Prevention and Early Intervention in Mental Health- Puberty to Early Adulthood

Puberty to Early Adulthood

Puberty to early adulthood is the final critical stage of blooming and pruning cells in the brain, similar to that seen in the early years of life. Rapid growth in the brain’s gray matter before puberty is met by a strengthening of pathways that are used most often and a weakening of those that are not used often as the brain refines itself through pruning.[i] Research has started to explore the connection between brain changes such as an abnormal pruning of the brain (exacerbated by disruptions in sleep and increased stress) with the onset of various mental health problems including schizophrenia, substance use, mood disorders, anxiety disorders, and eating disorders.[ii]^{,[iii],[iv], [v],[vi]} The brain changes are combined with changes in friendships, social roles, self-esteem, hormones, and challenging expectations. Most students will be advancing to high school, which can be massively stressful, particularly for vulnerable students. This is also a time when many mental health disorders become more apparent or when teens start showing symptoms of mental health disorders. With so many transitions and new stressors, puberty to early adulthood is an especially vulnerable time for teens’ mental health.

Health

• Sleep: The rapid changes in the brain and body that occur during puberty make it a crucial time for sleep. As a child hits puberty, the body’s relationship with sleep begins to change. The circadian rhythm, or the combination of internal influences that determine the body’s schedule of wakefulness and sleep, leads those in this age group to begin feeling tired about two hours later than they did in childhood.[vii] They also begin to require an increased amount of sleep each night. Current pressures on kids, teens, and young adults emphasize success in academics and sports or clubs, in addition to dealing with peer pressure and part-times jobs. For many, overscheduling, early school start times, and other concerns take priority over sleep at a time when sleep increasingly important. Disruptions in sleep can result in trouble concentrating, mood swings, hyperactivity, nervousness, and aggressive behavior.[viii] One study showed that adolescents who slept fewer than six hours a night were three times for likely to experiences psychological distress than those who slept a healthy amount.[ix]
• Substance Use: Substance use during this time may also be associated with later mental health problems.[x]  In particular, studies have found a potential causal relationship between the amount of marijuana used during this time and likelihood of later experiencing psychotic symptoms.[xi] Studies show the clearest link between marijuana use and later symptoms of psychosis among heavy users with preexisting vulnerability. For example, one study showed daily users with a specific gene variant were seven times as likely to develop psychosis than infrequent or non-users with the same gene.[xii]
• Physical Activity: Regular physical activity in childhood and adolescence has been associated with improved mental health, while screen time has been associated with poorer mental health.[xiii]

Safety or Security

• Intimate Partner Violence: For many, puberty to early adulthood is when romantic relationships become more common and important. While these relationships can be a healthy part of growing up, this is also when people young people may begin experiencing intimate partner violence, including physical, emotional, psychological, and sexual abuse. 10 to 30% of teens report being physically abused by their romantic partner. Anywhere from 20 to 50% report being psychologically or emotionally abused. 10 to 13% report sexual coercion or assault by their partner.[xiv] Those who experience intimate partner violence are more likely to show symptoms of depression and anxiety, abuse substances, and report thoughts of suicide, in addition to being at an increased risk for victimization during college.[xv]

Resources

• Supports: For students who are struggling, it can be challenging to get help, especially with fears of talking about mental health or asking for help. Even when one asks for help, access to supports might be influenced by insurance coverage, cost of treatment, and availability of providers in the area. Schools are mandated to provide Individualized Education Programs (IEPs), which are designed to give children with mental health problems the supports and accommodations they need to be successful in school. However, funding for IEPs is limited so many children with mental health problems will not receive an IEP or receive inadequate support from their IEP. As a result, children that are considered to have an emotional disturbance qualifying them for an IEP have a high school graduation rate of 43.3%, the lowest of all disabilities.[xvi] In addition to difficulties in obtaining treatment and supports at schools, community providers and IEP teams are not often coordinated to ensure that they are working effectively together.  Care needs to be integrated between school and community treatment and supports to best support children.

Relationships

• Bullying: The 2014–2015 School Crime Supplement - PDF (National Center for Education Statistics and Bureau of Justice Statistics) indicates that, nationwide, about 21% of students ages 12-18 experienced bullying. The 2015 Youth Risk Behavior Surveillance System (Centers for Disease Control and Prevention) also indicates that an estimated 16% of high school students were bullied electronically in the 12 months prior to the survey.[xvii] With Mental Health America’s Bullying Survey, over 60% of respondents in seventh through twelfth grade reported being cyberbullied. When it comes to bullying in schools, a 2013 report by the Bureau of Justice Statistics stated that 28% of students age 12-18 reported being bullied in the past year.[xviii] A report by the Centers for Disease Control and Prevention in 2013 stated 7.2% of students report not going to school due to personal safety concerns.[xix] The same study highlighted the dramatically increased risk for bullying among students who self-identify, are identified by others, or are questioning their identification as LGBT. 12 to 28% of students in this group reported being threatened or injured with an object on school property within the past year.[xx] Those who experience bullying are at an increased risk for depression, anxiety, substance abuse, poor school performance, and suicidal behavior. Conversely, students, regardless of sexual orientation, who reported a positive school climate and were not experiencing homophobic teasing, had the lowest levels of depression, suicidal feelings, substance use, and unexcused absences.[xxi]
• Isolation: Puberty into early adulthood is a time when relationships with peers are especially important, as young people are forming their identities and navigating their transition to adult roles. Adolescents who report high levels of social isolation also report more depressive symptoms, lower self-esteem, and are at a higher risk for suicide or suicide attempts than those who do not feel isolated.[xxii] This demonstrates that socially inclusive environments are important for ensuring adolescents get the support they need during this time.

Interventions:

Prevention and early intervention at this stage take into account the unique challenges of high school and transition to adulthood.  Many of the universal prevention programs focus on managing high-risk behaviors, like substance abuse, which can be linked to later mental health. Life Skills Training is an example of a middle school curriculum that reinforces self-esteem and resilience to social pressures. This program demonstrates decreased substance use in adolescents and the Washington State Institute of Public Policy calculated that it has a return on investment of $13 for every $1 spent.[xxiii]          

Because puberty into adulthood is a time when symptoms of specific disorders become more apparent, three key steps are important in getting youth the care they need to stop the progression of worsening problems. First, providing universal mental health screenings is a necessary and critical first step for intervention. Screening for mental health problems should be as ubiquitous as vision or hearing screenings and provided during puberty.  A positive screen should be followed by a comprehensive mental health assessment. Secondly, universal education about early signs is important to bring in key community members who are mostly likely to catch problems when they occur. A commitment to funding outreach and education to individuals including teachers, mentors, churches, pediatricians and hospitals is necessary to identifying youth who are often tentative about sharing their mental health problems. Finally, once a youth has received a full psychosocial assessment, we must provide access to specialized services that have been proven effective. Examples of evidenced based specialty mental health care should include wraparound services like those included in Family-Aided Assertive Community Treatment or Coordinated Specialty Care for First Episode Psychosis.[xxiv] Currently, getting early care often comes down to a combination of resources, knowledge of the mental health system, location, and timing, since even with adequate resources and insurance coverage, getting help can still come down to whether or not good treatment is available in your area. For those that do not have access to specialty care during this critical time, focusing on reducing stress, increasing sleep, and proper nutrition has been shown to help build protective factors. For example, in one study, adolescents deemed ultra-high risk for developing psychotic disorders who took 1200 mg of fish oils were four times less likely to develop a psychotic disorder 2 years later.[xxv] For adolescents who might be showing early signs of mental illness, it is crucial for us to provide them treatment to keep them in school and engaged in the community, with supports that allow them to reach their personal recovery goals.