Upfront: Mental health issues in adolescents who have experienced abuse and neglect

Adolescence is a complex biophysical process. Dramatic and rapid physical changes with the onset of puberty are accompanied by longer and more subtle emotional, cognitive and social developments, often all evolving asynchronously. These challenges are further complicated in young people who have experienced violence, neglect and other forms of abuse and challenging behaviours, which have resulted in them coming into the care of Child, Youth and Family.

Receiving love is the most important mental health need

The most basic mental health need for adolescents is to be loved. Each parent or caregiver experiences this differently and provides it in different ways, making this aspect of mental health difficult to study scientifically. However, there are some aspects of loving that can predictably help young people recovering from abuse and trauma.

The following points can be considered and applied also to the health professional-adolescent patient relationship:

1. Listen when they talk and encourage them to tell their stories. Treat their stories with respect even when they may be hard to believe. Not all young people are ready to talk about their traumas and so will not benefit from being specifically encouraged to discuss traumatic events, however, it is important to be ready to listen.
2. Provide a place of safety – both emotional and physical; a place where they will not be mocked, put down or physically harmed.
3. Treat them with respect even when they do things that are unacceptable.
4. Forgive the bad things they do (which is not the same as condoning).
5. Use a framework of helping them to grow up rather than just controlling their behaviour.

Other core needs for adolescent mental health

Need for safety from violence and abuse of all types

• Safety of the young person – from themselves, peers, caregivers and community
• Safety of other young people and their caregivers
• Safety of the community

Need for positive development

• Care in a protective environment
• Individualised education programme
• Positive relationships and experiences
• Identity development, self efficacy
• Sexual identity and sexual relationships
• Moral development
• Self extension and skills
• Creative expression

Need to align with society

• Pro-social skills
• Adherence to societal laws and constraints
• Belonging to a group or identity
• Contributing to family and society

Need to address specific potential health and development challenges

• Nutrition and activity
• Positive choices around risky behaviours
• Health conditions and disability
• Mental health and illness
• Addictive behaviours
• Education and skills deficits
• Lifestyle choices (e.g. smoking)

Characteristics of mental health problems in adolescents

Western medicine divides mental health from other aspects of health, but for many young people in New Zealand, mental health cannot easily be separated from family or whānau health, spiritual health or physical health. Rather than identifying that they have a mental health problem, many young people will express their distress through criminal behaviour, withdrawing from social life or school, self harm or drug and alcohol use. Often young people who are obviously distressed will deny having a mental health problem but attribute their distress to the actions of others. Therefore it is useful to have a broad rather than narrow definition of mental health problems.

We recognise mental health by its ordinariness: attending school, gaining skills, interacting socially. Happiness is often associated with mental health but is not necessary for it. The young person who is stressed out (unhappy) by high academic or sporting expectations will overall have better mental health and lower risks. The distressed young person who throws themselves into helping at the Marae or school may do better than those happily playing computer games by themselves. The young person who is angry but channels that anger into high performance or artistic endeavour will do well.

Common mental health disorders in adolescents in New Zealand include depression (and suicide), conduct disorder and substance abuse. Often these occur together, but rather than thinking of these as co-morbidities, it may be useful to consider that young people who are distressed often find multiple ways of finding relief. In addition, the symptoms of mental health problems can vary with age, so that younger men might use marijuana but when they are older they might use alcohol. Younger women might cut (self-harm), but when older they might have depression.

Causes of mental health problems in adolescents

Common causes of mental health problems in adolescents include; a family or genetic pre-disposition, poor attachment, lack of love and affection, as well as exposure to violence. Some young people have mental health symptoms in perfectly ordinary circumstances and this might be attributed more to their temperament. Some young people are born with disabilities such as foetal alcohol or autistic spectrum disorder which give rise to mental health symptoms. Some co-morbidities, such as attention deficient hyperactivity disorder (ADHD), seem to be extremes of normal behaviour. Mental health symptoms in Māori youth have increased since the migration to the cities. Unfortunately many of the causes of mental health problems co-exist, so that the child with exposure to alcohol in the womb may also suffer from neglect and abuse.

Family/caregiver support and community activities

Regardless of the specific mental health problem or symptoms, all young people have some basic needs for their mental health:

1. The need to feel loved
2. The need to belong
3. The need for hope and faith in the future

These three needs can be provided by family/whānau, and where families cannot provide them, other sources such as schools, churches, sporting clubs or mentors may help. Without addressing these basic needs, mental health interventions often make limited progress.

The individualism of western culture often leaves young people feeling isolated and unsupported. This influence can be counteracted by encouraging the development of the wider family and its involvement in the lives of young people. For Māori, elements of belonging such as pepeha, visiting their marae, understanding tikanga or walking their land can be helpful.*

Mentors can be effective in some circumstances, particularly when working with adolescents with more severe problems. The availability of good mentor programmes (trained, supervised, regular and prolonged) is variable by region and demand often exceeds the capacity of the volunteers.

Culturally based programmes (particularly in acculturated youth) have been shown to be effective, particularly in adolescents with alcohol, drug and violence problems. These programmes are available through kaupapa Māori organisations.

Activities and exercise are useful for a range of symptoms but particularly those where the young person is feeling low. It is important that the young person finds an activity that suits their abilities, which could range from going for a walk with family or friends, to playing sport at an international level.

Positive youth development (assisting positive development in young people) is effective for individuals and groups. Youth development interventions that are effective tend to be intensive, prolonged and involve multiple areas of a young person’s life. Programmes are available in most communities and include, for example, groups focused on sports, conservation, culture, outdoor education and work experience. Participating in the group involves learning new skills and activities, being involved, socialising, having fun and taking risks within a safe environment.

Youth One Stop Shops are available in some regions, to allow young people to access the help they need on their own, with staff who are skilled in talking to, listening to and understanding young people. Sometimes the best one stop shop is at the high school (or alternative education), particularly if it has counsellors, nurses, general practitioners or mentors.

Psychological therapies

Cognitive behaviour therapy has been shown to be effective in a wide variety of situations. This teaches young people the relationships between their feelings, thoughts and actions and how to change their emotions and behaviours for themselves. Some general practices may offer these services or patients can be referred to specialist clinics.

“Talk therapies” can be effective and seem to rely more on the relationship with the therapist than the actual therapy involved. This is widely available in the community.

Motivational interviewing is a specific type of talk therapy targeting problem behaviours. It is effective for changing a range of unhelpful behaviours (that are associated with mental distress), from drug use to overeating. General Practitioners can assist patients to find a therapist who specialises in this method, such as a drug and alcohol counsellor.

Family interventions such as family therapy can be effective when the focus is on family dysfunction rather than the individual. This is offered by a number of organisations in the community.

Multi-systemic therapy and Functional Family Therapy have been shown to be effective in conduct disorder (persistent bad behaviour). Both are intensive family based interventions.

Medical treatment

In some circumstances, antidepressants may be considered for an adolescent with a mental health problem such as depression. However, antidepressants such as serotonin re-uptake inhibitors (SSRIs) are not approved for use in people aged under 18 years, so are used “off-label”. If an antidepressant is used, fluoxetine is considered the best choice for adolescents. It is important to maintain regular contact with the young person and to monitor for suicidal thoughts or other negative behavioural changes, especially in the first few weeks following prescription of the antidepressant. It is recommended that antidepressant treatment in a person aged less than 18 years should not be initiated in primary care without consultation with a child and adolescent psychiatrist.

For further information see: “ Depression in young people ”, BPJ Special Edition (Feb, 2010).