In the latest in our series from Pulse Live talks, Dr Alison Cowan, a GP with a special interest in young people’s health, discusses adolescent mental health
The 2021 national mental health survey of children and young people showed that approximately one in six had a probable mental health disorder (17.4% of those aged six-16 years, and 16.9% of those aged 17-23). This proportion has increased since 2017 – the adolescent age group has the highest rates of mental health disorder.
Children and young people regularly use general practice but are more likely than other age groups to feel inhibited about discussing personal problems. This may affect their ability to access appropriate help. The Children’s Society says 70% of children and adolescents who experience mental health problems have not had appropriate interventions at a sufficiently early age.
What is happening with adolescent mental health?
In this article, I use ‘adolescent’ to mean 10 to 24 years, representing 11.7 million young people in the UK.
Adolescence is a defining time for young people and one in which there is rapid development. Good health in adolescence leads to good health in adulthood. A report by Goodman et al in 2015 found: ‘Emotional health at age 16 [is] a stronger predictor of mental health and life chances at age 30 than either demographic or socio-economic factors.’
Some statistics illustrate the crisis of mental health in this age group:
- Half of lifetime mental illness begins before the age of 14 years and three-quarters of mental health problems begin before age 24.
- One-third of children and young people with a mental health condition can access specialist support.
Rates of poor mental health have continued to rise since the Covid-19 pandemic, increasing with age. Rates of mental illness are highest in marginalised groups. Low-income families are four times more likely to have mental health problems than children from high-income families. Of children in state care (Children Looked After, CLA), 60% are recorded as having mental illness, rising to 72% of those in residential care. Among young people with autism spectrum disorder, 70% experience mental health issues and they are seven times more likely to die by suicide. Similarly high rates of mental illness are found among LGBTQ+ adolescents.
Adolescence is also the period when risk-taking behaviour emerges. Risk-taking is a normal part of adolescence, but adolescents with a mental illness are the cohort most likely to engage in such behaviour.
Why are there high rates of mental health issues among adolescents?
Contributory factors linked to this rise in mental illness can be divided into developmental changes (biological, neurobiological and psychological) and sociocultural pressures.
- Pubertal changes, stimulated by the neuroendocrine network, lead to the typical secondary sexual characteristics. Even when these processes are normal, children are not always happy with their changing bodies. One third of primary pupils are not happy about their body changes and growing up, and this is more common in girls. Children with abnormalities of puberty or who consider their gender as different from their birth gender may find puberty presents even more mental health challenges.
- Neurobiological changes explain some of the emotional upheaval. The adolescent brain is wired to learn faster, with more synapses and excitability in childhood and adolescence than the adult brain, mediated by hormones such as dopamine, the reward hormone. The adolescent brain has more dopamine receptors than the adult brain and these receptors are more active. This helps explain adolescent sensation-seeking behaviour. The adolescent brain has increased synaptic plasticity, as a result of processes that strengthen or prune synapses. Good habits can be strengthened but so can bad habits. This explains why addictions arising in adolescence can be harder to tackle.
- Myelination allows the development of interconnections between parts of the brain leading to speedier nerve conduction. This process occurs from the back of the brain and moves forward so the last part of the brain to be connected is the frontal lobe. The frontal lobe deals with executive processes such as decision-making, planning, problem-solving, judgement, impulse control and empathy; the imbalance between the limbic or reward system of the brain and the sensible and organised prefrontal cortex can also contribute to some of the behaviour and psychological changes we see in adolescence.
- During adolescence children move from concrete thinking to more abstract thinking, which includes the ability to understand the long-term impact of actions. Abstract thinking is not thought to become fully established until the age of 21 and can be affected by neurodiversity.
- Psychological changes allow the development of identity. Our thinking pattern and how we perceive ourselves in relation to the world allows us to build our personal identity. This includes sexual and gender identity. Personal identity is closely bound up with self-esteem and mental health. The less a young person feels that they ‘fit in’, the worse their mental health, which helps explain some of the poor mental health seen in transgender and LGBTQ+ children and young people.
- These include developmental changes such as a drive for independence while striving to conform and be accepted by peers. Social changes also feed into sociocultural pressures facing young people, which can be divided into educational pressure and social pressure.
- Young people identify school and exams as a big source of stress. A recent survey lists the top three worries as schoolwork (56%), appearance (49%) and future prospects (48%).
- Adolescents are hypersensitive to social exclusion, resulting in poor mental health when excluded. Social media offers more opportunity for exclusion, which may explain some of the negative impact that is seen through social media use, and in particular passive use. In addition, cyberbullying can occur through social media channels. On average, a child opens their first social media account at 11.4yrs.
How can primary care best support mental health?
Primary care can offer young people information and advice on how to keep physically and mentally fit and maintain good sexual health. Clinicians can identify and support patients with problems too, remembering that physical health symptoms can also often be passport symptoms to mental health problems.
Young people are regular users of healthcare services and have a high attendance in general practice. A survey in 2020, showed 66% of Year 10 pupils (age 14-15) had visited their GP in the previous six months. A good approach to managing young people in primary care can lead to good health outcomes, including improved mental health.
Seeing patients alone and confidentiality
Young people have a right to see a clinician on their own, and offering this is a government quality criterion. If a young person exercises this right, the clinician must check that they have the capacity to make decisions about their health and treatment. Capacity is assumed for people over 16 years, but under this age the Gillick competency criteria, originally developed with reference to contraception, are used as a legal test to assess capacity. These criteria have the same underlying principles as for people over 16 years but include a focus on encouraging parental involvement and best-interest decisions. The criteria may also be referred to as Fraser guidance, which relates to a court ruling made around capacity and contraception.
Many children are not aware they have a right to confidentiality and to be seen on their own. It is crucial to highlight this, preferably within earshot of parents. It is also important to explain the right of children and young people to confidentiality but also the limits of that and when it might be necessary to involve other adults. This is usually when the clinician is concerned that the young person (or someone they speak of) is at risk of harm.
Access to services
The majority of children and young people prefer to be seen in person, according to research, but neurodiverse patients may prefer remote contact. A welcoming, informal environment and informal dress are important to young people. Clinicians should adopt a non-judgemental, respectful and empathetic approach. Remember the importance of non-verbal cues – young people have 75% of the vocabulary of their adult counterparts.
It’s also important to bear in mind the stage of development and thinking pattern of the young person. Relay information in a clear and simple format, with the most important information first.
Useful communication tools
Communication tools can be helpful in assessments of children and young people. These include the OARS/OCARS and RULES mnemonics. The HEEADSSSSS tool is a useful framework to explore any psychosocial factors that might be affecting the young person and their presentation.
O: Open-ended questions
C: Closed questions (potentially)
A: Affirming statements
R: Reflections – after every 3-4 questions – paraphrasing responses
S: Summarising – pulling together key themes of the discussion
RULES R: Resist ‘righting reflex’ to put the young person right when they express their thoughts
U: Understand/explore clients motivations
L: Listen with empathy
E: Empower client and encourage optimism
S: Support self-efficacy
HEEADSSSSS H: home life
E: education and employment; home schooled. In relation to school, ask specifically about bullying, work pressure and future aspirations
E: eating: weight, body image and dieting
A: activities and access to supportive peer group:
D: drugs: smoking/vaping, alcohol, weed, other drugs, legal highs
S: sex, sexuality and gender identity
S: self-harm and suicidality
S: safety and risk-taking behaviours and criminality
S: sleep. Recommended 9-10hrs/night
S: social media usage: especially passive use
We need to adapt our approach when assessing and managing neurodiverse patients. It is especially important to allow time for processing and to adapt our style of communication. This includes:
- Asking one question at a time
- Using questions with only one point at a time
- Being specific
- Using concrete language and avoid idioms or metaphors such as ‘feeling blue’
- Asking about actions rather than feelings
- Being aware that young people may disguise their true emotions and be aware that risk assessment tools may not be effective.
Similarly, streamline the management process and limit the number of steps, using simple direct instructions and setting clear expectations.
More detailed information around how to create a young person friendly setting is outlined in the newly revised ‘You’re Welcome’ standards against which every young person’s service is encouraged to measure itself.
Framework for managing emotional/mental health issues in young people
Hertfordshire GPs have developed a framework to assist primary care services in the management of children and young people who present with emotional or mental health issues.
The framework uses the TRAM tool. This helps to distinguish between a normal emotional issue/adolescent angst and a mental health problem. Emotional upset and stresses are a normal part of life and can even be a useful prompt to highlight the need for change. The tool highlights situations when normalisation of mental health and resilience building may be more appropriate than a mental health intervention.
Other tools that can help young people to regulate their emotions in these situations include RULER and STOPP.
Appropriate to age and developmental stage
Manageable and not affecting functioning.
RULER R– Recognise emotions
U – Understand emotions
L – Label emotions
E – Express emotions
R – Regulate emotions
STOPP S– Stop
T – Take a breath
O – Observe what’s happening
P – Pull back
P – Practice what works
Key questions in the initial assessment
Assessment of needs requires the GP to uncover the presenting psychological and physical health symptoms in a non-judgemental and empathetic way. It is helpful to establish level of risk and need early in a consultation to enable prioritisation of the limited time available.
Key questions include: ‘Often when young people feel as anxious and overwhelmed as you describe, they can have thoughts of harming themselves or ending their lives. Has that ever been part of your thought processing?’
If the answer is in the affirmative, the GP should spend time exploring and managing the risk at this point and conducting a psychosocial assessment. It is important not to rely wholly on risk-assessment tools, especially in neurodiverse patients, as these may not be accurate.
If the young person denies any self-harming or suicidal ideation, then ensure that their presenting mental health concern is not impacting their eating pattern. There is a close link between mental health problems and disordered eating or eating disorders. If you suspect their eating pattern is significantly impacted, capture physical health data at this stage to establish the level of risk.
If eating is unaffected, take the remainder of the history, including the psychosocial assessment. Sleep is especially important. There is a strong link between poor sleep and mental health.
The initial management of listening, validating and suggesting an explanation of the basis to emotions with reference to presenting symptoms is a valuable first step in management and common to all levels of presenting need. The next stage of management depends on level of risk or need identified during the initial assessment.
Self-management resources may be appropriate for young people presenting with lower levels of need, or to accompany professional input for those presenting with higher need. These include healthy habits and self-care resources to stay mentally fit.
The Every Mind Matters and Anna Freud websites offer a good number of such resources.
The Smiling Mind app helps young people establish a regular mindfulness practice (across all ages from three years upwards) or to access sleep modules to help with sleep hygiene.
What’s Up app: highlights the sorts of thinking traps that may develop and how to challenge them. It has a useful information section which then runs through all the problems that may arise from this, including resulting thoughts and behaviours and practical ways of addressing them
Mindshift: details the sorts of thoughts and behaviours underpinning the main anxiety disorders and how to correct them. It has a useful Quick Relief button on the tool bar. It is linked to the Anxiety Canada Youth website, which includes more detail on a suitable system to use to address such problematic thinking styles and behaviours
Clear Fear app: more suitable for managing anxiety in the younger age group
WorryTree: a good tool to capture worries
Calm Harm: helps the user find suitable alternatives to self-harm to manage overwhelm and ride the wave and was built by self-harmers.
The Sleep Charity and Teen Sleep hub includes a helpline. Support for body image and eating difficulties can be found through the Be Body Positive resources and BEAT eating disorders charity. There are further educational resources for professionals on e-LFH eating disorder training .
Dr Cowan is a GP Lead for the Thrive Young Person’s Clinic in Hertfordshire and CYPMHS GP Clinical Lead for Hertfordshire and West Essex Integrated Care System.
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