Adolescent Mental Health

Prevention and Intervention

Terje Ogden, Kristine Amlund Hagen

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315295350
• Edition: 2
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Adolescence is a period characterized by both increased susceptibility to risks and new-found strength to withstand them. Whilst most young people are well equipped to manage the changes associated with growing up, other maladjusted and marginalized adolescents already have, or are at risk of developing, mental health problems.

Adolescent Mental Health: Prevention and Intervention is a concise and accessible overview of our current knowledge on effective treatment and prevention programs for young people with mental health problems. Whilst addressing some of the most common mental health issues among young people, such as behavioral problems and drug-related difficulties, it also offers a fuller understanding of the evidence-based treatment and prevention programs that are built upon what we know about how these behavioral and emotional problems develop and are sustained.

The volume illustrates contemporary and empirically supported interventions and prevention efforts through a series of case studies. It has been fully updated in line with the latest NICE and DSM-V guidelines, and now includes an added chapter on implementation, and what factors facilitate implementation processes of intervention efforts.

Adolescent Mental Health: Prevention and Intervention will be essential reading for students and practitioners in the fields of child welfare and mental health services, and any professional working with adolescents at risk of developing mental health problems.

1

Adolescent development

What is adolescence?

Adolescence has been described as a period of life that starts in biology and ends in society (Kagan, 1975). This portrayal indicates that the onset of adolescence is denoted by the hormonal changes of puberty, whereas becoming an integral part of one’s social environment marks the conclusion of this period of life. For many youths, however, the description is unfitting: whilst virtually all youths go through the biological transformations of sexual maturity and increased cognitive capacity, a significant proportion of young people do not end up in society; rather, they become maladjusted and marginalized. Youths who become marginalized, that is, end up on the outskirts of society, are the very youths this book is about. They show maladaptive and dysfunctional behavior and they can teach us much about how to intervene and how to prevent such problems in future generations of adolescents. Adolescence is the period between childhood and adulthood and is often referred to as the teenage years. The period is divided into early (11–13 years), mid- (14–16 years), and late (17–19 years) adolescence. Historically, adolescence has expanded in length, probably due to teenagers’ increased time spent in school and decreased time spent in the work force during this period. Adolescence has been described as a period of reconstruction, characterized by significant changes in biological, cognitive, social, and emotional systems. To some extent, adolescent development is fairly predictable in the sense that most young individuals experience similar changes in multiple systems and face many of the same developmental challenges. Yet, in other ways, development is utterly idiosyncratic. For example, the way adolescents cope with new demands, contexts, and expectations varies considerably, and how well they deal with these tasks is important for their well-being and mental health, both at the present and in the future (Garbarino, 1985).

The question of whether it is something unique about the adolescent period that places individuals at greater risk for difficulty as they pass through it has been posed (Eccles et al., 1993, p. 90). The question is timely, but the flip side of this inquiry is whether it is something unique about the adolescent period that equips individuals to tackle the developmental challenges of this period. The answer to either question is yes. As we will discuss next, the adolescent period is characterized by changes in both susceptibility to risks and new-found strength to withstand them. Oftentimes, the outcomes will depend on the willingness and ability of the context to accommodate these changes in a healthy way. The challenge for researchers and clinicians alike is to identify those who are vulnerable and in what contexts their vulnerability results in deviant or unhealthy development.

In order to understand normal and abnormal development in adolescence, we think it is important to shed light on some of the important features of this developmental period. Although it is not the aim of this book to give a full account of adolescent development, we want to emphasize several developmental characteristics that are of importance in the process of planning, developing, and testing preventive and treatment interventions.

Biological and physical development: maturation

The biological development of adolescence includes many physiological alterations, and the hormonal changes that trigger puberty are important in understanding adolescent development. Biological changes and psychosocial development, however, do not develop in a vacuum; they are dependent on and influenced by each other. Moreover, each of these developmental domains are systems within a greater system, that is, the youth him- or herself who, in turn, is part of even higher-order systems made up by the family, the social network, and the culture, each interconnected and exerting mutual influence on each other (Garbarino, 1985). Many changes of maturity are visible, such as growth in height, weight, secondary sex characteristics, fat, and muscles. Because youth of the same chronological age may look and act differently from each other, they are, as a result, often treated differently, creating variability in individual experiences. At a period of life when social comparison is at its most salient, the youth who perceives him- or herself to fall short of such comparisons may develop a lack of self-esteem or a poor self-concept.

There are great individual differences in both onset and tempo of pubertal development, though the sequence of puberty is fairly consistent across individuals. With regard to timing, the onset of sexual maturation has been identified as a potential risk factor for mental health problems. For example, the maturational deviance hypothesis proposes that any aberration from the norm is associated with vulnerability for both mood and behavioral problems. Because girls, on average, mature earlier than do boys, early-maturing girls and late-maturing boys will be at greatest risk for maladjustment because these girls and boys will be the most physically “deviant” in the peer group. It could be the case, however, that adolescents compare themselves more readily to peers of the same gender, in which case early- and late-maturing adolescents of both genders will be at heightened risk for developing adjustment problems. Alternatively, the developmental readiness hypothesis posits that increases in vulnerability to mental health problems during the transition to adolescence are due to an asynchrony between physical, cognitive, social, and emotional growth. Specifically, the less time an adolescent has had to adapt to these new biological changes, to assimilate stimuli, and to develop healthy coping skills, the worse the youth will fare. Hence, early-maturing adolescents, and early-maturing girls in particular, will have had less time to adapt to changes and new demands and are thus at greater risk for maladaptive outcomes. Late-maturing children, and late-maturing males especially, will be the least likely to develop mental health problems (Negriff & Susman, 2011).

Both of these assumptions find support in empirical work, and their accuracy depends in part on which outcome is in focus. Caspi and Moffitt (1991) reported that early-maturing girls were more prone to develop behavioral problems and adjustment difficulties than their “on-time” or late-developing female counterparts. Other studies have shown, however, that some of the negative effects of very early puberty may be transient. For example, by age 25, early-maturing girls of a Stockholm sample no longer differed from their age-mates when it came to rule-breaking behavior (Stattin & Magnusson, 1990). They did, however, evince lower educational qualifications due to early school dropout.

A third possibility has been introduced, namely, the stressful change hypothesis (Caspi & Moffitt, 1991). If true, it would repudiate a commonly held belief that great changes offer opportunities for discontinuity of “old” patterns in individuals. Research findings indicate that stressful transitions such as entrance to puberty actually accentuate preexisting individual characteristics. In other words, when individuals go through stressful transitions, such as puberty, individuals’ dispositions emerge more clearly, leaving adolescents who were already at risk with an even greater vulnerability. As such, the manner in which new challenges are met and handled depends in large part on the assets and competencies that the individual brings to the table. If these are few and/or maladaptive, then the way new demands are handled will likely set the stage for further dysfunction.

Pubertal timing, however, is but one side of the story. The time it takes for an adolescent to progress through the different stages of puberty—that is, the tempo—also plays a role in determining how well the youth adapts. Mendle, Harden, Brooks-Gunn, and Graber (2010) reported that, for boys, the rate of pubertal development was more important in predicting depressive symptoms than was pubertal timing, and boys who matured both quickly and early reported the highest levels of depressive symptoms. For girls, the onset of puberty was a significant predictor of depressive symptoms, whereas pubertal tempo was not.

Belsky, Steinberg, and Draper (1991) introduced an evolutionary-based model of reproductive development that is appropriate to mention in this regard. The authors posited that early experiences of availability of resources and endurance of close relationships both affect individuals’ reproductive strategies. Children who grow up with limited resources and with the expectation that emotional bonds are unstable or unsupportive tend to enter puberty sooner and to reproduce at an earlier age. Conversely, children reared in contexts of sufficient resources and that are characterized by warm, stable, and trustworthy caregiving are more likely to delay entrance to puberty and defer sexual activity. Ellis, Shirtcliff, Boyce, Deardorff, and Essex (2011) investigated this assumption empirically and took the line of reasoning one step further. The results from their study suggested that children who were brought up in high-quality parenting contexts entered puberty later and showed slower initial pubertal progression, if they demonstrated heightened sensitivity to environmental effects. For such highly susceptible children, the reverse outcome (early and hastened pubertal development) was more likely if their rearing environment was harsher and more negative. For the less environmentally sensitive children, the association between rearing environment and onset of puberty was non-significant.

Brain maturation and cognitive development

Modern brain imaging technology has shown that brains take longer to develop than previously assumed, and the brain maturation process continues as young people move through adolescence. Brains undergo a massive reorganization and remodeling between the 12th and 25th year, resembling a network and wiring upgrade (Dobbs, 2011). In her book about the teenage brain, Jensen (2015) draws on her personal experiences as well as on neuroscience when she describes the challenges and opportunities relating to bringing up adolescents:

In order to truly understand why teenagers are moody, impulsive, and bored: why they act out, talk back, and don’t pay attention; why drugs and alcohol are so dangerous for them; and why they make poor decisions about drinking, driving, sex – you name it – we have to look at their brain circuits for answers.

(p. 22)

In adolescence, the biggest changes occur in the parts of the brain that process cognitive and emotional information: the frontal lobes. Executive functions, which represent the ability to plan, gain insight, make judgments, and generate abstractions are located in the frontal lobes. They are involved in decision-making and cognitive control, as well as other higher cognitive functions. They are also the source of self-awareness and the ability to assess danger and risk, so they use this area of the brain to choose their course of action.

The maturation of the brain lays the foundation of new cognitive skills in adolescence, such as increased capacity for abstract reasoning, as well as critical and creative thinking (Blakemore & Choudhury, 2006). The ability to think creatively is often demonstrated by an increase in divergent thinking, originality, and flexibility, and can be exemplified by engagement in popular youth activities such as writing, drawing, acting, and playing musical instruments. During this time, the majority of young people, though not all, develop formal operational abilities that allow them to analyze problems, generate solutions, consider consequences, make logical decisions, and form links from specific examples to general principles as well as from the general to the specific. A more complex level of information processing that is closely related to intelligence is enabled, including more advanced and differentiated social information processing skills (Crick & Dodge, 1994). The concept of “the social brain” is used to describe major social functions such as interaction synchrony (or turn-taking), empathy, social cognition, interaction skills, and concern for others (Goleman, 2007). Lieberman (2013), asserts that we are “wired to be social,” that is, “we are driven by deep motivation to stay connected with friends and family” and that we are “naturally curious about what is going on in the minds of other people” (p. 1). In other words, adolescents are wired for reaching out and interacting with others and when they have nothing else to do, they think about themselves in the social world. The development of social–cognitive competence underlies school success, both socially and academically. Deficits in social information processing skills are actually one of the major problems of aggressive individuals (Fontaine & Dodge, 2009). For example, antisocial adolescents often have a tendency to attribute hostile intentions to others, when these intents are in fact positive or neutral. They often also have problems recognizing and decoding feelings of others. Moreover, they have difficulties generating solutions to social problems and assessing the potential consequences of alternative solutions and regulating emotional arousal (Crick & Dodge, 1994).

Adolescents have been described as egocentric or self-centered in their thinking. For example, teenagers are oftentimes perceived (most often by adults) to be self-conscious and focused on their own ideas and experiences. Paradoxically, teenagers are typically also hypersensitive to everyone else’s evaluation of them. Furthermore, they have a tendency to become more idealistic and critical of other people, particularly parents and teachers. The cognitive development in the teenage years changes adolescents’ relationships to their parents because they are better equipped to question rules and expectations, they are more ardent to be heard, they show greater appreciation for social reciprocity, they are better at social reasoning, and show greater mental flexibility (Holmbeck, Paikoff, & Brooks-Gunn, 1995).

Identity formation

The process of forming an identity is a central endeavor during the teenage years and, for the adolescent, it involves gaining a sense of who he or she is as an individual and as a member of various social groups. Developing a sense of identity starts in adolescence but is a lifelong and dynamic process (Beyers & Gossens, 2008). It is a daunting task, especially because of the multiple influences from family, school, peers, and from their greater social networks. It is somewhat of a paradox that the task of forming a personal identity (a highly individual endeavor), actually involves ongoing adjustment to transactions with other people. Thus, identity grows in response to both internal and external factors and is shaped by how they are perceived to be by important persons in their environment. During adolescence, the young person typically moves from dependency to independence and autonomy. Autonomy, however, does not mean the absence of connectedness. Adolescents who rate themselves as being more positively attached to their parents also tend to be more advanced in their identity development, be more interested in exploratory activities (such as going abroad), be better able to differentiate themselves from their parents, and be less indecisive of career choices (Quintana & Lapsley, 1990).

The process of forming an identity is also affected by an adolescent’s self-theory. A self-theory involves a person’s tendency to view his or her own characteristics and abilities as either stable and fixed or as malleable and subject to change (Rosenberg, Burt, Forehand, & Paysnick, 2016). When faced with social or personal challenges, this division in self-theory is especially salient. Adolescents who are fixed in their beliefs about themselves and their abilities are less prone to seek out various solutions to problems and are in turn also at greater risk of developing mental health problems. In a study of adolescents (aged 14–17 years) and emerging adults (aged 18–39 years), results indicated that having more flexible beliefs about oneself was associated with more productive coping strategies and lower levels of internalizing and externalizing problems. Findings also indicated that this was true for adolescents only; self-theory and coping strategies were not related to behavioral problems for adults (Rosenberg et al., 2016).

Coping strategies and emotion regulation

The refinement of coping strategies is also a part of adolescent development as the handling of adversities are related to the management of stress and negative life events. When in a difficult or stressful situation, like everyone else, adolescents cope. Coping strategies, however, may be effective or ineffective and consequently result in more or less adaptive functioning. Positive coping skills such as seeking the advice or support from others including family, friends, teachers, or health professionals are related to better mental health among youths. Another adaptive strategy is to reformulate or reframe a problem into a challenge to be overcome so as to make it less threatening or difficult. Humor and optimism may also be helpful in the process of reframing experiences. For some, finding alternative goals or activities may be a constructive coping strategy for handling failure, for instance when failed academic ambitions are replaced by successes in sports. Adolescents may, however, actively devalue good grades and school achievement if they perceive these goals as unattainable. Among the less adaptive and often ineffective coping skills are denial, rumination (a repetitive focus on stressors, and on their possible causes and consequences), and the tendency to blame oneself or others: “He asked for it,” “I always screw up,” or “Everyone else does it!”

How well an adolescent copes with stressors or challenges is also affected by his or her emotion regulation. Emotion regulation is part of emotional competence; adolescents often experience swift and strong mood changes. They may evince strong emotions such as anger, sadness, or frustration and react strongly to social rejection, such as when they are deceived by a friend or not invited to a party. But during the adolescent years, most boys and girls learn effective ways of controlling or regulating emotions. Emotion regulation and effortful control show marked advances in the adolescent years.

The famous marshmallow experiment conducted by Walter Mischel (1958) removed attention from self-esteem to self-control as the latter predicted positive outcomes in several areas of development. The ability to delay gratification, in addition to parent supervision, seemed to promote the development of self-control. The relationship between parent supervision and self-control was demonstrated in Joan McCord’s (1979) study which showed that lack of adult supervision in the teenage years turned out to be one of the strongest predictors of criminal behavior. In a recent study of 420 seventh-graders who were followed over a period of 30 months, the results showed that teachers’ report of students’ emotional regulation predicted whether the youth had been arrested. Adolescents whose teachers assessed them to have better emotion regulation skills were less likely to have been arrested. Interestingly, neither self-report nor parent report of emotion regulation skills were predictive of arrests.

Some decades later, Baumeister and Tierny (2011) summarized: “Adolescents have higher self-control to the extent that their parents generally know where their offspring are after school and at night, what they do with their free-time, who their friends are, and how they spend money” (p. 210).

Social development

Social development has several important aspects, one being the formation of the interrelated concepts of self-awareness, self-concept, and self-esteem, and the other the establishment of social relationships in family, at school, and among peers. Greater self-awareness, and greater awareness of others and their emotions and thoughts is characteristic of adolescence. As children, they defined themselves by physical traits whereas, as...