Adolescent Mental Health
Psychiatrists, psychologists, and other mental health professionals diagnose psychological disorders with a standard system. Internationally, most use the International Classification of Diseases-11 (ICD 11; World Health Organization, 2020). In the United States, they often use the closely related Diagnostic and Statistical Manual -Fifth Edition (DSM-5) published by the American Psychiatric Association (APA, 2013). These publications list the criteria for a person to be diagnosed as having a specific disorder.
These diagnostic systems are sometimes criticized because they impose rules and remove clinician’s judgment. Yet, they allow people to speak in a similar language. For example, when a counselor who uses the ICD-11 in Hemu Village in China discusses depression, the goal is that she can talk about the same symptoms as a social worker in Palco, Kansas.
The DSM-5 contains a section for disorders that arise in childhood. However, they do not seem to pay as much attention to adolescent problems (Ng & Weisz, 2018). This chapter will discuss present research regarding the mental health of today’s adolescents. It will focus on the most common problems that many clinicians see, including depression, anxiety, and Attention Deficit Hyperactivity Disorder.
Anxiety And Fears
Anxiety is perhaps the most rapidly rising of all disorders in today’s teenagers. While the Millennials were the group most likely to be depressed, Gen -X members are more likely to experience anxiety.
The Diagnostic and Statistical Manual (DSM-5) lists several types of anxiety disorders. These are also discussed at the website of the National Institute of Mental Health (NIMH) https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml. Much of the discussion that follows is from this public domain website.
One type of anxiety that is rapidly increasing is Generalized Anxiety Disorder or GAD. The National Institute of Mental Health notes that Generalized Anxiety Disorder symptoms include:
Symptoms of Anxiety
Feeling restless, wound-up, or on-edge.
Being easily fatigued.
Having difficulty concentrating; mind going blank.
Having muscle tension.
Difficulty controlling feelings of worry.
Having sleep problems, such as difficulty falling or staying asleep, restlessness, or unsatisfying sleep.
To obtain this diagnosis, a person must have these symptoms at a level where they interfere with their life. They also must have shown these symptoms for six months.
A phobia is an intense and irrational fear. The anxiety is out of proportion to the danger. The person who has phobias recognizes the fear as abnormal (Adams, Sawchuk, Cisler, Lohr, & Olatunji, 2014). Yet, they cannot control it. The NIMH notes that there are several types of phobias and phobia-related disorders:
Adolescents and others with a specific phobia have an intense fear or anxiety about particular objects, events, or specific situations. Examples include the fear of blood, heights, receiving injections, and animals such as spiders, dogs, or snakes, or flying.
Social anxiety disorder (previously called social phobia) is increasingly common. Adolescents and others with social anxiety disorder have an intense fear of social or performance situations. They often worry that behaviors associated with their anxiety will be negatively evaluated by others. This will lead them to feel embarrassed. The worry is often so severe that they avoid social situations. Social anxiety disorder can manifest in various conditions, such as within the workplace or the school environment. This may be particularly likely to occur during the teenage years and can be challenging to treat.
Agoraphobia literally means fear of being in outside spaces. It used to be considered rare, but that was probably because no one looked to find it in their clients. According to the DSM-5 (APA, 2013), people with agoraphobia have an intense fear of two or more of the following: Using public transportation, being in an open space, being in an enclosed space, being outside, or being in a crowd.
Adolescents with this disorder may avoid these situations because they feel they will be “stuck” and cannot leave them. They may also feel they might have panic-like reactions or other embarrassing symptoms while involved. In the most severe form of agoraphobia, a person becomes housebound. This used to be relatively rare in adolescents but has become more common especially following Covid 19.
Before teletherapy, treatment for people with agoraphobia was difficult. Because people would not leave their house to seek therapy, they often did not receive any type of intervention at all. As a result, they often became much worse in time.
Young people with agoraphobia or other phobias may self-medicate with drugs or alcohol. Unfortunately, this does not work well as a treatment. While self-medication may work for a few minutes or hours, it only intensifies the problem.
Adolescents with Separation Anxiety Disorder have fears about being separated from people they care about. They often worry that something bad will happen to their loved ones while they are separated. This fear may lead them to avoid being separated from people in their lives. People who experience separation anxiety may also have terrifying and recurrent nightmares about being apart from loved ones. They may become physically ill when they have to separate from people they care about, such as parents, close friends, or siblings.
Sometimes these disorders occur together, as the vignette below illustrates.
Vignette 9.1: A COVID SURVIVOR
Justin was a high school senior when the Covid-19 quarantine began. The virus struck his family particularly hard. His grandfather died. An uncle almost died. His father, who developed Covid-19 symptoms before a vaccine was available, was out of work for several months. Justin then decided to forgo college for a while and help his family take care of his younger children attending school online.
When quarantine gradually subsided, Justin realized that he did not want to leave home. The thought of being more than a block or two from his family made him highly anxious. He stated that he was afraid that his house would burn down, though he knew this was an irrational fear.
Justin recalled that his anxiety increased over time. He felt guilty and foolish, but he could do little other than managing an occasional trip to the grocery. The idea of being around strangers was particularly terrifying to him.
Justin was able to connect with a local mental health provider. As a result, he was able to overcome his anxiety and enroll in college
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Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder occurring in some people who have experienced a scary or dangerous event outside of normal human experiences. The NIMH notes that it is natural to feel afraid after a traumatic situation. Most people will recover from initial symptoms on their own. However, people who experience continued problems may be diagnosed with PTSD. Traumatized people who have PTSD may feel stressed or frightened, even when they are completely safe.
PTSD can intensify and become worse if it is not treated. However, successful treatment is available. Treatment involves psychotherapy and may also involve various medications. Adolescents and others who feel they may have PTSD should consult a professional and not diagnose themselves. People should not look to social media for diagnosis. Finding a mental health professional with experience in this disorder may be essential for the best treatment results.
Depression
Depression is also called a major depressive disorder or clinical depression. It is not simply “having a bad day.” Depression causes severe symptoms that affect how people feel, think, behave, and handle daily activities (Nolen-Hoeksema & Hilt, 2009).
According to the DSM -5, to receive the diagnosis of depression, five of these symptoms must be present for at least two weeks:
Persistent sad, anxious, or “empty” mood,
Feelings of hopelessness or pessimism.
Irritability.
Feelings of guilt, worthlessness, or helplessness.
Loss of interest or pleasure in hobbies and activities.
Decreased energy or fatigue.
Difficulty concentrating, remembering, or making decisions.
Moving or talking more slowly.
Feeling restless or having trouble sitting still.
Difficulty sleeping, early-morning awakening, or oversleeping.
Appetite and/or weight changes.
Thoughts of death or suicide, or suicide attempts.
Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment.
Not everyone who is depressed experiences every symptom. Some people experience only a few symptoms, while others may experience many. Symptoms can vary in intensity and may also change as the level of a person’s depression changes.
Many research studies have shown that depression can be successfully treated. The earlier that treatment can begin, the more effective it is. Depression is usually treated with medications or psychotherapy or often with a combination of the two.
Antidepressants are prescribed medicines that treat depression. Sometimes they have other uses. For example, these drugs may help improve the way people’s brains use chemicals that control mood or stress. Unfortunately, people may need to try several different antidepressant medicines before finding the one that improves their symptoms and has manageable side effects. This is often difficult for adolescents because of impatience, lack of resources, family concerns, or peer pressure. In addition, antidepressants often take several weeks or longer to work.
The NIMH notes that if people begin taking antidepressants, they should not stop taking them without the help of a health care professional.
Psychotherapy is also very helpful for people with depression. Many mental health therapists prefer to treat clients with evidence-based therapies. This means that there is sufficient scientific evidence that the therapies that they use work for the problem at hand. Examples of evidence-based approaches for depression include cognitive-behavioral therapy, which has the most research so far. Some types of family therapy are also evidence-based for the treatment of depression.
Bipolar Disorders
Bipolar disorder (formerly manic depression) is a mental disorder that causes unusual mood, energy, and activity levels (Semple & Smyth, 2019).
Three types of bipolar disorder are recognized by DSM-5. Moods range from periods of significantly “up,” elated or energized behavior (known as manic episodes) to very “down,” sad, indifferent, or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.
Bipolar I Disorder— defined by manic episodes that last at least seven days or manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least two weeks.
Bipolar II Disorder is defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes typical of Bipolar I Disorder.
Cyclothymic Disorder (also called Cyclothymia) is defined by periods of hypomanic symptoms and depressive symptoms lasting for at least two years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.
Some people experience both manic and depressive symptoms in the same episode. This is labeled as an episode with mixed features. People with mixed features may feel very sad or hopeless, while, at the same, time feeling extremely energized. This is a very difficult condition to imagine, but it is often debilitating for clients.
Bipolar disorder is often diagnosed during late adolescence or early adulthood (Mash & Wolfe, 2013). Occasionally, bipolar symptoms can appear in children. Bipolar disorder can also first occur during a woman’s pregnancy or following childbirth. It can also occur in later life as well, although this seems to be rare. Although the symptoms may vary over time, bipolar disorder usually requires lifelong treatment. According to the NIMH, following a prescribed treatment plan can help people manage their symptoms and improve their quality of life.
Appropriate diagnosis and treatment help people with bipolar disorder lead healthy lives. Adolescents who feel they might have symptoms of this disorder should talk with a doctor or other licensed health care provider. As always, people should not try to diagnose themselves or turn to the internet for diagnosing.
Health care providers diagnose bipolar disorder from a person’s symptoms, lifetime history, and family history. Usually, it is necessary to rule out other conditions that might be causing the symptoms. These include many physical problems that can mimic bipolar symptoms. Psychotherapy is also very helpful in helping clients cope and in avoiding relapse, although it does not replace medication.
Excellent information about bipolar disorders is available here:
https://www.nimh.nih.gov/health/topics/index.shtml
Schizophrenia
Schizophrenia is a mental illness that affects how a person thinks, feels, and behaves. It is NOT “multiple personalities” or moodiness.
People who have schizophrenia may appear as if they have lost touch with reality. If left untreated, the symptoms of schizophrenia can be persistent and are often disabling. However, effective treatments are available for many people to alleviate symptoms.
Schizophrenia is often diagnosed in the late teen years. It tends to emerge earlier in males than females for reasons that are not known. A diagnosis often follows the first episode of psychosis when individuals first display symptoms of schizophrenia. Psychotic symptoms are discussed below.
Changes in thinking and social functioning often begin before the first episode of psychosis. These often start in mid-adolescence. Schizophrenia can occur in younger children, but this is rarer.
The symptoms of schizophrenia fall into the three categories:
Psychotic symptoms include altered perceptions (e.g., hearing voices). They also include abnormal thinking and odd behaviors. For example, people with psychotic symptoms may have delusions that are not supported by reality. They may also have thinking that seems disorganized and may not make sense to others. Their speech may also be jumbled and may not be coherent to family, friends, and others.
Negative symptoms of schizophrenia include loss of motivation, disinterest, social withdrawal, and problems showing emotions. A person may have a “flat affect,” which means decreased expressions or decreased overall emotions.
Cognitive symptoms can be common in schizophrenia. These may include difficulties in paying attention and problems in memory and concentration. These symptoms may get worse when a person with schizophrenia feels nervous or threatened.
People with schizophrenia may also have difficulty processing new information. This can make it hard for them to make appropriate decisions. This tendency may get worse when they are distracted, in new situations, or are emotional.
Behavioral scientists and other researchers do not fully understand the causes of schizophrenia. Genetic studies suggest that many different genes combining together put some people at greater risk for this disorder. There is no single schizophrenia gene.
Research suggests that environmental factors are also important in the risk for schizophrenia. These include living in a poor community, high stress, and exposure to viruses before birth. However, the exact role of environmental factors and the way that they act is not clear. Therefore, it is not possible to accurately predict who will experience schizophrenic symptoms.
Neuroscientists think there may be differences in brain structure in some people with schizophrenia. For example, areas of the brain involved with the neurotransmitter dopamine seem to be more likely to show changes than these areas in other people. Again, however, much more research is needed.
Vignette 9.2 Dawn: A Recovering Person with Schizophrenia
“My story is really strange,” said Dawn, a 28-year-old nurse. “I’m a psychiatric nurse, and I have a history of diagnosed schizophrenia.”
Dawn states that she began having paranoid symptoms in high school. “I thought these were just part of growing up. To be honest, I was smoking a lot (of weed). That might have had something to do with it.”
By the time Dawn reached college, she had stopped marijuana use. “I wanted to be a nurse, and it was all about studying. When I was tired or run down was usually the time. Sometimes I would hear voices. I just thought this was normal, nothing odd.”
“I took classes in nursing and in psychology that discussed mental illness. I just did not make the connection.”
Dawn graduated and eventually became a licensed registered nurse. Her work performance was excellent. “I went to work on a psychiatric unit. Go figure that one.”
Eventually, Dawn’s roommate moved out because Dawn seemed disagreeable. “She also said I watched too much TV. She said I never showed my emotions anymore. I just remember being really tired.”
One summer night, Dawn was working a double shift on her unit. It was about 2 AM, she recalled. A patient had just been admitted. “I was doing the paperwork, calling the doctor, ordering the lab work. Then, suddenly, I looked at the patient’s history. I had a phone call and kept hearing people say my name in place of the patient’s.”
Dawn realized she was hallucinating. As she looked at the patient’s chart, she realized that she had many of the patient’s symptoms. These included not only hallucinations but social withdrawal, delusions, and paranoia.
“I called the doctor on call. I said, hey, I think I have many of these symptoms. She thought it was a joke, a prank, but I was serious.
“I didn’t have to be hospitalized, but I was on antipsychotic medicine. I stayed home for over a month. My family took care of me.
“It took a while, but I returned to work. First thing I learned was I can’t work nights! That’s when I have symptoms. It’s been a couple of years, and I am still on medication, but it’s much less. I watch my stress and exercise and eat right….I talk to my therapist every week. I don’t know that I have this problem beat, but I sure am trying.
“I’m getting married next year, so that is stressful. But I believe if I keep getting help, I’ll be fine. My fiance and I plan on a typical family and don’t think my illness will be a problem.”
Attention-Deficit/Hyperactivity Disorder
Attention-Deficit/Hyperactivity Disorder (ADHD) is a disorder usually first diagnosed in childhood. It involves an ongoing pattern of inattention, hyperactivity, and impulsivity. ADHD is also referred to sometimes by its old term, ADD, or Attention Deficit Disorder. However, the newer term is more accurate.
Most adolescents diagnosed with the disorder have the combined type of ADHD.
Inattention means that a person wanders off task, has problems focusing, and is disorganized. Adolescents with inattention features often make careless mistakes and overlook details. They have difficulty paying attention and often do not seem to listen. They may have difficulty following through on commitments. They may have difficulty concentrating on material that they consider boring or not interesting.
Hyperactivity means that a person moves about excessively, talks excessively, or fidgets. In addition, they may move around, tap fingers or toes, fidget, or engage in other body movements. In class, students with this disorder often yell out the answers.
Impulsivity means a person acts without sufficient thinking. There are many ways to be impulsive. For example, in social situations, an impulsive person may frequently interrupt others. In addition, they may have a history of seeking immediate rewards instead of working in their best interest by delaying gratification.
As the NIMH notes, symptoms of ADHD are often mistaken for emotional or disciplinary problems or missed entirely. This is especially likely in quiet, well-behaved children, leading to a delay in diagnosis. Adolescents with undiagnosed ADHD may have a history of poor academic performance, school problems, or difficulties at home or with friends. Other conditions, such as anxiety disorder, depression, and substance abuse, are common in people with ADHD.
Both the NIMH and the DSM-5 note that ADHD symptoms often change over time as a person gets older. In adolescence, hyperactivity seems to lessen and be displayed as restlessness or fidgeting. Inattention may remain. Impulsivity may increase.
Researchers do not know the causes of ADHD. However, like many other illnesses, several factors seem to contribute. These include genetics, brain injury, exposure to cigarette smoke or alcohol before birth, a low birth weight, or exposure to environmental toxins like lead at a young age. In addition, ADHD is not caused by poor or inconsistent parenting, although poor parenting practices can make ADHD much worse.
There is no cure for ADHD. However, treatments can reduce symptoms and help improve functioning. Treatments include medication, psychotherapy, and education.
The most effective medications used for treating ADHD are stimulants. These drugs release or recycle the neurotransmitters dopamine and norepinephrine. With medical supervision, stimulant medications are considered safe, although anyone with questions should consult their physician. In addition, anyone taking medications must be monitored by their prescribing doctor.
No one should share ADHD medication with others. This is illegal and also very dangerous. Medication needs to be taken as prescribed for effectiveness.
Some other ADHD medications are not stimulants. They can improve symptoms, though they work slower and, in some cases, less effectively. A person should always consult with their health care professional and not attempt to treat themselves.
Several psychotherapeutic interventions have been shown to help clients with ADHD. Behavioral and cognitive-behavioral therapies have been helpful with this disorder. In addition, educational specialists help the adolescent, their parents, and their teachers make classroom and homework assignments to help the teenager succeed.