Cultural context is important when considering mental health problems as certain societies, ethnic
groups and customs foster behaviours that could be viewed differently in another society (Dogra
et al., 2009). Cross-cultural comparisons are therefore difficult as cultural conceptualisation of
what constitutes a disorder may vary. Likewise, existing mental illness constructs are noticeably
Westernised. There are also certain disorders that appear to be more prevalent in certain parts of
the world such as the emergence of eating disorder in the Western world (Bordo, 2013; Levine and
Smolak, 2010; Swanson et al., 2012). Across Asian countries, those who are mentally ill are commonly
believed to be dangerous.. This can then lead to social distancing behaviours and isolation
from the community, which can in turn create a consequence for potential marriage partners, thus
also stigmatising the family (Lauber and Rössler, 2007; Ng, 1997; Yang et al., 2007). In addition,
young refugees or asylum seekers are at an increased risk of developing mental health problems.
This is due to potentially experiencing or witnessing traumas, as well as having to acclimatise to a
new culture (Dogra et al., 2009, p. 121). Discrimination against and social exclusion of those in a
minority ethnic status can have deleterious effects on an individual’s mental health and wellbeing
(Dinos, 2014). Societal pressures to conform to expectations from the family, peers and communities
may be different to what a young person desires, which could also present issues. See Chapters
2 and 3 for further discussion of cultural, religious and ethnic minority influences
Experiencing abuse and maltreatment
Abuse and experience with violence during childhood and adolescence are known to be risk factors
for poor mental health (Sansone et al., 2005). Increases in rates of anxiety, depression and suicidal
ideation have been linked to early experiences of abuse (physical and/or sexual), parental neglect
or exposure to violence (Brodsky and Stanley, 2008; Ward et al., 2001). UK epidemiological data
on severe child maltreatment, defined as severe physical, sexual and emotional abuse by any adult,
report exposure to such victimisation to be approximately 18.6 per cent for 11–17 year olds (19 per
cent female; 18.2 per cent male), rising to 25.3 per cent in 18–24 year olds (30.6 per cent females;
20.3 per cent males). For younger children, maltreatment is more likely to come from adults known
to the child, such as relatives, neighbours or family friends, whereas with older groups, the most
likely perpetrator tend to be unknown to the victim, or strangers (Radford et al., 2011). Young people
exposed to family adversity or who have a pre-existing mental health problem and experience
bullying should be given a high priority in the provision of interventions as these are the ones most
likely to self-harm (Fisher et al., 2012). There is evidence to suggest that patterns of sexual abuse
can also differ, with males more likely to be abused by people from outside the family, whereas
females are more at risk of intra-familial abuse (Rogers and Pilgrim, 2010).
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Peer influence upon adolescent mental health
Peer relationships are where many adolescents learn about themselves, others and the world. A
strong social support is crucial for managing conflict and stressful life events. Social relationships
are integral to all age groups but require notable attention during the adolescent period. In Western
countries, a young person’s primary confidant is thought to shift from parents towards close peers
from ages 12–14 years onwards (Dogra et al., 2009, p. 110). It has been reported that young people
experiencing mental health problems or engaging in harmful risk behaviours are likely to influence
others to do the same and this can also impact on the individual to repeatedly commit this behaviour
(Coleman, 2011, pp. 180–181). However, having peers who conform to more conventional attitudes
and behaviours, such as alcohol use, may serve to act as a protective factor against abuse (Corte and
Sommers, 2005). Aikins et al. (2005) recognise that peer relationships offer a platform for social
learning and a source of support in adolescence.
Adolescents tend to be considered more sociable than children are and more sensitive to their
acceptance or rejection by peers (Steinberg and Morris, 2001). Adolescent girls may also be more
sensitive to this as they have been found to invest more into relationships (Girgus and Nolen-
Hoeksema, 2006, as cited in Corcoran, 2011, p. 144). Peer rejection can lead to increased rates of
anxiety and depression (Litwack et al., 2010; Masten et al., 2009, 2012). This may be mediated
in part by increasingly sensitive and active regions of the brain (Masten et al., 2009, 2010, 2012).
Attempting to conform and fit within a group enhances the impact of peer influence and may make
an individual more susceptible to peer pressure. Behavioural risks in early developing females have
been attributed to the influence from older teens in their social group (Cavanagh, 2004). Moreover,
in areas of increased deprivation, violence committed by young males has been linked to friendships
involving older peers (Harding, 2009). The varied rates of development and intense changes adolescents
undergo during this period may mean that some are introduced to certain types of potentially
harmful behaviours, or complex social and sexual relations, earlier than most. If this is the case then
an individual may incur greater detriment to their health, wellbeing, sociability and academic or
work-related performance.
Enabling a young person to identify the influence of their social peers and their influence on
others could help to improve self-awareness. By encouraging an individual to seek out and build on
the more positive relationships, and clarify their identity among peers, separating out the behaviour
of the group and themselves, may help to boost a young person’s self-efficacy. Peers and social
networks are clearly important for this age group and the influence of their peers bears consideration
(Figure 6.1).
Influence of pubertal timing
Pubertal timing refers to the onset of puberty and its progress in development compared with samesex
or similar-aged peers. Adolescents vary discernibly in their timing at onset of puberty. The
extent of this variance has been associated with an increased risk of mental health problems, including
depressive symptoms (Benoit et al., 2013; Ge et al., 2003; Michaud et al., 2006), anxiety-related
issues (Kaltiala-Heino et al., 2003; Zehr et al., 2007), conduct and problem behaviours (Burt et al.,
2006; Celio et al., 2006), negative self-body image (McCabe and Ricciardelli, 2004), disordered
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Adolescence and young adult mental health 123
eating patterns (Striegel-Moore et al., 2001; Zehr et al., 2007), and drug and alcohol abuse (Biehl
et al., 2007; Bratberg et al., 2007), among others. Social and environmental factors such as the
adolescent peer group (Cavanagh, 2004), parenting styles and relationships (Arim and Shapka,
2008), romantic partners (Halpern et al., 2007; Natsuaki et al., 2009) and stressful life events (Ge
et al., 2001) have all been found to moderate the effects of pubertal timing on mental health. The
detrimental effects of pubertal timing may be mediated by complex interactions between childhood
experiences and adolescents’ interpersonal relationships, such as a stressful family context (Benoit
et al., 2013). Furthermore, the psychological outcomes of pubertal timing have been found to persist
into young adulthood (Graber et al., 2004; Zehr et al., 2007). However, for many this impact may
reduce once a person reaches the onset of puberty and maturing into adulthood (Coleman, 2011, p. 34).
For females, early maturation among peers has been associated with reductions in perceived
popularity, inner turmoil and may exhibit increased bodily dissatisfaction (Alsaker and Flammer,
2006; Benoit et al., 2013; Graber et al., 2006; Moore and Rosenthal, 2006). On the other hand,
for males, the earlier onset of puberty may lead to more positive consequences, such as increased
self-confidence, popularity, greater athletic and academic ability, as well as the social advantages of
a more mature physical appearance (Benoit et al., 2013; Moore and Rosenthal, 2006). In this regard,
later maturing males may be at risk (Conley and Rudolph, 2009; Moore and Rosenthal, 2006; Siegel
et al., 1999). The deviance hypothesis proposes that those adolescents who are maturing earlier or
later than what is expected or socially and culturally accepted are more vulnerable to psychological
maladjustments, as they do not fit with the peer trajectory of change (Petersen and Crockett,
1985; Simmons and Blyth, 1987; Susman et al., 2003). Supporting adolescents during this period
Figure 6.1 Developing a young person’s self-efficacy and self-awareness is important
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is crucial, as is ensuring the provision of sufficient information to this group about the variance in
pubertal maturation.
Influence of media and social media
It is worthwhile reflecting on the role of the media and the rise in technology that is now in use
among adolescents. The rate of change in technology and the power of the Internet are redefining
social communication. For adolescents, the dramatic increase in mobile phones, the ubiquity of
online social networks and the availability of information sharing are forging each generation in
stark contrast to previous ones. The utility of online resources opens up access to global information,
educational resources, entertainment, activism and resources for advice, as well as sharing
experiences with others. On the other hand, it does present a number of risks such as access to illegal
content, biased information or misinformation, on-site advertising, abuse, cyber-bullying, possible
grooming by strangers and invasion of privacy (Livingstone, 2009). Moves should be made to enable
and encourage the opportunities that the age of the Internet offers, whilst attempting to reduce
the exposure to the additive risks it introduces. An open and transparent discussion on these matters
is important so that adolescents are aware of the benefits and risks.
Social networking sites have increased in popularity over the last decade, particularly among adolescents.
A survey looking into access to social networking sites involving 12–17 year olds (n=802)
found rates to be increasing year on year, as was the amount of information this group shared online.
Almost half of the respondents admitted to logging on to a social networking site daily and their experiences
were mostly positive (Madden et al., 2013). Qualitative evidence involving 92 college students
in the US found the reasons for the use of Facebook centred mainly on communication, particularly
with those who were not immediately accessible geographically (Pempek et al., 2009). Nonetheless, it
is generally recognised that people become more disinhibited online, making the sending of negative
comments more likely as opposed to in the real world (Suler, 2004). Dutch adolescents aged 10 to
19 years receiving mainly negative comments and feedback online were more likely to report lower
self-esteem and mental wellbeing (Valkenburg et al., 2006). Poor-quality interactions online have
also been associated with higher levels of depressive symptoms being reported (Davila et al., 2012;
Selfhout et al., 2009). Social networks open up a new aspect of human communication and may be a
helpful resource for many young people in times of social isolation. However, careful monitoring and
educating young people on the risks of social networks may lessen the dangers associated with them.
In the US, adolescents aged 14–17 years old send and receive on average 60 text messages a
day, with older adolescent girls sending the most at almost 100 or more daily (Lenhart et al., 2010).
These rates are similar to those found in the UK (Livingstone et al., 2014). Such activity presents
new phenomena to explore, such as the emergence of ‘sexting’, which involves the act of sending
sexually explicit images or messages to others by mobile phone. Evidence is still emerging on the
effects of this although evidence from the US has found an association between sexting and sexual
behaviours, substance use, excessive time spent texting and other health risk behaviours, including
suicidal ideation, in 12–18 year olds (n=1,289) (Dake et al., 2012). Many young people do not perceive
sexting to be a ‘big deal’ (Lenhart, 2009). Attention is now gathering in response to the legal
issues surrounding the age gap in some sexters (Calvert, 2009; Corbett, 2009; House of Commons
Health Committee, 2014). Educating young people on the risks associated with this practice is
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critical and must be done in a non-judgmental and respectful manner. Further research is also needed
to keep pace with the changes in technology and its effect on social interactions for young people.
Internet use may lead to depressive symptoms in adolescents who exhibit and report poor friendship
quality (Selfhout et al., 2009). Likewise prolonged periods of time engaged in video games
have also been linked to impact on a young person’s attention skills, emotional response, risk-taking
behaviour and academic performance (Beullens et al., 2011; Gentile, 2009; Hull et al., 2012;
Wang and Dey, 2009). Certain personality traits can predict increased hostility in gaming such as
an increased neuroticism and decreased level of agreeableness and conscientiousness (Markey and
Markey, 2010). On the other hand there are also notable benefits of gaming uncovered by research
such as improved eye-hand coordination in a virtual surgery task (Rosser et al., 2007), improved
contrast sensitivity functioning in the eye (Li et al., 2009), as well as reducing depressive symptoms
through playing a game orientated towards destroying negative thoughts (Merry et al., 2012b). A
prolonged period of anything is likely to have a detrimental impact on an individual. Balancing the
amount of exposure a young person has by limiting screen time will likely be beneficial.
The availability of the Internet opens up the possibility of accessing cognitive behavioural
therapy (CBT), self-help, support groups, or other related psychotherapeutic interventions online
(Andersson and Cuijpers, 2009; Foroushani et al., 2011; Grover et al., 2011; Richardson et al.,
2010). This may be helpful in overcoming the stigma associated with mental health problems, the
low rate of adolescents seeking or accessing treatment and improving access as the therapist support
required is reduced. Spence et al. (2011) separated 115 adolescents (12–18 year olds) into three
groups consisting of a course of online CBT programme, face-to-face CBT and a waiting list control
for the treatment of a range of anxiety disorders. After 12 weeks of treatment, there were no significant
differences between the online and face-to-face course of therapy but both were more effective
than the control group (p<0.05) and effects were maintained at 12-month follow-up. Satisfaction
among adolescent users of computerised CBT programmes tends to be high but the rates of dropout
are also noticeably high (Richardson et al., 2010). Online therapy programmes may hold promise
but more research is needed to explore who is likely to benefit most.
Health professionals are in a key position to educate families about the complexities of the digital
world, both in its risks and benefits (O’Keeffe and Clarke-Pearson, 2011). Encouraging open
discussion between adolescents and their parents as well as encouraging parents to become better
educated about the technology their children are using could be useful.
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