case study of an adolescent problems and needs

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

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Health Risks in Adolescence

Unique biological and psychosocial changes occurring during adolescence, brain development, sexual orientation and gender identification, legal status, mental health and emotional well-being, morbidity from high-risk sexual activity, the adolescent medical home, recommendations, appendix: online resources, lead authors, committee on adolescence, 2017–2018, unique needs of the adolescent.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Elizabeth M. Alderman , Cora C. Breuner , COMMITTEE ON ADOLESCENCE , Laura K. Grubb , Makia E. Powers , Krishna Upadhya , Stephenie B. Wallace; Unique Needs of the Adolescent. Pediatrics December 2019; 144 (6): e20193150. 10.1542/peds.2019-3150

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Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.

Adolescence, defined as 11 through 21 years of age, 1   is a critical period of development in a young person’s life, one filled with distinctive and pivotal biological, cognitive, emotional, and social changes. 2   The World Health Organization 3   ; the Office of Adolescent Health of the US Department of Health and Human Services 4   ; the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) 5 , 6   ; the Lancet , 7   with 4 international academic institutions 8   ; and the Society for Adolescent Health and Medicine 9   have called for a closer examination of the unique health needs of adolescents. In 2018, Nature devoted an issue to the advances in the science of adolescence and called for ongoing further study of this important population. 10   As a leader in adolescent health care, the American Academy of Pediatrics (AAP) is motivated to describe why adolescents are a unique and vulnerable population and why it is crucial that the AAP focus on adolescents’ health concerns to optimize healthy development during the transition to adulthood. Addressing the unique needs of adolescents with disabilities is outside the scope of this statement; several statements specific to this population are available at https://pediatrics.aappublications.org/collection/council-children-disabilities . In addition, specific guidance around the transition to adult health care is not covered in this statement; please refer to the list of transition resources at the end of this document.

The need for comprehensive health services for teenagers has been well documented since the 1990s. 11 – 13   The AAP advocates for the pediatrician to provide the medical home for adolescent primary care. 14   Other professional societies, such as the Society for Adolescent Health and Medicine, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists and school-based health initiatives ( https://www.sbh4all.org/ ), recognize the unique needs of adolescents. These organizations recommend an increase in adolescent medicine training, along with the Accreditation Committee for Graduate Medical Education. The Accreditation Committee for Graduate Medical Education currently requires only 1 month of adolescent medicine training from a board-certified adolescent medicine specialist for all pediatric residency programs (adolescent medicine; [Core] IV.A.6.[b].[3].[a].[i]); there must be one educational unit). 15   The importance of addressing the physical and mental health of adolescents has become more evident, with investigators in recent studies pointing to the fact that unmet health needs during adolescence and in the transition to adulthood predict not only poor health outcomes as adults but also lower quality of life in adulthood. 16  

A hallmark of adolescence is a gradual development toward autonomy and individual adult decision-making. However, adolescents are often faced with situations for which they may not be prepared, and many are likely to be involved in risk-taking behaviors, such as use of alcohol, tobacco, and other drugs and engaging in unprotected sex. Most recently, there is increased concern about the rise in electronic cigarette use among adolescence. 17   In fact, most health care visits by adolescents to their pediatricians or other health care providers are to seek treatment of conditions or injuries that could have been prevented if screened for and addressed at an earlier comprehensive visit. 18   Although some risk-taking behavior is considered normal in adolescence, engaging in certain types of risky behavior can have adverse and potentially long-term health consequences. The majority of mortality and morbidity during adolescence, which can be prevented, is attributable to unintentional injuries, suicide, and homicide. 19   Approximately 72% of deaths among adolescents are attributable to injuries from motor vehicle crashes, other unintentional and intentional injuries, injuries caused by firearms, injuries influenced by use of alcohol and illicit substances, homicide, or suicide. 20 , 21   These causes of death greatly surpass medical etiologies such as cancer, HIV infection, and heart disease in the United States and other industrialized nations. 21  

The AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents recommends a strength-based approach to screening and counseling around these behaviors that lead to mortality and morbidity in adolescents. 1 , 22   However, according to the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, only 39% of adolescents received any type of preventive counseling during ambulatory visits. 23   Seventy-one percent of teenagers reported at least 1 potential health risk, yet only 37% of these teenagers reported discussing any of these risks with their pediatrician or primary care physician. Clearly, screening for and counseling around these high-risk behaviors needs to be improved. 24  

New screening codes for depression, substance use, and alcohol and tobacco use as well as brief intervention services may provide opportunities to receive payment for the services pediatricians are providing to adolescents. These include 96127, brief emotional and behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder scale) with scoring and documentation, per standardized instrument, and 96150, health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires). 25   However, it is important to recognize that coding for specific diagnoses may be challenging if the patient does not want his or her parent(s) to know the reasons for the clinical visit. Adolescent visits and documentation of visits are confidential to promote better access and to protect the rights of adolescents. 26  

Another trend in the health status of adolescents (reflecting technological advances in pediatric medical care) is the increasing number of pediatric patients with chronic medical conditions and developmental challenges who enter adolescence. Adolescents with chronic conditions face developmental challenges similar to their healthy peers but may have special educational, vocational, and transitional concerns because of their medical issues. 27  

The prevalence of chronic medical conditions and developmental and physical disabilities in adolescents is difficult to assess because of the variation of study methodologies and categorical versus noncategorical approaches to the epidemiology of chronic illness. 28   According to the National Survey of Children’s Health, funded by the US Department of Health and Human Services, almost 31% of adolescents have 1 moderate to severe chronic illness, such as asthma or a mental health condition. 29   Other common chronic illnesses include obesity, cancer, cardiac disease, HIV infection, spastic quadriplegia, and developmental disabilities. 30 – 32   One in 4 adolescents with chronic illness has at least 1 unmet health need that may affect physical growth and development, including puberty and overall health status as well as future adult health. 33  

Within pediatric practice, integrating adolescent-centered, family-involved approaches into the care of adolescents as well as culturally competent and effective approaches (as outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents ) has the potential not only to identify threats to well-being but also to create a space to work with families to bolster opportunities for optimal development of all children. 1   When considering the health challenges adolescents face, it is imperative to take into account not only the ethnic and racial diversity of the adolescent population in the United States but also the social and ecologic factors (eg, socioeconomic status, family composition, parental education and engagement, neighborhood and school environment, religion, earlier childhood trauma and toxic stress, and access to health care).

The Search Foundation has conducted research that suggests that for minority youth, a positive ethnic identity is a critical spark for emergence of the required developmental assets to enable adolescents to develop into successful and contributing adults. 34 , 35   This theory is supported by a recent study in The Journal of Pediatrics that suggests minority youth are still prone to depression because of isolation and discrimination faced during adolescence while navigating neighborhood and school environments, even when they have educated and supportive parents. 36   African American male adolescents have the highest rates of mortality, followed by American Indian, white, Hispanic, and Asian American or Pacific Islander male adolescents, pointing to racial and ethnic disparities in adolescent health and the potential to achieve a healthy adulthood. 37  

The AAP has previously published policy statements addressing the unique strengths and health disparities that exist for specific groups of adolescents, such as lesbian, gay, bisexual, and transgender youth and those in the juvenile justice system, foster care, and the military. 38 – 42   Pediatricians must pay attention to how care is delivered to the increasingly diverse adolescent populations to prevent a decline in health status and increase in health care disparities.

Biological and psychosocial changes that occur during adolescence make this age group unique. Research describing the timing and physiology of puberty has been invaluable in revealing not only differences between racial groups but also between adolescents with different chronic conditions. 43 – 46  

Puberty is the hallmark of physiologic progression from child to adult body habitus. Chronic conditions, such as obesity and intracranial lesions, or trauma may cause early puberty, which may put the adolescent at risk for engagement in higher-risk behaviors at an earlier age. 44   Delayed puberty is often a variant of normal development but may also be seen in adolescents with inflammatory bowel disease, eating disorders, and chronic conditions that create malnutrition as well as adolescents who have undergone treatment of malignancies. Comorbid mental disease (eg, an eating disorder that causes delayed puberty) or medication for psychiatric illness that causes obesity, which may cause early puberty, can complicate optimal adolescent psychosocial development.

The work of Giedd 47   and others shows that brain development during adolescence is ongoing and affects behavior and health. Because of changes in signaling that relate to the reward system in which the brain motivates behavior and the continuing maturation of the parts of the brain that regulate impulse control, adolescents may have a propensity to be involved with high-risk behaviors and have heightened response to emotionally loaded situations. In addition, adverse childhood experiences can have an impact on brain development, affecting behaviors and health during adolescence. 48   During adolescence, there is a “pruning” of gray matter and synapses, which makes the brain more efficient. 47   White matter increases throughout adolescence, which allows the older adolescent and adult brain to conduct more-complex cognitive tasks and adaptive behavior. 49  

Increasingly, studies show that the adolescent brain responds to alcohol and illicit substances differently than adults. 50 , 51   This difference may explain the increased risk of binge drinking as well as greater untoward cognitive effects of alcohol and marijuana.

Sexual (and gender) development is a process that starts early in childhood and involves negotiating and experimenting with identity, relationships, and roles. In early adolescence, people begin to recognize or become aware of their sexual orientation. 52 , 53  

However, some adolescents are still unsure of their sexual attractions, and others struggle with their known sexual attraction. Adolescence is a time of identity formation and experimentation, so labels that one uses for their sexual orientation (eg, gay, straight, bisexual, etc) often do not correlate to actual sexual behaviors and partners. Sexual orientation and behaviors should be assessed by the pediatrician without making assumptions. Adolescents should be allowed to apply and explain the labels they choose to use for sexuality and gender using open-ended questions. 54 – 56  

Sexual minority adolescents may engage in heterosexual practices, and heterosexual adolescents may engage in same-sex sexual activity. Depending on their specific behaviors and the gender of various partners, all sexually active adolescents may be at risk for sexually transmitted infections and unplanned pregnancy. Sexual minority youth are at higher risk of sexually transmitted infections and unplanned pregnancy, often because they do not receive education that applies to their sexual behaviors and are less likely to be screened appropriately ( http://www.cdc.gov/healthyyouth/disparities/smy.htm ). 57 , 58  

Sexual minority and transgender youth, because of the stigma they face, are also at higher risk of mental health problems, including depression and suicidality, altered body image, and substance use. 38  

There is strong evidence that when sexual minority and transgender youth feel they cannot express their true selves, they go underground by either hiding or denying their attractions and identity. 59   When this is combined with reinforcing parental rejection, bullying, etc, it is believed to lead to internalization, low self-esteem, and ultimately, depression and suicide. 59   Using an explanation like this places the problem on the societal context, not the adolescent or his or her identity. 38 , 39 , 60 , 61  

A relatively higher proportion of homeless adolescents are lesbian, gay, bisexual, transgender, and queer or questioning youth. 61   They leave their family homes because of abuse or having been thrown out. These adolescents are at high risk for victimization and often need to engage in unsafe sexual practices to provide themselves food and shelter. 61  

Mental health problems may become more pronounced when sexual minority teenagers come out during adolescence to unsupportive family members and friends or health care providers. 38   These youth are more likely to experience violence both in their homes and in their schools and communities. Studies have shown that sexual minority youth reveal higher rates of tobacco, alcohol, marijuana, and other illicit substance use. 62  

Most adolescents identify by and express a gender that conforms to their anatomic sex. However, some adolescents experience gender dysphoria with their anatomic sex when entering puberty. As they consider transgender options, they are at an increased risk of mental or emotional health problems, including depression and suicidality, victimization and violence, eating disorders, substance use, and unaccepting or intolerant family members and peers. Crucial to the successful navigation of gender dysphoria issues are health care providers who can assist transgender youth and families to achieve safe, healthy transitioning both in the postponement of puberty, when indicated, and in transitioning to preferred gender with psychosocial and behavioral support. 59  

Adolescence heralds a change of legal status, in which the age of 18 or 19 years transforms legal status from minors to adults with full legal privileges and obligations related to health care. However, certain states afford minors the right to confidentiality and consent to or for reproductive and mental health and substance use treatment confidential health services. 26 , 63   Generally, minors may receive confidential screening and care for sexually transmitted infections in all 50 states and the District of Columbia. However, accessing contraception to prevent unwanted pregnancy as well as the ability to self-consent to pregnancy options counseling, prenatal care, and termination of pregnancy vary between states. 64   These discrepancies also exist in accessing outpatient mental health and substance use services. Many adolescents in need of these services do not know they may have the right to access them on their own and may avoid interaction with the health care system to assist with reproductive and mental health concerns. 16   Delaying such care leads to adverse health outcomes. 16   A recent survey confirms that adolescents value private time with their health care providers, with confidentiality assurances by health care providers. 65   The need for office policies in negotiating private time was suggested. Moreover, health care providers reported needing more education in the provision of confidential services. 66   Adolescents in foster care may also be limited in their autonomous access to confidential services, which varies state to state. 41   In certain states, pregnant and parenting adolescents may have the right to consent for their care and the care of their child ( https://www.guttmacher.org/state-policy/explore/minors-rights-parents , https://www.schoolhouseconnection.org/state-laws-on-minor-consent-for-routine-medical-care/ ). Few adolescents are considered emancipated minors and, thereby, entitled to all legal privileges of adults. 67  

Mental health and emotional well-being, in combination with issues pertaining to sexual and reproductive health, violence and unintentional injury, substance use, eating disorders, and obesity, create potential challenges to adolescents’ healthy emotional and physical development. 68   Approximately 20% of adolescents have a diagnosable mental health disorder. 69   Many mental health disorders present initially during adolescence. Twenty-five percent of adults with mood disorder had their first major depressive episode during adolescence. 70  

Suicide is the second leading cause of death in adolescents, resulting in more than 5700 deaths in 2016. 71   Between 2007 and 2016, the overall suicide rate for children and adolescents ages 10 to 19 years increased by 56%. 71   Older adolescents (15–19 years of age) are at an increased risk of suicide, with a rate of 5 in 100 000 for girls and 20 in 100 000 for boys. 71   According to the 2017 Youth Risk Behavior Survey of high school students, 7.4% of high school students attempted suicide in the last 12 months, and 13.6% made a suicide plan. 72   Adolescents with parents in the military were at increased risk of suicidal ideation (odds ratio [OR]: 1.43; 95% confidence interval [CI]: 1.37–1.49), making a plan to harm themselves (OR: 1.19; 95% CI: 1.06–1.34), attempting suicide (OR: 1.67; 95% CI: 1.43–1.95), and an attempted suicide that required medical treatment. 73  

Eating disorders typically present in the adolescent years. Although the incidence of eating disorders is low compared with depression, anxiety, and other mental health problems, these problems are often comorbid with eating disorders. 74   Moreover, the incidence of anorexia nervosa, bulimia nervosa, and other disordered eating is becoming more prevalent in formerly obese teenagers, male teenagers, and teenagers from lower socioeconomic groups. 75 – 77  

Teenagers with mental health issues may have subsequent poor school performance, school dropout, difficult family relationships, involvement in the juvenile justice system, substance use, and high-risk sexual behaviors. 78   Almost 70% of youth in the juvenile justice system have a diagnosed mental health disorder. 79 , 80  

Rates of serious mental health disorders among homeless youth range from 19% to 50%. 81 , 82   Homeless youth have a high need for treatment but rarely use formal treatment programs for medical, mental, and substance use services. 81   Confidentiality is also an issue for adolescents, as evidenced by the fact that in adolescents to whom confidentiality is not assured, there is a higher prevalence of depressive symptoms, suicidal thoughts, and suicide attempts. 83   There is a paucity of adequately trained mental health professionals to care for adolescents with these mental health challenges. 84   In addition, coverage for mental health services by insurance plans can be variable. 78  

Multiple factors, including the increase in use of long-acting reversible contraception, have resulted in the teenage pregnancy rate decreasing in the United States over the past 20 years. 85 , 86   However, pregnancy still contributes to delays in educational and career success for adolescents. Moreover, pregnant teenagers are more likely to delay seeking medical care, putting them at risk for pregnancy-related health problems and putting their children at risk for prematurity and other negative birth outcomes. 87  

Adolescents continue to have the highest rates of sexually transmitted infections (eg, gonorrhea and Chlamydia ). 88   Although screening most sexually active adolescents for Chlamydia infection is covered by the Patient Protection and Affordable Care Act (Pub L No. 111–148 [2010]) and recommended by the AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , adolescent concerns about billing and confidentiality are obstacles to medical screening. 1 , 89   Pediatricians can refer to AAP guidance to find appropriate codes for payment for providing adolescent health services ( https://www.aap.org/en-us/Documents/coding_factsheet_adolescenthealth.pdf ).

Consideration of the unique health risks as well as the biological and psychosocial elements of adolescence allows the AAP-endorsed patient-centered medical home (PCMH) to serve as an ideal conceptual framework by which a primary care practice can maximize the quality, efficiency, and patient experience of care. In 2007, the AAP joined the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association to endorse the “Joint Principals of the Patient-Centered Medical Home,” which describes 7 core characteristics: (1) personal physician for every patient; (2) physician-directed medical practice; (3) whole person orientation; (4) care is coordinated and/or integrated; (5) quality and safety are hallmarks of PCMH care; (6) enhanced access to care; and (7) appropriate payment for providing PCMH care. 90   The AAP, American Academy of Family Physicians, and American College of Physicians assert that optimal health care is achieved when each person, at every age, receives developmentally appropriate care. 91   Pediatricians provide quality adolescent care when they maintain relationships with families and with their patients and, thus, help patients develop autonomy, responsibility, and an adult identity. 92   Issues unique to adolescence to consider within the PCMH model include the following: adolescent-oriented developmentally appropriate care, which may require longer appointment times; confidentiality of health care visits, health records, billing, and the location where adolescents receive care; providers who offer such care; and the transition to adult care. 91 , 93   Moreover, using a strengths-based approach in the care of adolescents, as well as capitalizing on resiliency, is instrumental to maintaining the health of the individual adolescent. 94  

Schools have an important role for adolescents who either do not have access to a PCMH or do not use their access to receive recommended preventive services. School-based health centers and school-based mental health services can meet the needs of adolescents who do not have a PCMH or can coordinate school-based health services with the PCMH if the student has one. School nurses can help identify and refer adolescents who need these services. 95  

Financing health care of the adolescent can be challenging. Please see the detailed AAP policy statement on reforms in health care financing with the ultimate goal to improve the health care of all adolescents. 92  

On the basis of the unique biological and psychosocial aspects of adolescence, the AAP supports the following:

continued recognition by international and national organizations, including the AAP, the Society for Adolescent Health and Medicine, the American College of Obstetricians and Gynecologists, the North American Society for Pediatric and Adolescent Gynecology, and the American Academy of Family Physicians, of the need for policies and advocacy related to adolescent health and well-being;

sustained funding for research to further elucidate the biological basis of the growth and development of adolescents and how they affect adolescent behavior;

educational programs and adequate financial compensation for pediatricians and other health care professionals to support them in providing evidence-based, quality primary care for adolescents;

pediatricians receiving training on how to maintain the clinical setting as a “safe space,” particularly in terms of confidentiality, especially when working with lesbian, gay, bisexual, transgender, and queer or questioning adolescents;

the role of schools, including school nurses and school-based health centers, and their role in promoting healthy adolescent development and providing access to health care;

further education, training, and advocacy for mental health care services that specifically address the needs of adolescents, preferably as part of a medical home model, stressing the importance of mental health for all youth;

federal confidentiality protection for mental health and reproductive services, as is currently provided in many states;

innovative postresidency training programs to increase the number of adolescent-trained pediatric providers in the workforce;

improved access to medical homes for all adolescents to ensure access to preventive medical care;

affiliation of middle and high schools with a physician trained to care for adolescents, unless the student already has access to comprehensive adolescent health services;

education for pediatricians so that they are aware of the laws regarding confidential care of adolescents in their states; and

familiarity with community resources for confidential reproductive and mental health care if they cannot provide confidential care themselves. Pediatricians who are unable to provide these services should learn about local community resources that provide confidential reproductive and mental health care.

The AAP recommends the following strategies targeted at improving financing for the health care of adolescents:

Federal and state agencies should increase their efforts to further reduce the number of adolescents who are not insured or who lack comprehensive and affordable health insurance.

The Centers for Medicare and Medicaid Services should implement its regulatory authority to update its standards for essential health benefits, as defined in the Patient Protection and Affordable Care Act, in the 2 categories of mental and behavioral health services and pediatric services. These essential health benefits should be consistent with the full scope of benefits outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (including health supervision visits, recommended immunizations, screening for high-risk conditions, and adequate counseling and treatment of conditions related to sexual, reproductive, mental, and behavioral health and substance use disorder). In this way, all adolescents can access the full range of services needed during this developmentally critical period to secure optimal physical and mental health on entry into midadulthood.

All health plans should provide preventive services without member cost sharing. In addition, to reduce financial barriers to care for adolescents, payers should limit the burden on families by reducing or eliminating copayments and eliminating coinsurance for visits related to anticipatory guidance and/or treatment of sexual and reproductive health, behavioral health, and immunization visits.

To provide sufficient payment to physicians and other health care providers for medical services to adolescents, insurers’ claims systems should recognize and pay for all preventive medicine Current Procedural Terminology codes related to services for health and behavior assessment, counseling, risk screening, and/or appropriate interventions recommended in Bright Futures : Guidelines for Health Supervision of Infants, Children, and Adolescents. These services should not be bundled under a single health maintenance Current Procedural Terminology code.

Government and private insurance payers should increase the relative value unit allocation and level of payment for pediatricians delivering care and clinical preventive services to adolescents to a level that is commensurate with the time and effort expended, including health maintenance services, screening, and counseling.

The Centers for Medicare and Medicaid Services should mandate that payers provide enhanced access to cost-effective and clinically sound behavioral health services for adolescents, ensure that payment for all mental health services is more equitable with payment provided for medical and surgical services, and ensure that pediatricians are paid for mental health services provided during health maintenance and follow-up visits.

American Academy of Pediatrics

Confidentiality Protections for Adolescents and Young Adults in the Health Care Billing and Insurance Claims Process: http://pediatrics.aappublications.org/content/137/5/e20160593

Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth: http://pediatrics.aappublications.org/content/pediatrics/132/1/e297.full.pdf

Society for Adolescent Health and Medicine

Resources for adolescents and parents are online resources aimed specifically at adolescents and their parents. Health care providers and youth-serving professionals can offer these additional resources or print a 1-page reference sheet (PDF) for adolescents and parents looking for additional information, including support groups, peer networks, helplines, treatment locators, and advocacy opportunities.

Mental Health Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Mental-Health/Mental-Health-Resources-For-Adolesc.aspx

Mental Health Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Mental-Health/Mental-Health-Resources-For-Parents-of-Adolescents.aspx

Substance Use Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Substance-Use/Substance-Use-Resources-For-Adolesc.aspx

Substance Use Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Substance-Use/Substance-Use-Resources-For-Parents-of-Adolesc.aspx

Confidentiality in Health Care Resources for Adolescents and Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Confidentiality/Confidentiality-Resources-For-Adolesc.aspx

Sexual and Reproductive Health Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Sexual-Reproductive-Health/Sexual-Reproductive-Health-Resources-For-Adolesc.aspx

Sexual and Reproductive Health Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Sexual-Reproductive-Health/SandRH-Resources-For-Parents-of-Adolesc.aspx

Physical and Psychosocial Development Resources for Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Physical-and-Psychosocial-Development/Physical-Pschosocial-Develop-Resources-For-Adolesc.aspx

Physical and Psychosocial Development Resources for Parents of Adolescents: http://www.adolescenthealth.org/Topics-in-Adolescent-Health/Physical-and-Psychosocial-Development/Physical-Psych-Resources-For-Parents-of-Adolesc.aspx

Transition Resources

General resources.

National Health Care Transition Center ( www.gottransition.org )

Family Voices, Inc ( www.familyvoices.org )

National Alliance to Advance Adolescent Health ( www.thenationalalliance.org )

Transition Care Plans

AAP/National Center for Medical Home Implementation ( www.medicalhomeinfo.org/how/care_delivery/transitions.aspx )

British Columbia Ministry of Children and Family Development, “Transition Planning for Youth With Special Needs” ( www.mcf.gov.bc.ca/spec_needs/pdf/support_guide.pdf )

University of Washington, Adolescent Health Transition Project ( http://depts.washington.edu/healthtr )

Transition Assessment and Evaluation Tools

AAP/National Center for Medical Home Implementation ( www.medicalhomeinfo.org/health/trans.html )

JaxHATS, evaluation tools for youth and caregivers and training materials for medical providers ( www.jaxhats.ufl.edu/docs )

Texas Children's Hospital transition template ( http://leah.mchtraining.net/bcm/resources/tracs )

Carolina Health and Transition Project ( www.mahec.net/quality/chat.aspx?a=10 )

Wisconsin Community of Practice on Transition ( www.waisman.wisc.edu/wrc/pdf/pubs/THCL.pdf )

National Alliance to End Homelessness

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Article Contents

Literature review, alive program, implications for school social work practice.

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Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program

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Jason Scott Frydman, Christine Mayor, Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program, Children & Schools , Volume 39, Issue 4, October 2017, Pages 238–247, https://doi.org/10.1093/cs/cdx017

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Middle-school-age children are faced with a variety of developmental tasks, including the beginning phases of individuation from the family, building peer groups, social and emotional transitions, and cognitive shifts associated with the maturation process. This article summarizes how traumatic events impair and complicate these developmental tasks, which can lead to disruptive behaviors in the school setting. Following the call by Walkley and Cox for more attention to be given to trauma-informed schools, this article provides detailed information about the Animating Learning by Integrating and Validating Experience program: a school-based, trauma-informed intervention for middle school students. This public health model uses psychoeducation, cognitive differentiation, and brief stress reduction counseling sessions to facilitate socioemotional development and academic progress. Case examples from the authors’ clinical work in the New Haven, Connecticut, urban public school system are provided.

Within the U.S. school system there is growing awareness of how traumatic experience negatively affects early adolescent development and functioning ( Chanmugam & Teasley, 2014 ; Perfect, Turley, Carlson, Yohannan, & Gilles, 2016 ; Porche, Costello, & Rosen-Reynoso, 2016 ; Sibinga, Webb, Ghazarian, & Ellen, 2016 ; Turner, Shattuck, Finkelhor, & Hamby, 2017 ; Woodbridge et al., 2016 ). The manifested trauma symptoms of these students have been widely documented and include self-isolation, aggression, and attentional deficit and hyperactivity, producing individual and schoolwide difficulties ( Cook et al., 2005 ; Iachini, Petiwala, & DeHart, 2016 ; Oehlberg, 2008 ; Sajnani, Jewers-Dailley, Brillante, Puglisi, & Johnson, 2014 ). To address this vulnerability, school social workers should be aware of public health models promoting prevention, data-driven investigation, and broad-based trauma interventions ( Chafouleas, Johnson, Overstreet, & Santos, 2016 ; Johnson, 2012 ; Moon, Williford, & Mendenhall, 2017 ; Overstreet & Chafouleas, 2016 ; Overstreet & Matthews, 2011 ). Without comprehensive and effective interventions in the school setting, seminal adolescent developmental tasks are at risk.

This article follows the twofold call by Walkley and Cox (2013) for school social workers to develop a heightened awareness of trauma exposure's impact on childhood development and to highlight trauma-informed practices in the school setting. In reference to the former, this article will not focus on the general impact of toxic stress, or chronic trauma, on early adolescents in the school setting, as this work has been widely documented. Rather, it begins with a synthesis of how exposure to trauma impairs early adolescent developmental tasks. As to the latter, we will outline and discuss the Animating Learning by Integrating and Validating Experience (ALIVE) program, a school-based, trauma-informed intervention that is grounded in a public health framework. The model uses psychoeducation, cognitive differentiation, and brief stress reduction sessions to promote socioemotional development and academic progress. We present two clinical cases as examples of trauma-informed, school-based practice, and then apply their experience working in an urban, public middle school to explicate intervention theory and practice for school social workers.

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

Traumatic experiences may create difficulty with developing and differentiating another person's point of view (that is, mentalization) due to the formation of rigid cognitive schemas that dictate notions of self, others, and the external world ( Frydman & McLellan, 2014 ). For early adolescents, the ability to diversify a single perspective with complexity is central to modulating affective experience. Without the capacity to diversify one's perspective, there is often difficulty differentiating between a nonthreatening current situation that may harbor reminders of the traumatic experience and actual traumatic events. Incumbent on the school social worker is the need to help students understand how these conflicts may trigger a memory of harm, abandonment, or loss and how to differentiate these past memories from the present conflict. This is of particular concern when these reactions are conflated with more common middle school behaviors such as withdrawing, blaming, criticizing, and gossiping ( Card, Stucky, Sawalani, & Little, 2008 ).

Encouraging cognitive discrimination is particularly meaningful given that the second social developmental task for early adolescents is the re-orientation of their primary relationships with family toward peers ( Henderson & Thompson, 2010 ). This shift may become complicated for students facing traumatic stress, resulting in a stunted movement away from familiar connections or a displacement of dysfunctional family relationships onto peers. For example, in the former, a student who has witnessed and intervened to protect his mother from severe domestic violence might believe he needs to sacrifice himself and be available to his mother, forgoing typical peer interactions. In the latter, a student who was beaten when a loud, intoxicated family member came home might become enraged, anxious, or anticipate violence when other students raise their voices.

Cognitive Development and Emotional Regulation

During normative early adolescent development, the prefrontal cortex undergoes maturational shifts in cognitive and emotional functioning, including increased impulse control and affect regulation ( Wigfield, Lutz, & Wagner, 2005 ). However, these developmental tasks can be negatively affected by chronic exposure to traumatic events. Stressful situations often evoke a fear response, which inhibits executive functioning and commonly results in a fight-flight-freeze reaction. If a student does not possess strong anxiety management skills to cope with reminders of the trauma, the student is prone to further emotional dysregulation, lowered frustration tolerance, and increased behavioral problems and depressive symptoms ( Iachini et al., 2016 ; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ).

Typical cognitive development in early adolescence is defined by the ambiguity of a transitional stage between childhood remedial capacity and adult refinement ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Casey and Caudle (2013) found that although adolescents performed equally as well as, if not better than, adults on a self-control task when no emotional information was present, the introduction of affectively laden social cues resulted in diminished performance. The developmental challenge for the early adolescent then is to facilitate the coordination of this ever-shifting dynamic between cognition and affect. Although early adolescents may display efficient and logically informed behaviors, they may struggle to sustain these behaviors, especially in the presence of emotional stimuli ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Because trauma often evokes an emotional response ( Johnson & Lubin, 2015 ), these findings insinuate that those early adolescents who are chronically exposed will have ongoing regulation difficulties. Further empirical findings considering the cognitive effects of trauma exposure on the adolescent brain have highlighted detriments in working memory, inhibition, memory, and planning ability ( Moradi, Neshat Doost, Taghavi, Yule, & Dalgleish, 1999 ).

Using a Public Health Framework for School-Based, Trauma-Informed Services

The need for a more informed and comprehensive approach to addressing trauma within the schools has been widely articulated ( Chafouleas et al., 2016 ; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011 ; Jaycox, Kataoka, Stein, Langley, & Wong, 2012 ; Overstreet & Chafouleas, 2016 ; Perry & Daniels, 2016 ). Overstreet and Matthews (2011) suggested that using a public health model to address trauma in schools will promote prevention, early identification, and data-driven investigation and yield broad-based intervention on a policy and communitywide level. A public health approach focuses on developing interventions that address the underlying causal processes that lead to social, emotional, and cognitive maladjustment. Opening the dialogue to the entire student body, as well as teachers and administrators, promotes inclusion and provides a comprehensive foundation for psychoeducation, assessment, and prevention.

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

Note: ALIVE = Animating Learning by Integrating and Validating Experience.

Psychoeducation

The classroom is a place traditionally dedicated to academic pursuits; however, it also serves as an indicator of trauma's impact on cognitive functioning evidenced by poor grades, behavioral dysregulation, and social turbulence. ALIVE practitioners conduct weekly trauma-focused dialogues in the classroom to normalize conversations addressing trauma, to recruit and rehearse more adaptive cognitive skills, and to engage in an insight-oriented process ( Sajnani et al., 2014 ).

Using a parable as a projective tool for identification and connection, the model helps students tolerate direct discussions about adverse experiences. The ALIVE practitioner begins each academic year by telling the parable of a woman named Miss Kendra, who struggled to cope with the loss of her 10-year-old child. Miss Kendra is able to make meaning out of her loss by providing support for schoolchildren who have encountered adverse experiences, serving as a reminder of the strength it takes to press forward after a traumatic event. The intention of this parable is to establish a metaphor for survival and strength to fortify the coping skills already held by trauma-exposed middle school students. Furthermore, Miss Kendra offers early adolescents an opportunity to project their own needs onto the story, creating a personalized figure who embodies support for socioemotional growth.

Following this parable, the students’ attention is directed toward Miss Kendra's List, a poster that is permanently displayed in the classroom. The list includes a series of statements against adolescent maltreatment, comprehensively identifying various traumatic stressors such as witnessing domestic violence; being physically, verbally, or sexually abused; and losing a loved one to neighborhood violence. The second section of the list identifies what may happen to early adolescents when they experience trauma from emotional, social, and academic perspectives. The practitioner uses this list to provide information about the nature and impact of trauma, while modeling for students and staff the ability to discuss difficult experiences as a way of connecting with one another with a sense of hope and strength.

Furthermore, creating a dialogue about these issues with early adolescents facilitates a culture of acceptance, tolerance, and understanding, engendering empathy and identification among students. This fostering of interpersonal connection provides a reparative and differentiated experience to trauma ( Hartling & Sparks, 2008 ; Henderson & Thompson, 2010 ; Johnson & Lubin, 2015 ) and is particularly important given the peer-focused developmental tasks of early adolescence. The positive feelings evoked through classroom-based conversation are predicated on empathic identification among the students and an accompanying sense of relief in understanding the scope of trauma's impact. Furthermore, the consistent appearance of and engagement by the ALIVE practitioner, and the continual presence of Miss Kendra's list, effectively counters traumatically informed expectations of abandonment and loss while aligning with a public health model that attends to the impact of trauma on a regular, systemwide basis.

Participatory and Somatic Indicators for Informal Assessment during the Psychoeducation Component of the ALIVE Intervention

Notes: ALIVE = Animating Learning by Integrating and Validating Experience. Examples are derived from authors’ clinical experiences.

In addition to behavioral symptoms, the content of conversation is considered. All practitioners in the ALIVE program are mandated reporters, and any content presented that meets criteria for suspicion of child maltreatment is brought to the attention of the school leadership and ALIVE director. According to Johnson (2012) , reports of child maltreatment to the Connecticut Department of Child and Family Services have actually decreased in the schools where the program has been implemented “because [the ALIVE program is] catching problems well before they have risen to the severity that would require reporting” (p. 17).

Case Example 1

The following demonstrates a middle school classroom psychoeducation session and assessment facilitated by an ALIVE practitioner (the first author). All names and identifying characteristics have been changed to protect confidentiality.

Ms. Skylar's seventh grade class comprised many students living in low-income housing or in a neighborhood characterized by high poverty and frequent criminal activity. During the second week of school, I introduced myself as a practitioner who was here to speak directly about difficult experiences and how these instances might affect academic functioning and students’ thoughts about themselves, others, and their environment.

After sharing the Miss Kendra parable and list, I invited the students to share their thoughts about Miss Kendra and her journey. Tyreke began the conversation by wondering whether Miss Kendra lost her child to gun violence, exploring the connection between the list and the story and his own frequent exposure to neighborhood shootings. To transition a singular connection to a communal one, I asked the students if this was a shared experience. The majority of students nodded in agreement. I referred the students back to the list and asked them to identify how someone's school functioning or mood may be affected by ongoing neighborhood gun violence. While the students read the list, I actively monitored reactions and scanned for inattention and active avoidance. Performing both active facilitation of discussion and monitoring students’ reactions is critical in accomplishing the goals of providing quality psychoeducation and identifying at-risk students for intervention.

After inspection, Cleo remarked that, contrary to a listed outcome on Miss Kendra's list, neighborhood gun violence does not make him feel lonely; rather, he “doesn't care about it.” Slumped down in his chair, head resting on his crossed arms on the desk in front of him, Cleo's body language suggested a somatized disengagement. I invited other students to share their individual reactions. Tyreke agreed that loneliness is not the identified affective experience; rather, for him, it's feeling “mad or scared.” Immediately, Greg concurred, expressing that “it makes me more mad, and I think about my family.”

Encouraging a variety of viewpoints, I stated, “It sounds like it might make you mad, scared, and may even bring up thoughts about your family. I wonder why people have different reactions?” Doing so moved the conversation into a phase of deeper reflection, simultaneously honoring the students’ voiced experience while encouraging critical thinking. A number of students responded by offering connections to their lives, some indicating they had difficulty identifying feelings. I reflected back, “Sometimes people feel something, but can't really put their finger on it, and sometimes they know exactly how they feel or who it makes them think about.”

I followed with a question: “How do you think it affects your schoolwork or feelings when you're in school?” Greg and Natalia both offered that sometimes difficult or confusing thoughts can consume their whole day, even while in class. Sharon began to offer a related comment when Cleo interrupted by speaking at an elevated volume to his desk partner, Tyreke. The two began to snicker and pull focus. By the time they gained the class's full attention, Cleo was openly laughing and pushing his chair back, stating, “No way! She DID!? That's crazy”; he began to stand up, enlisting Tyreke in the process. While this disruption may be viewed as a challenge to the discussion, it is essential to understand all behavior in context of the session's trauma content. Therefore, Cleo's outburst was interpreted as a potential avenue for further exploration of the topic regarding gun violence and difficulties concentrating. In turn, I posed this question to the class: “Should we talk about this stuff? I wonder if sometimes people have a hard time tolerating it. Can anybody think of why it might be important? Sharon, I think you were saying something about this.” While Sharon continued to share, Cleo and Tyreke gradually shifted their attention back to the conversation. I noted the importance of an individual follow-up with Cleo.

Natalia jumped back in the conversation, stating, “I think we talk about stuff like this so we know about it and can help people with it.” I checked in with the rest of the class about this strategy for coping with the impact of trauma exposure on school functioning: “So it sounds like these thoughts have a pretty big impact on your day. If that's the case, how do you feel less worried or mad or scared?” Marta quickly responded, “You could talk to someone.” I responded, “Part of my job here is to be a person to talk to one-on-one about these things. Hopefully, it will help you feel better to get some of that stuff off your chest.” The students nodded, acknowledging that I would return to discuss other items on the list and that there would be opportunities to check in with me individually if needed.

On reflection, Cleo's disruption in the discussion may be attributed to his personal difficulty emotionally managing intrusive thoughts while in school. This clinical assumption was not explicitly named in the moment, but was noted as information for further individual follow-up. When I met individually with Cleo, Cleo reported that his cousin had been shot a month ago, causing him to feel confused and angry. I continued to work with him individually, which resulted in a reduction of behavioral disruptions in the classroom.

In the preceding case example, the practitioner performed a variety of public health tasks. Foremost was the introduction of how traumatic experience may affect individuals and their relationships with others and their role as a student. Second, the practitioner used Miss Kendra and her list as a foundational mechanism to ground the conversation and serve as a reference point for the students’ experience. Finally, the practitioner actively monitored individual responses to the material as a means of identifying students who may require more support. All three of these processes are supported within the public health framework as a means toward assessment and early intervention for early adolescents who may be exposed to trauma.

Individualized Stress Reduction Intervention

Students are seen for individualized support if they display significant externalizing or internalizing trauma-related behavior. Students are either self-referred; referred by a teacher, administrator, or staff member; or identified by an ALIVE practitioner. Following the principle of immediate engagement based on emergent traumatic material, individual sessions are brief, lasting only 15 to 20 minutes. Using trauma-centered psychotherapy ( Johnson & Lubin, 2015 ), a brief inquiry addressing the current problem is conducted to identify the trauma trigger connected to the original harm, fostering cognitive discrimination. Conversation about the adverse experience proceeds in a calm, direct way focusing on differentiating between intrusive memories and the current situation at school ( Sajnani et al., 2014 ). Once the student exhibits greater emotional regulation, the ALIVE practitioner returns the student to the classroom in a timely manner and may provide either brief follow-up sessions for preventive purposes or, when appropriate, refer the student to more regular, clinical support in or out of the school.

Case Example 2

The following case example is representative of the brief, immediate, and open engagement with traumatic material and encouragement of cognitive discrimination. This intervention was conducted with a sixth grade student, Jacob (name and identifying information changed to ensure confidentiality), by an ALIVE practitioner (the second author).

I found Jacob in the hallway violently shaking a trash can, kicking the classroom door, and slamming his hands into the wall and locker. His teacher was standing at the door, distressed, stating, “Jacob, you need to calm down and go to the office, or I'm calling home!” Jacob yelled, “It's not fair, it was him, not me! I'm gonna fight him!” As I approached, I asked what was making him so angry, but he said, “I don't want to talk about it.” Rather than asking him to calm down or stop slamming objects, I instead approached the potential memory agitating him, stating, “My guess is that you are angry for a very good reason.” Upon this simple connection, he sighed and stopped kicking the trash can and slamming the wall. Jacob continued to demonstrate physical and emotional activation, pacing the hallway and making a fist; however, he was able to recount putting trash in the trash can when a peer pushed him from behind, causing him to yell. Jacob explained that his teacher heard him yelling and scolded him, making him more mad. Jacob stated, “She didn't even know what happened and she blamed me. I was trying to help her by taking out all of our breakfast trash. It's not fair.”

The ALIVE practitioner listens to students’ complaints with two ears, one for the current complaint and one for affect-laden details that may be connected to the original trauma to inquire further into the source of the trigger. Affect-laden details in case example 2 include Jacob's anger about being blamed (rather than toward the student who pushed him), his original intention to help, and his repetition of the phrase “it's not fair.” Having met with Jacob previously, I was aware that his mother suffers from physical and mental health difficulties. When his mother is not doing well, he (as the parentified child) typically takes care of the household, performing tasks like cooking, cleaning, and helping with his two younger siblings and older autistic brother. In the past, Jacob has discussed both idealizing his mother and holding internalized anger that he rarely expresses at home because he worries his anger will “make her sick.”

I know sometimes when you are trying to help mom, there are times she gets upset with you for not doing it exactly right, or when your brothers start something, she will blame you. What just happened sounds familiar—you were trying to help your teacher by taking out the garbage when another student pushed you, and then you were the one who got in trouble.

Jacob nodded his head and explained that he was simply trying to help.

I moved into a more detailed inquiry, to see if there was a more recent stressor I was unaware of. When I asked how his mother was doing this week, Jacob revealed that his mother's health had deteriorated and his aunt had temporarily moved in. Jacob told me that he had been yelled at by both his mother and his aunt that morning, when his younger brother was not ready for school. I asked, “I wonder if when the student pushed you it reminded you of getting into trouble because of something your little brother did this morning?” Jacob nodded. The displacement was clear: He had been reminded of this incident at school and was reacting with anger based on his family dynamic, and worries connected to his mother.

My guess is that you were a mix of both worried and angry by the time you got to school, with what's happening at home. You were trying to help with the garbage like you try to help mom when she isn't doing well, so when you got pushed it was like your brother being late, and then when you got blamed by your teacher it was like your mom and aunt yelling, and it all came flooding back in. The problem is, you let out those feelings here. Even though there are some similar things, it's not totally the same, right? Can you tell me what is different?

Jacob nodded and was able to explain that the other student was probably just playing and did not mean to get him into trouble, and that his teacher did not usually yell at him or make him worried. Highlighting this important differentiation, I replied, “Right—and fighting the student or yelling at the teacher isn't going to solve this, but more importantly, it isn't going to make your mom better or have your family go any easier on you either.” Jacob stated that he knew this was true.

I reassured Jacob that I could help him let out those feelings of worry and anger connected to home so they did not explode out at school and planned to meet again. Jacob confirmed that he was willing to do that. He was able to return to the classroom without incident, with the entire intervention lasting less than 15 minutes.

In case example 2, the practitioner was available for an immediate engagement with disturbing behaviors as they were happening by listening for similarities between the current incident and traumatic stressors; asking for specific details to more effectively help Jacob understand how he was being triggered in school; providing psychoeducation about how these two events had become confused and aiding him in cognitively differentiating between the two; and, last, offering to provide further support to reduce future incidents.

Germane to the practice of school social work is the ability to work flexibly within a public health model to attend to trauma within the school setting. First, we suggest that a primary implication for school social workers is not to wait for explicit problems related to known traumatic experiences to emerge before addressing trauma in the school, but, rather, to follow a model of prevention-assessment-intervention. School social workers are in a unique position within the school system to disseminate trauma-informed material to both students and staff in a preventive capacity. Facilitating this implementation will help to establish a tone and sharpened focus within the school community, norming the process of articulating and engaging with traumatic material. In the aforementioned classroom case example, we have provided a sample of how school social workers might work with entire classrooms on a preventive basis regarding trauma, rather than waiting for individual referrals.

Second, in addition to functional behavior assessments and behavior intervention plans, school social workers maintain a keen eye for qualitative behavioral assessment ( National Association of Social Workers, 2012 ). Using this skill set within a trauma-informed model will help to identify those students in need who may be reluctant or resistant to explicitly ask for help. As called for by Walkley and Cox (2013) , we suggest that using the information presented in Table 1 will help school social workers understand, identify, and assess the impact of trauma on early adolescent developmental tasks. If school social workers engage on a classroom level in trauma psychoeducation and conversations, the information in Table 3 may assist with assessment of children and provide a basis for checking in individually with students as warranted.

Third, school social workers are well positioned to provide individual targeted, trauma-informed interventions based on previous knowledge of individual trauma and through widespread assessment ( Walkley & Cox, 2013 ). The individual case example provides one way of immediately engaging with students who are demonstrating trauma-based behaviors. In this model, school social workers engage in a brief inquiry addressing the current trauma to identify the trauma trigger, discuss the adverse experience in a calm but direct way, and help to differentiate between intrusive memories and the current situation at school. For this latter component, the focus is on cognitive discrimination and emotional regulation so that students can reengage in the classroom within a short time frame.

Fourth, given social work's roots in collaboration and community work, school social workers are encouraged to use a systems-based approach in partnering with allied practitioners and institutions ( D'Agostino, 2013 ), thus supporting the public health tenet of establishing and maintaining a link to the wider community. This may include referring students to regular clinical support in or out of the school. Although the implementation of a trauma-informed program will vary across schools, we suggest that school social workers have the capacity to use a public health school intervention model to ecologically address the psychosocial and behavioral issues stemming from trauma exposure.

As increasing attention is being given to adverse childhood experiences, a tiered approach that uses a public health framework in the schools is necessitated. Nevertheless, there are some limitations to this approach. First, although the interventions outlined here are rooted in prevention and early intervention, there are times when formal, intensive treatment outside of the school setting is warranted. Second, the ALIVE program has primarily been implemented by ALIVE practitioners; the results from piloting this public health framework in other school settings with existing school personnel, such as school social workers, will be necessary before widespread replication.

The public health framework of prevention-assessment-intervention promotes continual engagement with middle school students’ chronic exposure to traumatic stress. There is a need to provide both broad-based and individualized support that seeks to comprehensively ameliorate the social, emotional, and cognitive consequences on early adolescent developmental milestones associated with traumatic experiences. We contend that school social workers are well positioned to address this critical public health issue through proactive and widespread psychoeducation and assessment in the schools, and we have provided case examples to demonstrate one model of doing this work within the school day. We hope that this article inspires future writing about how school social workers individually and systemically address trauma in the school system. In alignment with Walkley and Cox (2013) , we encourage others to highlight their practice in incorporating trauma-informed, school-based programming in an effort to increase awareness of effective interventions.

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Understanding Troubled Young Adolescents Who Have Problems at School: Case Studies

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Travis McCoy

Journal of High Institute of Public Health

Dr Safaa Rabea Osman

Background & Objective(s): Emotional and behavioral problems among adolescents represent a considerable public health problem in developing countries. These problems are considered a source of stress for adolescents as well as their families, schools and community. Emotional health and well-being of young people have implications on their self-esteem, behavior, school attendance, educational achievement, social cohesion and future health and life chances. To estimate the prevalence of emotional and behavioral problems and to determine the association between these problems and socio-demographic variables among adolescent students in Assiut district. Methods: A cross sectional study was conducted in randomly selected secondary schools (2 urban and 2 rural) in Assiut district, and 400 students were included in the study. Self-administered questionnaires were used to collect study data which included: personal data, socioeconomic status scale and self-reported version of Strengths and Difficulties Questionnaire (SDQ) (Arabic version) which included 25 items divided into 5 subscales (conduct problems, hyperactivity, emotional symptoms, peer problems and prosocial behavior) Results: About 45 % of adolescents were identified with emotional and/or behavioral problems using the SDQ. These problems included conduct, emotional, peer problems, prosocial and hyperactivity difficulties (36.0%, 42.3%, 5.0%, 28.5% and 24.8% respectively). Emotional difficulties were significantly higher (p value= 0.02) among females (40.4%), while conduct difficulties were more prevalent among males (47.5%). The majority of students with emotional/ behavioral problems (90%) reported high negative impact of such problems that was significantly associated with female sex, rural residents, students of low socioeconomic level and whose mothers were housewives. Conclusion: Screening secondary school adolescents in Assiut district revealed high prevalence of emotional and behavioral problems that was associated with perceived enormous negative impact. Further studies and intervention programs are greatly needed to address adolescent mental health needs.

Journal of Child and Family Studies

Douglas Cullinan , Edward J Sabornie

Esther Mccartney

Students with emotional/behavioral disorders have identified disruptive behaviors that negatively impact their academic performance. The US Department of Education and the American School Counselor Association have supported the use of school-wide Multitiered Systems of Support (MTSS) to reinforce pro-social behaviors for all students, but to also ensure the development of targeted and intensive interventions for students who need more support. As stakeholders, school counselors are often involved in the development and implementation of MTSS’s tiered interventions to provide support to all students, especially those with disabilities. Using consensual qualitative research study, the research team aimed to examine elementary school counselor’s perspective in developing, implementing, and assessing behavioral plans within an MTSS framework and working with students with EBD. The results, implications, and suggestions for future research will also be presented

Evidence-Based Practice in Child and Adolescent Mental Health

Jennifer Keenan

Fariha Iram

Present study was conducted to find the profiles and patterns of emotional and behavioral problems in adolescents from general population who had never been reported or diagnosed. A sample of 300 adolescents from public and private schools of Lahore, (13 to 17 years old, Mean=14.8) participated in the study. Participants completed the self-report standardized questionnaires, Youth Self-Report (YSR: Achenbach, & Rescorla, 2001) in Urdu language. The study revealed that majority of the adolescents was found to have normal behavior but a noticeable number of adolescents show emotional and behavioral problems. About 2 to 15% adolescents were found in clinical range and 3 to 10% in border line range of problems. Findings also suggest that in broadband scales externalizing problems were most prevalent in adolescents i.e. 15% and among DSM oriented problems conduct problem and anxiety problem were found most common in adolescents.

Revija za elementarno izobraževanje

Katja Vrhunc Pfeifer

Employees in education, especially in residential treatment centres, face crisis situations as a result of emotional and behavioural problems/disorders of children and adolescents. They most often face various types of violence, self-aggression, use of illicit substances and abuse. Cases of children and adolescents with mental health problems are frequent. Crisis interventions differ with the complexity of the situation, and regardless of the approach, an appropriate relationship is crucial to any solution. The purpose of this article is to present and elaborate the most common crisis situations and some successful interventions in such cases.

International Research Journal Commerce arts science

Adolescents are highly vulnerable to psychiatric disorders. This study aimed to explore the prevalence and patterns of behavioural and emotional problems in adolescents. It was also aimed to explore associations between socio environmental stressors and maladaptive outcomes. A school based cross-sectional study was conducted between January and July 2008. A stratified random sampling was done. 1150 adolescents in 12 to 18 year age group in grades 7 to 12 in 10 co-educational schools (government run and private) were the subjects of the study. Behavioural and emotional problems were assessed using Youth Self-Report (2001) questionnaire. Family stressors were assessed using a pre-tested 23 item questionnaire. Univariate and multivariate analysis were performed. Multiple logistic regression analysis was also done.

Science Park Research Organization & Counselling

The aim of this study is to find out numerous situations and counseling approaches that school counselors are likely to encounter during their training and the first five years of practice. We believe that attention to the various theoretical approaches that can be applied to resolve different cases will better prepare school counselors to deal with each dilemma using an efficient approach to school counseling. Thus it is important to know the most common cases seen and counseling approaches used in school counseling to prepare school counseling students to the profession. In order to achieve data about school counseling cases and approaches, fourteen high school counselors from public and private schools are interviewed with semi structured questionnaire prepared by researchers. School counselors are asked about the cases that they see the most, the approaches that they use with these cases, support systems that they seek for and therapy trainings that they take after their graduation from college. Study group is settled with random sampling from schools in different districts of Istanbul that have school counselor with at least one year experience. The results are analyzed with thematic analysis.

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Teenagers' struggle for mental health care: 'I needed help quite badly'

As GPs warn young people could suffer harm because of treatment delays, one 16-year-old talks about her experience

• Lack of NHS mental health services puts under-18s at risk, say GPs

I ndia knows all about the importance of getting timely help for mental health problems. “I have had issues since late primary school although I only recognised it in myself about four years ago,” said the 16-year-old from south-west London. “I had body image issues and and general anxiety about odd things like talking to strangers. I had issues of not eating and binge eating, purging, stuff like that.”

She says that when she first confided in her mother about three years ago and sought help, her mother took her straight to the GP. India was referred to NHS child and adolescent mental health services (Camhs), and she estimates that it took her a couple of weeks to be seen. She believes that if she had been forced to wait longer, it could have had dire consequences for her.

“At that stage it was very important that I was seen quickly,” she says. “I was not great and I needed help quite badly.”

The 12 sessions she had helped her but her problems did not go away and a couple of months ago India, in her own words, relapsed.

She went back to the GP and was referred to Camhs again. After an assessment, the eating disorders team decided not to take her case but the psychotherapy team said they would see her. She was told she would have to wait more than a month to be seen by the psychotherapy team, which, she says politely, “did seem like a while”.

An interim measure was put in place, although she stresses that it was not a substitute for receiving proper professional help. “The psychologist who assessed me got in touch with my school and within 12 hours they arranged counselling within the school,” she says. “It’s more just a place to talk about feelings. It’s nice to have some space to talk about it but it’s not necessarily benefiting my recovery, it’s not helping with the eating disorder stuff. It’s just a good place to let things out, it’s probably helping it to not get worse.”

Asked if she thinks it would have been difficult to cope in that month had the school counselling not been there to plug the gap, she answers straight away: “100%.”

India’s experience illustrates the importance of being seen quickly, yet she has been relatively lucky. GPs say delays can be as long as 18 months because Camhs services are overwhelmed.

While India’s wait was relatively short, that does not mean she has been immune to the fallout from the pressure put on Camhs. She believes that the 12 sessions she was entitled to when she first went to her GP two years ago were not enough for her needs.

“At the end of the counselling sessions I felt like I have just broken through the barrier, I was just getting to the breakthrough,” she says. “I wish I had got more [sessions] at that point. It may well have helped things not being as bad as they were a couple of months ago. You have to build on your relationship with your counsellor.”

But she is well aware that demand for CBT and other Camhs services means resources are limited. “At the same time, I do get that they have got a number of people who need help and I’d had my dose.”

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Psychosocial Development Research in Adolescence: a Scoping Review

• Original Article
• Published: 01 February 2022
• Volume 30 , pages 640–669, ( 2022 )

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• Nuno Archer de Carvalho   ORCID: orcid.org/0000-0001-6620-0804 1 , 2 &
• Feliciano Henriques Veiga   ORCID: orcid.org/0000-0002-2977-6238 1 , 2  

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Erikson’s psychosocial development is a well-known and sound framework for adolescent development. However, despite its importance in scientific literature, the scarcity of literature reviews on Erikson’s theory on adolescence calls for an up-to-date systematization. Therefore, this study’s objectives are to understand the extent and nature of published research on Erikson’s psychosocial development in adolescence (10–19 years) in the last decade (2011–2020) and identify directions for meaningful research and intervention. A scoping review was conducted following Arksey and O’Malley’s framework, PRISMA-ScR guidelines, and a previous protocol, including a comprehensive search in eight databases. From 932 initial studies, 58 studies were selected. These studies highlighted the burgeoning research on Erikson’s approach, with a more significant representation of North American and European studies. The focus of most studies was on identity formation, presenting cross-cultural evidence of its importance in psychosocial development. Most of the studies used quantitative designs presenting a high number of different measures. Regarding topics and variables, studies emphasized the critical role of identity in adolescents’ development and well-being and the relevance of supporting settings in psychosocial development. However, shortcomings were found regarding the study of online and school as privileged developmental settings for adolescents. Suggestions included the need to consider the process of identity formation in the context of lifespan development and invest in supporting adolescents’ identity formation. Overall, conclusions point out Erikson’s relevance in understanding adolescents’ current challenges while offering valuable research and intervention directions to enhance adolescent growth potential.

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Acknowledgements

The authors thank Conceição Martins and Filomena Covas for their help in assessing methodological options and text revision and Rita Fonseca and Sandra Torres for their advice regarding English accuracy.

This work was supported by the FCT — Fundação para a Ciência e a Tecnologia, IP, within the scope of the UIDEF — Unidade de Investigação e Desenvolvimento em Educação e Formação, under the reference UID/CED/04107/2020.

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NC and FV worked on the protocol and methodological design of the review. NC carried out the research, analyzed the studies, and presented the initial text for the results and their discussion. FV oversaw the conceptualization, research, and analysis of the studies. Both authors read and approved the final manuscript.

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de Carvalho, N.A., Veiga, F.H. Psychosocial Development Research in Adolescence: a Scoping Review. Trends in Psychol. 30 , 640–669 (2022). https://doi.org/10.1007/s43076-022-00143-0

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Case Study: Adolescence

Helping young people say 'no': the prevalence of risk-taking behaviour and what works to reduce it.

How many adolescents smoke, drink and take drugs and what kind of interventions work best to stop them?

Adolescent years are a notoriously challenging time, as children go through the biggest changes since their first year of life. It's this life stage that presents the greatest risk to future health, with damaging habits most often picked up between the ages of 11 and 19.

Research under the adolescent theme has examined the trends in health risk behaviours and reviewed interventions designed to prevent them, in order to inform UK health policy for this susceptible group.

Key Points:

• Two studies looked at trends in risky behaviours in adolescents and interventions designed to prevent them
• Smoking, drinking and drug use have individually declined, but a core of young people remain who engage in all three
• School-based interventions designed to empower young people to say 'no' have proved most effective at reducing multiple harmful behaviours

This case study is for the  Adolescence  theme.

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• Helping young people say no
• Cutting the risk
• Mental health in children
• Type 2 diabetes in children
• Family finances and disability
• Stories from data and young people
• Growing up happy in England

Our Case Studies

We have complied a series of publications and case studies to illustrate the type of projects we work on and how we support child health policy-making in England

• The Healthy Child
• Healthcare provision
• Mental health
• Adolescence
• Long-term conditions
• Sociology of health and illness:
• Health economics
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• Food, health and nutrition
• Mental wellbeing
• Mental health

Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

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By completing a case study participants will:

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• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
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Case studies prompt users to practice making decisions that are:

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Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
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• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
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The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
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There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
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• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
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• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
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Mental Health Problems among Young People—A Scoping Review of Help-Seeking

Katrin häggström westberg.

1 School of Health and Welfare, Halmstad University, SE-301 18 Halmstad, Sweden; [email protected] (M.N.); [email protected] (J.M.N.); [email protected] (P.S.)

2 Affecta Psychiatric Clinic, Sperlingsgatan 5, SE-302 48 Halmstad, Sweden

Maria Nyholm

Jens m. nygren, petra svedberg, associated data.

Documentation on the database searches, the stepped screening process and the thematic analysis are available from the corresponding author upon reasonable request.

Young people’s mental health is a public health priority, particularly as mental health problems in this group seem to be increasing. Even in countries with supposedly good access to healthcare, few young people seek support for mental health problems. The aim of this study was twofold, firstly to map the published literature on young people’s experiences of seeking help for mental health problems and secondly to validate whether the Lost in Space model was adaptable as a theoretical model of the help-seeking process described in the included articles in this scoping review. A scoping review was conducted in which we searched for literature on mental health help-seeking with a user perspective published between 2010 and 2020 in different databases. From the 2905 studies identified, we selected 12 articles for inclusion. The review showed how young people experience unfamiliarity and insecurity with regard to issues related to mental health and help-seeking. A strong wish for self-reliance and to safe-guard one’s own health were consistent among young people. Support structures were often regarded as inaccessible and unresponsive. There was a high level of conformity between the model on help-seeking and the analysed articles, reinforcing that help-seeking is a dynamic and psychosocial process.

1. Introduction

Young people’s mental health is a major public health issue. Mental health problems among young people contribute to impaired physical and mental health extending into adulthood [ 1 , 2 , 3 ]. Promoting young people’s mental health is an integral component in ensuring their development and improving health and social wellbeing across their lifespan [ 3 ]. In light of the high rate of mental health problems among this group, a corresponding high rate of help-seeking and use of support resources might be assumed; however, few young people actually seek and eventually access professional help. Delays in looking for help can be lengthy and are prevalent even in countries with good access to healthcare [ 4 , 5 , 6 , 7 , 8 , 9 ]. The process of searching for support involves barriers that relate to both individual and social context factors [ 8 , 10 ]. This contributes to the complexity involved in offering interventions to support them and highlights the need to understand the help-seeking process, whether online or in person, for young people with mental health problems.

Help-seeking is usually described as a rational, agency-based process where the individual plans, decides and acts on symptoms [ 11 ]. However, research also describes that help-seeking is not solely an individual act; rather, it is influenced by social factors throughout the process. Societal, organizational support structures set the limits and stipulate the opportunities to seek help [ 12 ]. Help-seeking thus depends both on factors at the individual level and structural resources for young people. Many studies that examine help-seeking for mental health among young people using cross-sectional designs on either the general community, or school populations [ 8 , 13 ] are based on descriptive data that is often generated through surveys, and focus on attitudes, rather than on experiences [ 14 ]. The main focus of previous literature has been on individual factors, such as mental health literacy, and less information can be found on the structural factors involved [ 8 , 13 ]. This calls for a deeper and more nuanced understanding of young people’s mental health help-seeking regarding contextual factors, with particular focus on their experiences and perspectives. An improved understanding of help-seeking for mental health problems can be used to improve practice and service delivery, and ultimately benefit young people’s mental health.

In this study, qualitative research exploring the help-seeking process in Sweden from the perspectives of young people with mental health problems was used as the theoretical point of departure [ 15 ]. Within this previous research, we produced a theoretical model of help-seeking, the Lost in Space model [ 15 ]. It showed how help-seeking was a long, non-sequential and dynamic process. In this research, young people described a process of moving in and out of the three help-seeking phases, Drifting, Navigating and Docking. Drifting was characterized by insecurity and unfamiliarity, with a lack of knowledge of mental health and the support system; Navigating was characterized by structural obstacles, a fragmented support system and wishes for help; while Docking was characterized by experiences of finding help. For the purpose of confirmability and usefulness, it is essential to validate and understand if the model can be applied to other settings and contexts—for example, whether the model is consistent with the experiences of help-seeking by young people in other countries. Therefore, the aim of this study was twofold, firstly to map the published literature on young people’s experiences of seeking help for mental health problems and secondly to validate whether the previously published Lost in Space model was adaptable as a theoretical model of the help-seeking process described in the included articles in this scoping review.

A scoping review was deemed the most preferable approach to responding to this broad area of interest [ 16 ]. Scoping reviews maintain a broad window for inclusion of studies of a range of types and levels of quality [ 17 ]. Our scoping review protocol was developed using the scoping review methodological framework proposed by Arksey and and O’Malley, entailing five framework stages. The framework was further developed by Levac, with a qualitative elaboration of the material [ 17 , 18 ]. These stages provide a clear sequential order in which to identify and collect studies, chart the data and report results, and the scoping review protocol was used for guiding the research.

2.1. Stage 1: Identifying the Research Question

A multidisciplinary research team with experience of health science research, including public health, nursing, and youth research was assembled to discuss and clarify the scope of inquiry and identify research questions. The target population of interest was defined as young people (ages 11–25) with experience of mental health problems, and experience of help-seeking in that regard. Mental health problems were defined as commonly experienced problems of depression or anxiety, as well as behavioural and emotional problems. Considering the concept of help-seeking, the term is used to understand the delay of care and to explore possible pathways for mental health promotion. For this study, help-seeking was defined as seeking and/or accessing professional help for mental health problems. Conceptually, help-seeking was regarded as a process influenced by social, psychological and contextual factors [ 12 ]. The research questions for this study were (1) to map general characteristics of published literature focusing on the young people’s experiences of seeking help for mental health problems, and (2) to explore how the previously published theoretical model Lost in Space could be further refined and complemented via an abductive approach, drawing the final set of categories and themes informed by the papers reviewed in this study.

2.2. Stage 2: Identifying Relevant Studies

A search strategy was developed in collaboration with a librarian to develop search terms using subject heading terms adapted to each of the three included databases: Medline/PubMed, PsycINFO and CINAHL. The search terms for the target population were adolescents, young and emerging adults; for the health outcome, they were mental health, depression, anxiety, and for the concept of interest, the term was help-seeking. Other criteria were limiting searches to studies written in English, and studies being published between 2010 and 2020 due to rapidly evolving research and policy changes in this area as well as the increased rates of mental health problems among young people. The searches were conducted during summer 2020. See Table S1 (Supplementary Materials) for the full search strategy.

Inclusion and Exclusion Criteria

Studies were eligible for inclusion if they investigated help-seeking among young people with mental health problems aged between 11 and 25. Only studies that specifically investigated young people’s own perspectives of experiencing or having experienced mental health problems and help-seeking were included. Since the intention was to understand help-seeking among young people with common mental health problems, studies on particular target groups or populations were excluded, such as studies on specific treatment interventions. Likewise, studies focusing on help-seeking attitudes or potential help-seeking intentions of general populations without personal experience of mental health help-seeking were excluded. Studies had to specifically focus on adolescents or young people; thus, studies with a more population-based perspective, or encompassing wider age groups, were excluded. Theses were not included as it was assumed that any material within a thesis on help-seeking, that otherwise fitted the inclusion criteria, would appear as published articles. Comments, editorials, consensus statements and other opinion-based papers were excluded, along with studies solely exploring the perspectives of others, other than the help-seekers themselves (e.g., families, helpers, professionals, etc.).

2.3. Stage 3: Study Selection

All identified studies from the searches were imported to the management reference tool EndNote, version 20.1, and duplicates were removed. Screening was carried out with a sequential, stepped approach and an iterative process between the authors of the study [ 18 ]. In the first step of study selection, titles and periodically abstracts were screened by KHW, who discarded obviously irrelevant studies based on the exclusion criteria. In the second step of study selection, abstracts of the remaining studies were screened independently by three of the authors (KHW, PS and MN) to determine eligibility based on the defined inclusion and exclusion criteria. Disagreements between the authors were discussed with a fourth author (JN) until consensus was reached. The third step required KHW to examine the full-text of the remaining articles to determine eligibility, subsequently discussing the articles with all authors. A PRISMA diagram ( Figure 1 ) details the screening process with number of papers retrieved and selection of the included studies.

Article search and selection process—PRISMA diagram.

2.4. Stage 4: Charting the Data

Data charting was conducted in accordance with scoping review standards using a template that was developed for the extraction of information from each study regarding the following: authorship, year of publication, journal, source of origin, design, population and age group, aims of the study, methodology and important results [ 17 ]. A descriptive, numerical summarization was made, presenting the extent, nature and scope of included studies [ 18 ], see Table S2 (Supplementary Materials) for the full bibliographic information of the included studies.

2.5. Stage 5: Collating, Summarizing and Reporting Results

A qualitative thematic analysis was conducted to examine and aggregate the findings from the help-seeking process, as depicted in the included studies [ 18 ]. For the thematic analysis, an abductive approach was taken [ 19 ], based on the previous Lost in Space model [ 15 ]. According to such an approach, hypotheses can be explicated through deduction and verified through induction. Abduction thus means that new explanations are based on background theories and, whilst taking empirical material and restrictions into account, may lead to elaborated knowledge [ 19 ].

The analysis began with reading the findings in the included articles several times, then identifying and inductively coding text and quotes [ 20 ] in relation to young people’s experiences of seeking help for mental health problems. In this phase, data were inductively scrutinized to discover experiences, expressions and perspectives, keeping codes close to the data; for example, the text ‘Some young people reported that discussing uncomfortable emotions was unfamiliar’ was coded as the theme Unfamiliarity. The deductive process followed, in which the theoretical model Lost in Space was employed. It describes help-seeking among young people with mental health problems in a Swedish context [ 15 ]. A categorization matrix was developed based on the model, emanating from the original subcategories and categories, the themes within the subcategories and the properties of themes. The deductive process in the analysis involved going back to the data and placing the inductively derived codes into themes and subcategories of the theoretical model. All themes from the original model were found through coding the analysed articles. Codes from the new material that did not match the original theoretical model subcategories contributed with new aspects to existing themes of the model and, in some cases, generated new themes, thereby broadening the understanding of help-seeking. In one instance, the name of one subcategory was altered to reflect new material. KWH performed the data analysis and, to enhance the quality and validity of the analysis, the data analysis was discussed continuously with all authors.

3.1. Mapping the Characteristics of Published Literature

In total, 1540 articles were identified as potentially relevant records, after duplicates were removed through the database searches. After the first screening of title and abstract, 1207 articles were excluded on the basis of age, format type, content (i.e., not dealing with help-seeking), focusing on specific populations or not being based on a user perspective. In the second round of screening, another 243 articles were excluded due to the eligibility criteria. In the third round of screening, the remaining 90 articles were reviewed in full-text and of these 12 articles met the full set of eligibility criteria.

The characteristics of the included studies are described in Table S2 (Supplementary Materials) . Seven articles were published between 2010 and 2015, and five after 2016. The designs were mostly qualitative, with individual interviews ( n = 9) and focus groups ( n = 7). Seven articles employed a combination of methods (for example, mixed methods), and two articles included information from surveys. The focus of articles covered: social and organizational factors impacting help-seeking, functional concerns, attitudes towards computerized mental health support, attitudes to consulting primary care, perceptions and help-seeking behaviours in schools, exploration and identification of barriers and facilitators in general populations with and without previous experience of mental health support, barriers and facilitators in male groups, links between masculinity and help-seeking, comparisons of groups’ help-seeking strategies and descriptions of experiences, self-management and help-seeking. The recruitment of participants varied, utilising educational settings ( n = 4), youth mental health services ( n = 2), community websites ( n = 1), primary care ( n = 1), youth services ( n = 2), previous participation in longitudinal studies ( n = 2) and community samples ( n = 3). Four articles focused specifically on young males, and four on barriers to help-seeking. Three articles were set in the USA, one in Canada, three in Australia and five in Europe. The age range, 11–25, was seen in a variation of age clusters, with the smallest age range being two years (ages 20–22) and the largest 13 years (ages 12–25); the mean age range covered was six years.

3.2. Examination of the Help-Seeking Process from the Perspectives of Young People

The findings from this examination showed a high level of agreement with the theoretical model Lost in Space. Overall, the results showed that help-seeking was a dynamic and psychosocial process without sequentially fixed stages, where young people expressed an unfamiliarity with, insecurity about and lack of knowledge of mental health issues, a longing for self-reliance and, in some contexts, a presence of stigma. Young people did not consider the support structures to be responsive or accessible. Below, Figure 2 outlines the examination of the help-seeking process from the perspectives of young people. It includes confirmed content of the old model, new content derived from the analysed articles, and elaborations according to the abductive method. The ‘number of meaning units’ refers to coded material in the analysed articles. ‘Original’ refers to subcategories and themes from the Lost in Space model, where findings were corroborated by codes from the analysed articles (‘confirmed content’), other elements that emerged showed further dimensions of experiences that contributed to new perspectives of established subcategories in the model (‘new content’), and some themes that emerged in the analysis were not readily encompassed within the subcategories in the original model (‘new’) (see Figure 2 ).

Examination of the help-seeking process from young people’s perspectives.

3.2.1. Drifting

Drifting, the initial category of the Lost in Space model, encompassed a general feeling of unfamiliarity, lack of knowledge, trivialising oneself and problems due to insecurity often by normalizing and minimizing one’s experiences. Young people’s voices in the analysed articles corroborated Drifting well, through similar expressions and experiences.

Fumbling in Life

In the original model, Fumbling in life encompassed themes of unfamiliarity, insecurity and trivialisation. Likewise, young people in the analysed articles expressed unfamiliarity with both mental health problems and not recognizing oneself. Lack of knowledge was frequently described both with regard to communicating, distinguishing and assessing emotions but also regarding where and when to seek help, leading to a sense of insecurity. Because of this insecurity, young people practised trivialisation, trying to make their problems smaller or unimportant. They also had the impression and fear that their problems would not be sufficient to receive support. In some of the analysed articles, trivialisation was presented as a rational strategy, enabling young people to downplay their problems and rationalizing not actively dealing with them or approaching others for help, whereas, in the original model, trivialisation was carried out due to a sense of insecurity. In this section, no conceptual changes to the original model are suggested.

In the original model, Struggling was characterized by simultaneous descriptions of mental health problems and incessant attempts and strategies to feel better, ambivalence and a longing for self-reliance. These themes re-appeared in the included articles. Mental health problems were described by the participants as emotional problems, panic attacks, sadness, self-harm, anxiety and lack of motivation. Within Struggling in the original model, young people usually referred to mental health problems as being something “within” (internal) rather than originating “outside” (global). However, in several of the analysed articles, the mental health problems were attributed to something “outside”. Hence, young people also related mental health problems to relationships, stress and risk-taking behaviour.

Themes on endeavouring strategies trying to deal with mental health problems were common in the included studies, as was also the case in the Lost in Space model, pointing to the more-or-less continual and relentless attempts and strategies young people performed in order to deal with their problems. Although it was proposed by young people in individual studies that seeking help requires effort, lack of effort was not a dominant issue for young people in either the original model or in most analysed articles. In some articles, an in-depth exploration of the strategies employed was undertaken, according to having an ‘approach’ or ‘avoidant’ character, or gendered differences, adding to the variation in strategies, whereas in the model, an abundance of strategies was ascertained; however, the type of strategy was not explored. Denial was a common strategy in both the original model and in the included articles. In the Lost in Space model, this was described as “shutting off”, with the intent of ignoring feelings and problems. This strategy was directed towards oneself: wanting to manage things, being strong and coping. In some of the analysed articles, denial was presented as relating to a sense of embarrassment, or as being done in order to protect others. Several reasons were attributed to this phenomenon: that young people did not want to trouble others, did not want to burden or alarm others, and did not trust others. In the model, reasons for denial were differentiated by a sense of responsibility, enacted by, for example, not sharing information with family and friends. Withholding information thus seemed to relate to aspects additional to a sense of responsibility and self-reliance.

A frequent theme in both the original model and in the findings from the included articles was self-reliance. Statements of wanting to be strong, trying to cope on one’s own, not sharing information and an elevated sense of responsibility to manage one’s life and mental health problems were evident. Ambivalence as a theme recurred throughout the material, in both the included studies and the original model. Young people expressed simultaneous and contradictory feelings and thoughts towards both themselves and their problems, others and help-seeking per se. They were often hesitant to seek help, whilst at the same time expressing a need and a longing for help.

The analysis of the included articles suggested no major conceptual changes to the original model, although the themes Endavouring strategies and Mental health problems are both elaborated.

Reaching a Point of No Return

Within Reaching a point of no return in the original model, young people expressed deterioration and a reaching out for support, often with the help of others. In Lost in Space, others were called ’catalysts’, showcasing their importance in actually initiating a help-seeking process. Within the analysed articles, important others were consistently brought up by the young people, with examples of others coaching, supporting, guiding and, in some instances, taking control of the help-seeking process. A new perspective in the included articles was a negative perception of control, and how others exerted control over them, compelling them to seek help. While this aspect of negative control did not emerge in the original model, an elaboration of the model may expand on the various functions of the important others, e.g., by dividing them into controllers vs. supporters. The other theme in this subcategory, deterioration, was brought up in several articles, as in the Lost in Space model. This indicated a worsening of symptoms and a decreased ability to function. Young people described not leaving the house, escalated behavioural problems, self-harm and suicide attempts, or ‘having a melt-down’ as triggers for seeking help. Young people also described how their problems were ‘revealed’ and others became aware of their problems, which in turn led to seeking help.

The included articles emphasise that seeking help is often a long process that takes place during a prolonged time-span. Therefore, in this section, a change of title of the subcategory Reaching a point of no return, to Transitioning towards decision, is suggested.

3.2.2. Navigating

The category Navigating depicted attempts of trying to find support, personal reflections, hopes and longings and wrestling with structural barriers. Expressions from young people in the analysed articles conformed well with the subcategories Trying to dock and Wrestling with structure.

Trying to Dock

This subcategory in the Lost in Space model entailed descriptions of personal reflections, hopes, longings and disappointment when trying to seek support. All themes from the original model were exemplified in the included articles. Hopes for help, as well as being safe, noticed and understood, were common in the included articles, as were accounts of the opposite, feeling unsupported. Miscommunication while not being understood or listened to also appeared in both materials as did accounts of being treated like a child and not taken seriously, thus containing references to issues of power. Several analysed articles contained descriptions by young people on how support was perceived as impersonal and instrumental rather than person-centred. This added aspects of negative references to professionalism and reliance on medication. Young people expressed the importance of reframing negative and medical terminology in positive and informal terms. Both materials contained descriptions of young people feeling unsupported, which led to continued and continual efforts of seeking support. A new theme, trust, was identified in the thematic analysis from descriptions of lack of confidence in treatment, and how familiarity facilitated help-seeking. A lack of trust was depicted as arising from limited prior contact, from anxiety about seeking help, from concerns about professional competence and from negative perceptions of professionals. Within the theme of trust in the articles, concerns about confidentiality and parental involvement surfaced, whereas, in the original model, these concerns were interpreted as structural obstacles.

Common themes in the articles were stigma and shame, whereas in the original model, this was not pervasive. The included articles relayed young people’s strong sense of shame about seeking help. They perceived it as a display of weakness. Fear of social consequences, ridicule and a longing to fit in led young people to describe a feeling of shame or embarrassment, and to having thoughts of what others would think and say. They also made efforts to conceal both mental health problems and help-seeking. Articles focusing exclusively on males stressed the gendered aspect of this, claiming that this group was affected by masculine ideals of strength and autonomy, which hindered displays of weakness and prevented help-seeking. In the original model, some findings relating to this theme were described; however, the term stigma was never used. Instead, this was described in the subcategory Wrestling with structure, in relation to seeking support in school, with references of embarrassment and an undesirable show of weakness in front of peers.

In this section, the analysed articles provide more aspects on the Feeling unsupported and Miscommunication themes. The large presence of codes in the new material relating to Stigma and Trust suggests the incorporation of Stigma and Trust as unique themes into the model.

Wrestling with Structure

In both the original model and the analysed articles, there were multiple references to structural obstacles, such as access, waiting times, resources, continuity, inadequate chains of support, and lack of coordination between supporters. Young people voiced feelings of not being met by professionals in an appropriate and timely manner, and concerns about how they were passed on, being referred to other support structures, and how there was a perceived lack of resources, making access difficult. Help-seeking was described as inconsistent, with repeated attempts at initiating and discontinuing help. Young people in several articles, and the original model, expressed that primary care was not an option when seeking support. Primary care was regarded as handling physical health complaints and that its practitioners were not being skilled in mental health issues. Particularly for the ‘younger’ of the young people, expressions that primary care was not directed at their age group were voiced. The inadequate support services theme was thus corroborated by young people in other contexts.

Confidentiality and age issues were concerns for the young people, both within the original model and the thematic analysis, primarily relating to parental control and insight. Both materials contained descriptions of how young people assumed and were concerned that confidential information shared with professional supporters would be communicated to parents. In some articles, this was said to relate to the theme of trust; however, confidentiality was mainly related to being a minor lacking power. Young people also voiced that being a minor was as an obstacle for independently accessing help. Likewise, age was an issue for the ‘older’ young people, who reported feeling out-of-place at youth-specific services. In the original model, a sense of resignation, often related to difficulties accessing support and feeling unsupported, was evident. The included articles provided additional material relating to this, as a sense of powerlessness appeared in several subcategories, and in the process as a whole.

The analysis supported a clearer conceptual division between subcategories Wrestling with structure and Trying to dock in the model. The latter entailed primarily personal accounts and experiences, expressions of hopes, disappointments and recounts of feelings, and the former referred primarily to structural conditions. Recurring references in relation to powerlessness suggest this is elevated to a permeating theme, capturing young people’s experience of seeking help.

3.2.3. Docking

Docking in the original model contained references from young people to the subcategories Finding support and Changing as a person.

Finding Support

All original themes of the subcategory Finding support were found in the thematic analysis. In both the original model and the analysed articles, young people described experiences of being validated, accepted, recognized and listened to. The importance of the comfort of support and initial positive contact was stressed. Descriptions of good and bad supporters and preferences regarding, for example, gender and profession, were evident. Both materials contained descriptions of negative outcomes and unwanted consequences from having sought help; for example, in the original model, this was described as problems being exaggerated and social services becoming involved. In the analysed articles were descriptions of referrals to support services appearing as punitive rather than helpful. This subcategory also contained accounts in both the analysed articles and the original model of young people being disregarded and not being taken seriously.

In this section, no changes to the model are suggested.

Changing as a Person

In the original model, this subcategory described the consequences of successful help-seeking in the form of gaining knowledge and positive personal change. Young people in the original model stressed the positive aspects and changes after having experienced mental health problems. Some references were found in the articles with regard to this subcategory, with personal change depicted as finding a more positive outlook on life through one’s own determination and decisiveness.

In this section, the analysed articles provide more aspects on the theme Changing as a person, but no changes to the model are suggested.

Overall, the findings from the analysis aided in developing an elaborated model of help-seeking, Figure 3 . The overall notion of help-seeking as a fluid and dynamic process with the three categories Drifting, Navigating and Docking was reinforced.

Elaborated and further developed theoretical model of help-seeking among young people for mental health problems.

4. Discussion

This scoping review aimed to map published literature on young people’s experiences of seeking help for mental health problems, and to validate whether the previously published model Lost in Space was adaptable as a theoretical model of the help-seeking process. A high level of conformity was found between help-seeking as depicted by the original Lost in Space model and the analysed articles of this study. The analysis reinforced that help-seeking is to be regarded as a fluid and psychosocial process, often experienced by users as unfamiliar and obstacle-laden, tainted by feelings of powerlessness [ 21 , 22 , 23 , 24 ].

4.1. Discussion and Implications in Relation to the Original Model Lost in Space

After reviewing up-to-date literature on user perspectives of help-seeking for mental health problems among young people, it is clear that the depiction of the initial stage of help-seeking, as being characterized by a sense of drifting, was, to a large extent, corroborated from young people’s experiences described in the reviewed articles. Regardless of context, young people expressed a general feeling of unfamiliarity and a lack of knowledge, often coupled with a sense of insecurity, and trivialisation of experiences [ 21 , 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 ]. This was also supported by a large number of codes and expressions relating to the endeavouring strategies theme in an effort to be self-reliant [ 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. This points to the more-or-less continual and relentless nature of the efforts of young people to deal with their problems. A strong wish for self-reliance was consistently stressed in the reviewed articles, with a large variation and number of strategies used to implement self-reliance and deal with mental health problems. Incorporating an elaboration regarding the characteristics of strategies—whether positive/negative, destructive/constructive or approach/avoidant strategies—would provide an additional perspective on how mental health is dealt with by young people. The reviewed articles confirmed that reaching a decision to seek help often takes place with the aid of others [ 21 , 22 , 23 , 24 , 25 , 29 , 31 , 32 ] and distinction between ‘controllers’ and ‘supporters’ in this regard may further elaborate the model. Re-naming of the subcategory Reaching a point of no return into Transitioning towards decision would reflect the transitional nature of the mental health help-seeking process.

The category Navigating, capturing both personal experiences and structural barriers, was well confirmed by the review. Reflections of not being met by professionals in an appropriate and timely manner, and observations of a perceived lack of resources making access difficult, surfaced in both the original model and the included articles [ 23 , 26 , 29 ]. Accounts of not being taken seriously, being treated like a child, not listened to and disregarded, indicating power-issues relating to the experiences of young people, as well as descriptions of inconsistent use of support, repeatedly initiating and discontinuing help, appeared in the original model as well as the included articles [ 22 , 26 , 28 , 29 ]. Stigma and Trust surfaced as new themes, and Stigma in particular appeared with a large number of codes in the analysed articles. Young people described a feeling of shame, embarrassment, thoughts of what others would think and say and various efforts to conceal both mental health problems and their help-seeking [ 21 , 22 , 23 , 25 , 26 , 27 , 28 , 31 ]. Several articles dealt exclusively with young men and boys, proposing that the reasons for not seeking help were strongly conditioned by gender, with masculine ideals of strength and autonomy acting as obstacles for help-seeking [ 21 , 23 , 28 , 31 ]. Similar findings emerged in the Lost in Space model, where issues of self-reliance, wanting to be strong, and shunning displays of weakness, were shared between participants, and were not gender specific. Cultural variations may account for this difference between studies and findings. This said, most participants in studies on help-seeking are female and the findings may translate poorly to other populations and contexts. Help-seeking is exceptionally low among boys and young men, which in itself calls for a focus on specific populations with particularly low help-seeking [ 33 , 34 ].

The latter part of the original model, Docking, was not as well corroborated through the analysis. There were few descriptions of actually finding support and even fewer of personal reflections on the effects of finding help [ 21 , 22 , 31 ]. It may be that research on the help-seeking process does not focus on support and is discontinued as soon as support is established, and aspects of this may be found in other literature on service utilization or treatment satisfaction. However, by dividing the help-seeking journey into smaller isolated fractions, focus on the process as a whole could be missed, resulting in a stunted model and less understanding of the help-seeking process. Overall, the included articles reinforced the model of help-seeking as a dynamic and psychosocial process, consisting of different stages but without being sequentially fixed.

4.2. Discussion and Implications in Practice

This review on help-seeking for common mental health problems included young people from the age of 11 to 25, thus also including young adults. The studies described in the included articles were based on varied recruitment strategies from different contexts. No specific patterns according to age or context could be discerned. The concerns voiced in the studies included themes on structural barriers of the support system, an unfamiliarity and lack of knowledge of mental health and the support system, and simultaneously, a wish for self-reliance, suggesting possible strategies for meeting the help-seeking needs of young people. Although this study aimed to include articles focusing on groups that were wide enough to be defined as population-based, the focus of the included articles tended to be on particular populations, stressing the vulnerability and poor help-seeking of one particular group. Thus, the research had ethno-centric tendencies, whereas there were large overlaps and resemblances of experiences by young people in the help-seeking process regardless of contexts. The attribution of non-help-seeking to stigma and cultural norms amongst Black, Latino and Chinese American youth was observed by others, pointing to this being a more general, rather than group-specific phenomenon [ 32 ].

Structural factors, and how young people experience the support system, play an important role in the help-seeking process. Despite different contexts, young people expressed similar concerns relating to issues of availability and accessibility. There were views that waiting times were too long, resources were too few, and in some contexts, that costs and distances posed problems [ 21 , 23 , 25 , 26 , 28 , 29 ]. Other research has shown that there is a perceived inaccessibility of the support system across different groups of young people regarding resources, entry requirements and coordination between services [ 13 ]. Structural obstacles stretch over different geographical and socio-economic backgrounds at the macro level, with high-income countries still showing substantial delays and poor help-seeking rates for young people [ 14 , 35 ]. Thus, even in favourable circumstances, young people perceive structural barriers, pointing to how the support system does not accommodate the fluid and changeable nature of help-seeking. Young people regard mental health as a complex social and relational matter [ 36 ]. They often present with diagnostically confusing symptoms, and support systems that are traditionally organized according to medical specialities may not meet the needs of young people with common mental health problems [ 37 ]. Integrated youth centres, focusing on meeting young people’s needs in one place through multidisciplinary support with consideration of the context, show promising results [ 38 , 39 ]. In comparison to traditional support, which is by definition siloed and often entails entry requirements according to diagnostic thresholds, integrated youth-friendly services seem to increase help-seeking and access to support, even among groups that are usually hard to reach [ 33 , 39 ]. Studies in a Swedish context have pointed out that youth health clinics providing services to build upon with multi-professional teams and expertise on mental health are available throughout Sweden [ 40 ].

Young people reported a lack of knowledge on mental health and the support system, leading to a sense of insecurity and possibly a delay of help-seeking. Improved health literacy among young people may facilitate help-seeking through mechanisms of awareness of service availability and symptom recognition [ 13 ]. However, improved help-seeking and mental health among young people may require more than only improved knowledge. Previous reviews have, for example, shown past positive experiences and outcomes of help-seeking and positive contacts with support professionals to be facilitators for seeking help [ 4 , 8 ]. At the same time, a preference for self-reliance when facing mental health problems is consistently reported, with this being particularly prominent in studies with participants having previous experience of mental health problems and mental health support, contradicting the findings of past experiences facilitating help-seeking [ 8 , 23 ]. Young women in particular seem to have poor expectations regarding therapeutic outcomes, signalling a lack of trust in professional supporters, with treatment being perceived as impersonal and protocol-driven [ 23 ]. The results of this study identified the importance of supporters’ ability to meet young people responsively, using a person-centred approach. Young people felt more comfortable when the supporters did not use medical language and emphasized the importance of using positive and informal terms for improving communication between the young person and the supporter. Other studies have confirmed this finding, underlining the importance of having young staff who are skilled, respectful, welcoming, and allow for participation and shared decision-making [ 39 ].

With this review showing how young people experience mental health help-seeking as a psychosocial and fluid process, often with lack of knowledge and a sense of insecurity, prompt consideration of the organization of present support systems is needed. Young people need to be met in a person-centred and flexible manner. Perhaps, this is where the greatest effort is needed, addressing issues of power from the perspectives of young people, improving opportunities for personal self-reliance and personalized support.

5. Methodological Considerations

This review has some limitations. The choice of databases and keywords was developed in accordance with an experienced health literature librarian; however, making a choice always entails the risk that some information may have been missed. Other databases and different keywords may have produced different results. The criteria for including articles were that they should deal with the direct perspectives of young people who had experienced mental health problems and/or help-seeking. Whilst excluding those who had no experience of help-seeking (thus all articles dealing with intentions to seeking help only) might have been a clear-cut and easy choice, that would also have meant that we excluded those with experience of mental health problems who had not sought help for various reasons; thus, avoidance is also a perspective that is worth taking into consideration.

We aimed to include studies focusing on groups wide enough to be defined as population-based; nevertheless, these still often utilized an ethnocentric perspective, such as having a particular ethnic descent. This automatically raises the issue of generalizability and transferability. It was evident that studies consistently focused on particular populations, stressing the vulnerability and poor help-seeking of this particular group. However, similar claims kept reappearing, regardless of which particular group was being studied. A noteworthy phenomenon is that all included articles were published in Western countries. This also limits the transferability of the findings, as young people around the world may be situated in significantly different contexts.

In order to limit bias, the work was conducted by alternating methods of individual and joint reviews. However, subjectivity is a relevant issue that the authors of this review could not completely avoid.

6. Conclusions and Implication

The field of help-seeking among young people for mental health problems is receiving growing attention in research and academic literature. However, this review shows that there is substantial heterogeneity among studies with regard to methods, populations and how help-seeking is investigated. In qualitative literature exploring user perspectives, help-seeking is depicted as a fluid, dynamic and psychosocial process, validating the theoretical model of Lost in Space. Important findings include the presence of stigma, a lack of knowledge of mental health issues, a longing for self-reliance and a sense of powerlessness expressed by young people in various contexts and countries. Paying attention to these findings would imply acknowledging young people’s sense of feeling lost, making support services more flexible and person-centred.

Acknowledgments

Caroline Karlsson greatly contributed with the graphical model.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/ijerph19031430/s1 , Table S1, full search strategy, Table S2, characteristics of included studies.

Author Contributions

All authors (K.H.W., M.N., J.M.N. and P.S.) made significant contributions to the original paper. K.H.W., M.N., J.M.N. and P.S. together identified the research question and designed the study. The data search was conducted by K.H.W., and stepped screening was performed by K.H.W., M.N., J.M.N. and P.S. In addition, K.H.W. drafted the manuscript and M.N., J.M.N. and P.S. provided critical revision of the paper in terms of important intellectual content. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

This study did not require ethical clearance.

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Teenagers: learning from case reviews

Summary of risk factors and learning for improved practice around working with teenagers.

Published case reviews highlight that practitioners sometimes struggle to work with teenagers who are experiencing complex issues. Interventions can focus on tackling challenging behaviour, rather than exploring the underlying causes and risk factors. This sometimes causes practitioners to lose sight of the fact that teenagers are children in need of protection.

The learning from these reviews highlights that professionals need to listen to teenagers, but also be able to balance the young person’s wishes with their best interests. Intervention needs to be timely and appropriate.

Published: February 2021

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