Introduction
This chapter will focus specifically on the mental health of adolescents and young adults, as well as consider
how it can impact on an individual in later life. It will introduce the reader to concepts and theories
relating to adolescent mental health and the development of services within the UK, over the latter part
of the twentieth century, the behavioural, emotional and physiological changes that can occur during this
period and how they interact with one another will also be discussed. A section considering the role and
influence of family, friends and peers on adolescent mental health is also presented. The chapter will
conclude 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 the
nature of a young person’s 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 and
promoting positive mental health during this stage. The terms adolescent, young adult and young person
are used interchangeably and defining this stage is discussed within the text. Much of the research discussed
is 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 misunderstood
all the time.
Adolescence and young adult mental health
Adolescence is derived from the Latin word ‘adolescere’, which means ‘grow to maturity’. It is a
stage 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 concept
and 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 one’s identity, the development
of more complex social and sexual relationships, increased autonomy and independence, and
increased 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 the
onset of puberty greatly alter individuals’ body shape and size, reproductive related physiology
and brain development. It is often a period that is characterised as the transition from childhood to
adulthood 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 technologically
advancing state, increased prosperity, cultural migration, improved media and information
distribution, as well as increased liberalisation and civil rights are just a handful of factors that have
all 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 recent
history means there is an added pressure at this stage to achieve, potentially leading to greater anxiety
and stress. Disruptions during this stage, by way of poor mental health, could therefore have
considerable ramifications.
Early theories and concepts
The concept that adolescence is one of increased conflict and inner turmoil is as old as Ancient
Greek thinking (Coleman, 2011). Leading theories of adolescent development over the past century
also reflect this idea. Granville Stanley Hall proposed that the period of adolescence is one of
“storm and stress” (Hall, 1904 as cited in Arnett, 1999). Arnett (2006) discusses how Hall’s view
of adolescence was generally one of increased behavioural and emotional turmoil brought about by
dramatic and unpredictable growth spurts. Erikson’s (1968) Theory of Psychosocial Development
describes a crisis in identity at this stage due to a young person’s emerging identity being at odds
and in conflict with the role expectations of others. Likewise, Anna Freud describes an imbalance
of the id and ego during adolescent development (Muss, 1988). One final theory worthy of note is
David Elkind’s (1967) Egocentrism in Adolescence. Elkind characterised adolescence by a number
of 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 due
to perceiving themselves as being on a kind of ‘social stage’ with an ‘imaginary audience’. They
may also experience feelings of isolation, believing their abilities and experiences to be unique to
everyone else’s, a concept which Elkind coined ‘personal fable’.
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Adolescence and young adult mental health 115
The reason these theories have been selected and highlighted here is that they describe adolescence
as being a troubled and turbulent transition. However, developments in the latter part
of the twentieth century served to challenge these concepts. During the 1960s and 1970s, empirical
evidence began to emerge that suggested the majority of adolescents coped with stressful life
events 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 sought
to understand the aetiology of disorders in young people, attracting health professionals from various
specialities (Hersov, 1986). In more recent decades, efforts have been made to prioritise the
investigation 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 and
adolescence (Heginbotham and Williams, 2005).
Service provision and development
Government strategies within the UK and internationally have emphasised a multidisciplinary
approach 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 Human
Services, 1999). However, the fragmentation in services may serve as a barrier when accessing
care; a young person’s mental healthcare needs are often dealt with in less well equipped settings
such 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 managed
in primary care without the need to refer to specialist services (Dogra et al., 2009, p. 31). The development
in service provision for children and young people parallels many of the changes in adult
mental healthcare, changes which seek to provide greater community-based services as opposed
to inpatient care. Evidence from the US highlights this trend with hospitalisation length of stays
for 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 for
young people’s mental healthcare. In an attempt to review and offer a strategic framework for the
organisation of CAMHS, the Together We Stand (Health Advisory Service, 1995) and The Health
of the Nation: Child and Adolescent Mental Health Services (Department of Health, 1995) policy
documents were developed in order to help audit and benchmark services. The policy split care into
four tiers, of universal, specialist, multidisciplinary and inpatient care, with each tier determined by
the severity of an individual’s mental health condition. However this approach has been criticised
for promoting a hierarchical system of care, when in fact it is argued that CAMHS professionals
should be working across all tiers (Richardson et al., 2010). The number of nurses working
within CAMHS has increased rapidly over the last two decades and their roles have broadened. This
broadening of roles now means that nurses are increasingly involved in designing and managing
services as well as delivering them (Townley and Williams, 2009). CAMHS professionals provide
a range of psychotherapeutic interventions and deal in a range of multi-agency working. However
it is a specialism that is often little understood by service-users, professionals and commissioners
alike (Richardson et al., 2010). Other European countries also tend to provide separate specialist
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clinics for child and adolescent mental healthcare, but still place great emphasis on preventative
approaches (Jané-Llopis and Anderson, 2006).
We will now take a brief look at the changes that occur during adolescence in terms of development
and its potential impact on young person’s mental wellbeing.
Brain and physiological development
As mentioned previously, one of the defining characteristics of adolescence is marked by the onset
and ongoing development in puberty. The factors that affect pubertal onset can be complex and multifaceted,
determined by a person’s genes, environment and lifestyle (Alsaker and Flammer, 2006).
Physical and bodily changes that occur during this stage can have an impact on a young person’s
identity, sociability and self-esteem (Bearman et al., 2006; Chen and Jackson, 2012; Dawson and
Dellavalle, 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 considering
the development of the brain during adolescence.
The development of the brain and connections between brain regions during adolescence can be
defined 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 synaptic
pruning, the brain facilitates the neural structure to develop more efficient, focused and specialised
systems (Fair et al., 2008, 2009; Luna et al., 2010). Pruning refers to the overall reduction of the
neuronal and synaptic connections within the brain. This process is important in facilitating ‘topdown’
executive 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 by
factors 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 found
to 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 executive
functioning 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 more
developed regions, such as that of the limbic system, may dominate emotional processing. The
result 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 and
has 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. They
point out that the process would allow adolescents to explore social contact beyond the family unit
and thus help enhance genetic diversity. This may also help to explain the social behaviour seen
during adolescence, which aligns itself with an increase towards peer orientation (Forbes and Dahl,
2010; Steinberg and Morris, 2001). Cognitive development in adolescence allows thought processing
to become more abstract and analytical. The growing independence that emerges during this
stage aligns itself well with these ongoing brain developments.
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Changes to sleeping patterns
It is worth briefly considering the changes to sleeping patterns that are known to occur during
adolescence. 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 daytime
sleepiness (Feinberg and Campbell, 2010). When compared with children or adults, adolescent
groups 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 (8–11 years) could lead to decreases in
social interaction, further impacting on sleep. This growing cycle may then lead to irritability and
social withdrawal, potentially exacerbating feelings of social isolation. Less sleep in adolescence
has been associated with poorer academic performance and an increased likelihood of depressive
symptoms 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 could
be the ongoing developments in the brain discussed above that may also influence the complex
interaction of circadian, social and other factors (Feinberg and Campbell, 2010). Other exacerbating
factors might include the modern availability of media such as television and the Internet (Cain
and Gradisar, 2010; Punamäki et al., 2007; Van den Bulck, 2004). Therefore, attitudes towards
the sleeping patterns of adolescents are important and appreciating the impact of sleep deprivation
on behaviour and cognition may be helpful in raising awareness of this. Reacting positively to the
general functioning and patterns of sleep in this age group is necessary to reduce stress and discord
with other age groups that may not share the same patterns.
Recognising vulnerable adolescents
It is important to recognise that many adolescents will have a positive mental health status during
these years (Coleman, 2011). Although many adolescents can be resilient to the effects of mental
health problems and stressful life events, there are a number of young people who can go on
to develop behavioural, emotional or neurodevelopmental disorders. The study of adolescence
demands research that integrates biology, context and psychological development (Steinberg and
Morris, 2001). Additional stressors in the environment (family or illness-related) may have a noticeable
impact 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 13
and 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, with
over half of mental health disorders starting by this age (Kessler et al., 2005, 2007; Maughan and
Kim-Cohen, 2005). Current estimates within England suggest that around 1 per cent of 5–16 year
olds 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 (5,364
of 7,977), found that 30 per cent of those who had an emotional disorder in the original survey
were still experiencing it in the follow-up (Parry-Langdon, 2008). Estimates from the US for the
prevalence of disorders causing severe impairment and/or distress in 13–18 year olds (n=10,123) is
approximately 22.2 per cent (Merikangas et al., 2011). Epidemiological evidence from international
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sources suggests that longer periods of depressive and anxiety-related symptoms during adolescence
are associated with the emergence of a disorder in later life (Fergusson et al., 2005; Kessler
et 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 such
as family conflict, poor physical health, anti-social behaviours including crime and a decline in
academic performance (Rutter and Smith, 1995). Estimates from national and international surveys
report low numbers of young people accessing treatment, with only around a quarter of those with
a 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; Patel
et al., 2007). Despite a large proportion of mental health problems presenting in adolescence, treatment
tends not to occur until a number of years later (Kessler et al., 2007). Moreover, the costs
associated with untreated mental health problems in adolescence can be substantial for both the
individual and society (McCrone et al., 2008). The Kennedy Review (2010), on evaluating children
and young people’s NHS services, pointed out that adolescents can often be thought of as the
‘forgotten group’ in healthcare. The overriding stigma and common misunderstandings surrounding
mental illness within this group may mean that cases often go unnoticed and consequently
untreated. Recognising vulnerable adolescents early is crucial in preventing these onsets, therefore
making it a fundamental part of any health professionals’ work.
On the individual level, risk factors for experiencing poor mental health during adolescence
have been found to include a low IQ, learning disability, shifts in pubertal timing, communication
difficulties, a difficult temperament, physical or neurological illness, especially if chronic, poor
educational 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 of
reporting 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 impact
on their mental health and subsequent academic performance (Foresight, 2008). These are similar to
levels found in the US with a 9.7 per cent estimated prevalence rate (Altarac and Saroha, 2007).
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