The evidence base for young people and their mental health has steadily increased over the last
decade, although debate still exists around the uncertainties of available psychotherapeutic interventions
within this age group. Treatments tend to combine several approaches consisting of a
pharmacological, psychological and family and community component (Fonagy et al., 2002). In
place of generic psychological interventions, treatments are becoming increasingly specialised and
formulated (AACAP, 2007; beyondblue, 2011; Cheung et al., 2007; NICE, 2005). Having clear
protocols along with a standardised instrument is useful in helping health professionals to feel
more prepared for dealing with mental health problems in adolescents (Taliaferro et al., 2013). For
a systematic review of effective treatments of mental health disorders in children and adolescents,
consult Cartwright-Hatton et al. (2004) and Tennant et al. (2007).
Psychotherapy
As the importance of early experiences became more widely recognised, the emergence of more
specialised psychotherapeutic interventions for young people began to develop. The behaviourist
movement on operant and classical conditioning as well as the child-focused work of Donald
Meichenbaum and colleagues also served to help develop this field (Weisz and Gray, 2008).
Psychological therapies have demonstrated effectiveness for treating mental health problems in this
age group (Cartwright-Hatton et al., 2004; Fonagy et al., 2005, pp. 1–41; Kendall, 2011). However,
Murray and Cartwright-Hatton (2006) point out that without a robust and extensive training programme
put in place the delivery of evidence-based therapies could be ineffectual. Considering
this, it is also worth noting that a national survey of UK CAMHS professionals found two-thirds of
therapists self-disclosed that they required more training in child-focused CBT (n=538) (Stallard
et al., 2007). Other evidence also shares some concern around the apparent shortage of therapists
in some areas of England specialising in child and adolescent therapies (Department for Children,
Schools and Families, 2008). Recent developments in England have seen the implementation of
the Improving Access to Psychological Therapies (IAPT) programme. The IAPT programme is a
government-funded initiative first established to provide evidence-based psychotherapeutic interventions
to those who would not have had equitable access otherwise (DH, 2008). It has recently
widened its scope to include the provision of services for children and adolescents so they too can
gain access to evidence-based treatments. The programme has enlisted the workforce of existing
CAMHS health professionals and is nearing its final stages of national rollout.
CBT is a form of psychotherapy has been used extensively in treating young people’s mental health.
The technique aims to alter maladaptive behaviour and repetitive thinking patterns, which serve to
sustain the disorder, encouraging the young person to identify unrealistically negative thoughts and
challenge these with more positive interpretations (e.g. ‘Not everyone likes me, but at least I have
some really good friends’). It can be delivered in many forms, and across a range of formats. CBT
has demonstrated efficacy in the treatment of anxiety disorders for children and adolescents over no
treatment, or treatment-as-usual, although its efficacy long term or as against medication is still limited
(Cartwright-Hatton et al., 2004; Cox et al., 2012; Weisz, McCarty and Valeri, 2006).
Medication
Medication prescribing for children and adolescents in the UK remain quite rare, with approximately
7 per cent of those with an emotional disorder and 9 per cent with a conduct disorder taking
any form of medication. The main use of psychotropic medication in this age group is usually for
hyperkinetic disorders, taken by 43 per cent of young people with these disorders (Green et al.,
2005). Rates of antidepressant prescribing for adolescents are also low in the US (Merikangas et al.,
2013). Antidepressants have been linked to a decrease in suicide among young people (Isacsson and
Rich, 2008). While the use of antidepressants may be effective in the treatment of adult depression,
children and adolescents remain under-represented in research (Patel et al., 2007). Moreover, the
side effects that can result from medication may make them an unlikely treatment option and other
psychotherapeutic interventions are usually opted for, as they are considered to be relatively side
effect free.
Family-based interventions
Evidence to support family-based interventions is still emerging. Peer and familial relationships
should be encouraged to enhance positive processes and seek to minimise threats during
this crucial stage of life (Jehta and Segalowitz, 2012, pp. 53–69). The home environment and
family setting is where most young people live their lives and considering the family context is
necessary in most treatment plans. When assessing for risk in adolescents it is useful to engage
all parties including the individual, family, educators and health professionals to help create a
shared understanding of potential mental wellbeing difficulties. Working collaboratively with
families can help identify unhelpful family patterns without a risk of undermining parental
authority and capability in raising their child. Family-based interventions tend to take into
account different perspectives, contexts and interpretations and tend to consider the family as
being able to find their own resolutions to difficulties. Those administering these interventions
will need to meet and discuss with the family about their engagement and suitability, as well
as clarify the purpose of the sessions. The purpose of the interventions is to empower families
by educating them and providing them with useful problem-solving strategies. It is usually
delivered as part of a multi-modal approach in combination with other interventions (Dogra
et al., 2009, pp., 234–235).
Resilience building
Intervening at the point of crisis with a psychological treatment is one approach to combatting
the incidence of mental health problems in young people. However, Donovan and Spence (2000)
argue that the focus should not be on treatment but on prevention. Nonetheless, most prevention
programmes may produce only modest effects and be unable to treat a disorder once it develops
(Garber, 2006; Horowitz and Garber, 2006; Merry et al., 2012a; Stice et al., 2009). Although there
have been many advances in the field of psychological treatment many of those that suffer will
not receive treatment or may suffer in silence (see section on Recognising vulnerable adolescents
above, pp. 117–118). Those that do receive treatment may not experience any benefit and this could
lead them to discontinue prematurely or be referred elsewhere (Farrell and Barrett, 2007). The
ineffectiveness of treatment may be the result of it being implemented too late, with the effects of
a disorder already having made an impact on an individual’s life, both socially and academically
(Donovan and Spence, 2000). Universal programmes attempting to build resilience in young people
could be used to enhance general mental wellbeing of at-risk adolescents (Barrett and Turner, 2004;
Ng, Ang and Ho, 2012; Oliver et al., 2006). For family, personal and community units, an effective
prevention measure is to promote the development of cognitive resilience (Foresight, 2008).
Transitional care
There is a need for effective coordination of those transitioning from child and adolescent services
onto adult services, between the ages of 16 and 25 years, in order to address the gaps that can occur.
Singh et al. (2010) identified 154 individuals across six UK mental health services transitioning
from CAMHS onto adult mental health services over a one-year period. The authors encountered
difficulties searching the central CAMHS database and had to rely on clinician recall to identify
cases. They found that 64 (42 per cent) individuals did not make the transition to adult services yet
were considered eligible for referral. Interview data with 11 randomly selected participants reported
poor planning in a majority of cases and continuing parental involvement. Drawing on these findings
and other existing evidence, Singh et al. (2010) advise a number of measures to improve the
transitionary period. These include: aligning referral thresholds between services, adopting a flexible
transition boundary, carefully planning and preparing the individual and services for transition,
improving information transfer, managing and reducing multiple transitions, such as between teams
in adult services, increasing liaison, and developing an integrated youth mental health programme,
as opposed to emphasising silo treatment centres.
Living with poor mental health
This section selects and discusses briefly a select number of mental health problems that can emerge
during adolescence. This is by no means an exhaustive list and will provide the reader with only a
brief overview of the chosen conditions and available interventions.
Depression
Clinical depression involves feeling sad, down or irritable for at least two weeks, stopping a young
person from enjoying things they used to like, or engaging in social activities (Kelly et al., 2013).
During this stage, depression has been linked with an increased risk of suicide, reduced educational
performance and poorer social relationships (Gibb et al., 2010). It is considered the most prevalent
and widely reported mental health problem within this age group, with over a quarter of adolescents
reportedly affected by depressive symptoms (Rushton et al., 2002). The World Health Organisation
(WHO, 2014) estimated depression to be the top cause of illness and disability in 10–19 year olds
worldwide, with suicide reported to be the third main cause of death, behind road traffic accidents
and HIV/AIDS (WHO, 2014). In-patient treatment is recommended where there is a high risk of
self-harm or suicide. In mild-moderate cases, counselling or psychotherapy is usually recommended
to address issues of self-esteem, self-efficacy, relationship management and problem-solving skills.
Those who do not respond to these therapies could be considered for medication and more intense
psychotherapy. Issues around past experiences may need to be addressed where necessary and the
family may also need to be educated (Dogra et al., 2009, pp. 184–185).
Anxiety disorders
An anxiety disorder is usually typified by a heightened and constant state of arousal. This may make
daily activities difficult, both inside and outside of school or work (Department for Education, 2014;
Kitchener et al., 2013; McLoone et al., 2006). In Great Britain (England, Scotland and Wales) the
prevalence rate of anxiety disorders in young people is estimated to be 4.4 per cent (Green et al.,
2005). The onset of an anxiety disorder has also been found to emerge earlier than other mood and
emotional disorders (Merikangas et al., 2011). If left untreated, this may lead to greater difficulties
in late adulthood including an impact on one’s career, social circles, more time spent with healthcare
services and the development of possible comorbidities and substance abuse (Donovan and
Spence, 2000; McCrone et al., 2008; Patel et al., 2007; Rapee et al., 2005). In terms of treatment,
cognitive therapy is thought to be useful in its symptom reappraisal method. Encouraging the use of
self-talk may also be therapeutic for younger adolescents, who use it in their play and problem-solving
activities more readily than adults (Dogra et al., 2009, pp. 218–219).
Eating disorders
Dissatisfaction with one’s own body and appearance may result in the emergence of an eating
disorder. It is well recognised that these types of disorder affect adolescent girls in particular. For
example, 40 per cent of all anorexia nervosa cases are made up of girls between 15 and 19 years
of age (Bulik et al., 2005; HSCIC, 2013; Micali et al. 2013; Vostanis, 2007). The development of
eating disorders is thought to be the result of individuals striving for thinness and is reinforced by
culture, particularly in the Western world, as well as portrayals in the media or on social media.
Discrepancies between the supposed ‘ideal’ and the image of one’s self may then lead to conflict
and anxiety, perhaps leading to dietary action, such as restricting food and purging (Striegel-Moore
and Bulik, 2007). An eating disorder may also be an effort to exert control over one’s life (Fairburn
et al., 2003).
The major physiological changes that occur during puberty may lead young people to become
sensitive about their body shape and weight, particularly among girls. This may drive a series of
weight-controlling behaviours (Faulkner, 2007). Hereditary and genetic factors may also play a
role (Klein and Walsh, 2004). The recovery process for treating eating disorders is known to take a
considerable amount of time and effort, meaning that patience and understanding of the condition
on a case-by-case basis is crucial. The physical toll taken on an individual because of under-nutrition
is also worth considering. Encouraging a regular, well-balanced meal regime, in consultation
with a dietician, as well as educating the young person and their family about their condition, is also
recommended (Dogra et al., 2009, pp. 192–198).
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