forming a unique personality separate from those of one’s parents. It is a time of external conflict with those in authority and internal conflict with the adolescent struggling with life meaning. Adolescence is a time where confidence and self-esteem can develop or diminish. Conflict with parents is common and often centers on authority, autonomy, and responsibility. This conflict, however, is necessary to prepare adolescents for conflict resolution in later life.
Many theories and models attempt to explain the stages of development experienced by individuals. (See Chapter 21 for additional information on theories of growth and development.) One of the most common theories is that of Erikson (1968), in which he describes the identity crisis that adolescents face. During this crisis, adolescents attempt to discern who they are as they are faced with new feelings, a new body, and a new attitude. Their self-identity is built out of their perceptions of themselves and their relationships with others. Erikson argues that if they do not develop their own self-identity, then role confusion results.
Puberty and Self-Esteem
One of the major changes experienced by adolescents is puberty. Puberty is characterized by change and development in bodily functions. It usually begins around the age of 10 years, initially signaled with a growth spurt that continues into the late teenage years. During this time, young people compare themselves to others in terms of appearance and intellect. Sexual awareness also develops, which is often associated with increased self-awareness, which can affect self-esteem.
Self-esteem is important to overall well-being and has been associated with mental health problems in later life. Indeed, low self-esteem is associated with depression, eating disorders, and anxiety problems in adolescents. Levels of self-esteem change during adolescence, with it usually increasing with sexual maturity, but with the multitude of changes that happen during this period, healthy self-esteem may not develop until young adulthood.
Peer relationships develop in young children and play a significant role in overall development. As children become older and transition into adolescence, they spend more and more time with their peers. These relationships strongly influence an adolescent’s development. Peer group membership can have a negative effect. For example, lack of acceptance by a peer group can lead to low self-esteem, a decrease in academic performance, and social rejection (Veronneau, Vitaro, Brendgen, Dishion, & Tremblay, 2010). In addition, peer group influence can lead adolescents to engage in delinquency and antisocial behaviors (Monahan, Steinberg, & Cauffman, 2009). Moreover, the absence of supportive peer relationships can lead to young people living in a state of anxiety or fear, depression, or isolation. Research studies addressing peer relationships in adolescence suggest that stable peer relationships are related to high self-esteem (Birkeland, Breivik, & Wold, 2014) and that peer attachment can lead to life satisfaction in adolescence (Schwartz et al., 2012). Peer support was reported as protective against depressive symptoms if parental support was also present (Young, Berenson, Cohen, & Garcia, 2005), whereas peer rejection predicted the onset of depressive symptoms (Witvliet, Brendgen, Van Lier, Koct, & Vitavo, 2010).
Today, peer relationships are becoming more and more important related to the decline in the traditional family system. The numbers of single-parent families and mothers working outside the home have increased. Thus, adolescents are spending increased time with their peers. In addition, technological advances have led to more young people spending more time on computers and less time interacting face to face with their peers. This lack of physical interaction may lead to isolation from the community, resulting in adolescents failing to receive the necessary support to cope with the turbulence of this time of life. Adolescent participation in using social media has dramatically increased, leading more and more young people to communicate via texting or the Internet. Studies have indicated that it may affect self-esteem, both positively (Gonzales & Hancock, 2011) and negatively (Valkenburg, Peter, & Schouten, 2006). Specifically, they have been reported to reduce the stress of social exclusion (Chiou, Lee, & Liao, 2015), but to also lead to narcissism and low self-esteem the more they are used (Mehdizadeh, 2010). This increased use also has raised growing concern about adolescents being targeted by sexual predators online (Ybarra & Mitchell, 2008).
The development of self-esteem and identity are important developmental tasks in adolescence. Peer relationships play a major role in achieving these tasks.
Assessment, essential to any patient and plan of care, must consider the needs of both the individual adolescent and his or her family. More than one meeting may be needed to fully assess the adolescent’s needs and gain an accurate understanding of the problems.
Although the involvement of family is essential, assessing the adolescent, individually and by himself or herself, is important because there may be difficulties within the family. As a result, the adolescent may feel uncomfortable sharing information with the family present. In addition, meeting the adolescent alone can help foster the nurse–patient relationship and build trust. Many adolescents may be ambivalent about the difficulties they are facing or fearful of becoming stigmatized. Or they may be unable to articulate their problems or have issues with authoritative figures. Therefore, sensitivity is a major consideration.
When interviewing the adolescent individually, use appropriate language, remembering that the adolescent is neither a young child nor an adult. The adolescent is the primary concern and development of a therapeutic relationship is needed. Throughout the assessment, listen to the adolescent’s view of the problem and try to understand the problem from his or her frame of reference, including eliciting their values and preferences for care. Direct the questions to obtain information about how the difficulties are interfering with his or her life and how he or she is coping in school (if attending). Ascertain the quality of the relationships with peers and family members. In addition, determine the adolescent’s support system, the history of the difficulties, and any drug and alcohol use. To help focus the assessment, use the following questions as a guide:
How is the adolescent engaging with the assessment; is he or she forthcoming with answers: “How are you feeling about these questions?”
What makes him or her feel anxious, happy, sad: “What types of things make you happy? Sad? Upset?”
What is the adolescent’s perception of his or her family: “How do you view your family?”
How does he or she use leisure time: “What do you do for fun? For relaxation?”
How does the adolescent view himself or herself: “How do you picture yourself?”
Can he or she easily express his or her feelings: “How do you express your feelings? Do you talk about things? Do you keep things to yourself?”
Does the adolescent want things to change: “When you look at your life, is there anything that you would like to change?”
How does he or she want things to change: “You mentioned wanting to change______. How would you go about changing this?”
Assessment of the adolescent must include a family history addressing information on pregnancy, birth and early health history, medical history, school history, and family health problems. In conducting a family assessment, bear in mind that each family is different and has its own set of norms and internal dynamics. Identify the parenting style of the family (authoritative, coercive, ambivalent, or abusive) and determine if and how it may be influencing the adolescent’s behavior or mood.
Using the information from the assessment helps one to identify what the adolescent’s strengths are, if the adolescent meets the diagnostic criteria for a clinical syndrome, and what intervention may be necessary.
Assessment of an adolescent requires sensitivity and use of appropriate language to determine the adolescent’s view of the problem from his or her frame of reference.
COMMON MENTAL HEALTH PROBLEMS IN ADOLESCENCE
Adolescents can experience many of the mental health problems experienced by adults. However, some are more common, including depression, mania, self-harm, suicidal ideation, alcohol and drug use, eating disorders, and anxiety disorders such as obsessive-compulsive disorder (OCD). These disorders will be addressed briefly here. (Refer to Chapters 12, 13, 15, and 19 for more in-depth discussions.)
Some adolescent mental health problems are classified in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2014) and the International Classification of Diseases, 10th edition (ICD 10-CM; World Health Organization [WHO], 2011). However, adult classifications are used for most illnesses. Although both manuals have a section on problems in childhood and adolescence, the focus is on childhood and, in particular, on conduct and behavioral disorders. The DSM-5 also discusses age-related disorders throughout the manual.
Many factors can influence the development of adolescent mental health problems, including adolescent pregnancy, socioeconomic disadvantage, bullying, and abuse and neglect. Box 22-1 highlights some of the common forms of abuse. These difficulties can lead to a variety of emotional problems manifested by similar signs and symptoms. Therefore, avoiding assumptions and recognizing the signs are of the utmost importance.
Adolescents often experience mental health disorders that are the same as those in adults. Depression, mania, self-harm, suicidal ideation, alcohol and drug use, eating disorders, and anxiety disorders such as obsessive-compulsive disorder are common in adolescence.
Depression is the most prominent cause of disability and illness among 10- to 19-year-olds (WHO, 2014). Reports vary as to the prevalence of depression. However, it is believed that 3% to 8% of adolescents will experience a depressive disorder before entering adulthood (Zalsman, Brent, & Weersing, 2006). Indeed, it is estimated that in the United States 2.2 million adolescents have had at least one major depressive episode in the previous year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). In addition, children of parents with depressive disorders are at greater risk of developing depression. A combination of environment and genetic factors is believed to cause depression in adolescents. Little evidence exists to support a molecular link.
BOX 22-1: ADOLESCENT ABUSE: SIGNS AND SYMPTOMS
Abuse in adolescence may take several forms. It can range from bullying in school and by peer groups to sexual and physical abuse at home and by significant others.
• Bullying: Adolescents are usually bullied due to appearance or social status. Cyber bullying is becoming very common, with almost 50% of middle school and high school students reporting being bullied in this way (Mishna, Cook, Gadalla, Daciuk, & Solomon, 2010). Signs of bullying may include fear, anxiety, depression, social withdrawal, decreased self-esteem, and talk of revenge.
• Sexual abuse: Signs of sexual abuse in adolescents may include decreased self-esteem, social withdrawal, nightmares, changes in school performance, violence toward others, shame, guilt, and alcohol and drug use.
• Physical abuse: Signs of physical abuse may include aggression, deviancy, fear of adults, disruptive behavior, going to school early and leaving late, fearlessness, risk taking, being described as “accident prone,” low academic achievement, wearing clothes that cover most of the body, decreased maturity, regression, and dislike of physical contact.
The classification of depressive disorders has been described in Chapter 12. In contrast to adults, adolescents often experience a higher comorbidity with other disorders, such as anxiety disorders, conduct disorders, and substance misuse. In addition, depression is not to be confused with feelings of sadness in adolescents. The turbulence of adolescence commonly causes feelings of sadness and despondence. These feelings are often short-lived and do not necessarily indicate the presence of a depressive illness.
Possible precipitating and predisposing factors for adolescent depression are varied, but may include (Aslund, Nilsson, Starrin, & Sjoberg, 2007; MacPhee & Andrews, 2006; Thapar, Collishaw, Pine, & Thapar, 2012):
Academic difficulties, such as examination failure
Abuse (sexual, emotional, and physical)
Familial relationship problems/parental divorce
The major symptoms of depression in adolescents are similar to those in adults and may include low mood, lack of energy, loss of pleasure, decreased self-esteem and confidence, guilt, feelings of worthlessness, decreased concentration, sleep difficulties, hopelessness, and tearfulness. However, depression may manifest itself a bit differently. For example, the adolescent may present with behavioral problems, such as poor school performance, running away from home, and aggression. These behavioral problems are commonly noted in younger adolescents. Depression may also present as physical pains, often as complaints of headaches.
The treatment of adolescent depression depends on the nature of the problems identified. It should focus on relieving the depressive symptoms, promoting emotional and social functioning, and working with the family. Supportive therapy can be helpful for mild depression, whereas more structured therapeutic approaches are needed for severe depression. Whatever approach is adopted, the adolescent needs to be the central decision maker about his or her care. In some instances, psychopharmacology with antidepressants has been used. Currently, antidepressant medications are recommended only as a last resort because they have been shown to increase the risk of suicidal behavior in adolescents (Richmond & Rosen, 2005), and as such, the Food and Drug Administration (FDA) has issued a blackbox warning. Assessment of suicidal ideation is essential. If it is present, it must be addressed and may require inpatient treatment.
Mania is often seen as part of bipolar disorder (see Chapter 12 for more information). It more commonly develops in later adolescence. Mania is characterized by:
Flight of ideas
Treatment usually involves a combination of structured therapy, family therapy, and psychopharmacology. According to the American Academy of Child and Adolescent Psychiatry (2007), mood-stabilizing agents such as lithium, carbamazepine, and valproic acid may be used. In addition, antipsychotic agents such as risperidone (Risperdal) may be prescribed during an acute manic phase. If the adolescent is prescribed lithium, careful monitoring is needed because lithium can be lethal if taken in an overdose. As a result, it may not be suitable if the adolescent lacks family support to supervise adherence. In addition, there is a lack of controlled trials on the use of antipsychotic medication with adolescents (Schapiro, 2005).
The incidence of self-harm is very high in adolescents, conservatively estimated as affecting 5% to 8% of adolescents (Skegg, 2005). However, further studies have reported rates as high as 17% with a mean onset age of 15 years (Nixon, Cloutier, & Jansson, 2008). It is most common in young females. Self-harm is often associated with suicide. However, it can also occur without suicidal intent. Thus, a distinction is needed so that appropriate intervention can be offered.
Self-harm without suicidal intent often manifests itself as superficial cuts to the body, minor burns, head banging, and insertion of foreign objects into the body. The reasons for this type of behavior are often multifaceted and not merely attempts to seek attention as many believe. Indeed, self-harm is often conducted in private without the knowledge of family, friends, or health care practitioners. This further adds to the unclear incidence rates, as it is often underreported.
The reasons an adolescent engages in self-harm are numerous. Some of the more common ones include:
Relief of emotional pain
Desire to feel physical pain
Need to feel in control
Self-harm is believed to be a coping mechanism that an individual may use when experiencing distress. The distress is often related to certain triggers. These triggers are highly variable but may include bullying or peer rejection; sexual, emotional, or physical abuse or violence in the home; feelings of worthlessness, powerlessness, or loneliness; substance misuse; bereavement; or parental divorce. For some, self-harming behavior can become addictive and, subsequently difficult to control or stop. Therefore, the focus is on working with the adolescent in trying to find alternative coping strategies through problem solving.
An adolescent who engages in self-harm behaviors may or may not be experiencing suicidal ideation. Self-harm behaviors without suicidal intent result from a multitude of reasons and are not attempts to gain attention.
Suicide is becoming increasingly common in adolescence, particularly in older adolescence. Reports show that of the 4 million suicide attempts around the world each year, 90,000 of those are completed by adolescents (Greydanus & Shek, 2009). Suicide is among the leading causes of death for adolescents worldwide and is ranked as the second-highest cause in the United States. Suicide attempts need to be taken seriously and require immediate intervention. Four out of five adolescents show warning signs before a suicide attempt. Box 22-2 identifies some of the more common signs.
If suicidal signs are present, further assessment is warranted and needs to focus on the following:
The lethality of the method proposed or used if an attempt was made
The place where the attempt took place, the likelihood of discovery, and precautions taken to avoid discovery
The presence of suicidal communication such as a suicide note or blog entry
Previous attempts made
Evidence of a psychiatric disorder
The continued wish to die