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Assessing mental health in vulnerable adolescents

Farley, Holly R. EdD, RN

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doi: 10.1097/01.NURSE.0000697168.39814.93
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MENTAL ILLNESS in adolescents is a serious public health concern that is on the rise in the US. A dramatic shift in adolescent risks and behaviors during the 21st century threatens adolescents' mental well-being more than ever.1 Adolescents make up 12% of the US population, with 30% reporting symptoms of depression each year. One in five adolescents has had a serious mental health disorder at some point in life, and most children and adolescents who attempt suicide have at least one mental illness.2,3 ED visits for suicidal ideations or attempts rose 92% from 2007 to 2015, and suicide-related ideations, attempts, and death increased from 2008 to 2017.4,5

Suicide is the second leading cause of death in children and young adults between ages 10 and 24.6 Adolescent mental well-being is multidimensional and includes many risks that make this group vulnerable.1

Vulnerable populations can be defined by various characteristics or circumstances that create barriers to healthcare and constitute a potential threat to health.7 Adolescents are a vulnerable population and are susceptible to mental health issues by nature.

Adolescence is a time of great psychological and physical change.8 Many social and physical conditions and behaviors can impact adolescent health and heighten the risk of mental illness and suicide. Nurses have a crucial role in assessing vulnerable populations in all healthcare settings. Engaging in formal and informal assessments that can identify adolescents at risk for mental illness saves lives. However, to improve these alarming statistics, nurses must first understand the complexity of the many risk factors contributing to mental illness, the impact of early recognition, and the use of valid assessment and screening tools.

This article explores vulnerable adolescent populations, describes the importance of nurses in all categories of assessment for adolescent mental health, and identifies assessment strategies and immediate interventions for successful outcomes.

Background

Populations that are commonly considered vulnerable include ethnic minorities, people with a low socioeconomic status, members of the LGBTQ+ community, people with a disability, and those with a family history of mental illness. Individuals in these groups are typically not well integrated into the healthcare system and at risk for decreased access to care.

Adolescents as a group are vulnerable to health issues because of their stage of development, which affects their ability to make safe decisions, and the need to rely on others for support. They may feel that expectations from family and peers are too high, leading to feelings of stress and hopelessness.

In addition, adolescents can be particularly vulnerable due to risk factors that can contribute to stress during adolescence, such as a desire for greater autonomy, pressure to conform with peers, exploration of sexual identity, and increased access to and use of technology.9 The higher the number of risk factors, the greater the potential for mental illness.9

Adolescent mental well-being is multidimensional and is influenced by a shift in adolescent risks and behaviors during the 21st century. Traditional threats to mental health such as low socioeconomic status, poor living conditions, substance abuse, early sexual activity, and bullying are further compounded by contemporary risks such as little social support from parents, peers, or teachers; social media use; and cyberbullying.1 Without sufficient emotional and economic support, adolescents may be overwhelmed with feelings of helplessness, insecurity, and stress.8

Successful treatments exist for adolescents with mental illness; however, screening among this age group is low. A 2018 study of privately insured adolescents showed that those receiving routine wellness checks were not being screened for depressive disorder, which is a common issue in this age group.10 Timely interventions are imperative. If not diagnosed early, the clinical onset of mental illness during adolescence can lead to difficult-to-treat chronic mental illness throughout adulthood.11

Nurses interact with adolescents in many settings, such as schools, community or public health settings, outpatient clinics, and EDs. Nurses must be educated on the needs of vulnerable populations as well as mental illness and suicidal behaviors, and utilize every opportunity to identify mental health issues. When assessing patients, nurses must be aware of specific findings that identify adolescents with symptoms of mental health issues or increased risk.

Healthcare professionals often see vulnerable patients only in a school, public health agency, or urgent care setting due to high costs and limited access to routine healthcare. These settings are far from the walls of behavioral health units, leaving the responsibility of assessment to nurses on those front lines. All nurses should have the knowledge to assess and intervene, even if they are not trained mental health professionals. Nurses are perfectly positioned to get to know patients and their families, learn their history and family dynamics, and provide education and resources.11

Common mental health disorders in adolescents

The World Health Organization reports that half of mental health disorders start by age 14.9 Some common mental health disorders that emerge in adolescence may be risk factors for suicide. Recognizing the signs and symptoms is imperative.

Anxiety and depression are the most common mental illnesses affecting adolescents, with girls and boys displaying different manifestations of suicidal ideations.12 Teachers and parents noted in one study that young boys displayed behavior problems of dependency and anxiety, while girls displayed hyperactivity and aggressiveness. These are significant predictors of suicidal ideation.13

Along with anxiety and depression, emotional disorders can emerge in adolescents. Common early signs and symptoms include irritability, frustration, anger, unexpected outbursts, mood changes, and sleep disturbances. Young adolescents may develop additional physical symptoms such as constant abdominal pain, headaches, or nausea.9,14 Overall, girls have a higher percentage of anxiety and depression, and although girls have a higher rate of suicidal thoughts and ideations, more adolescent boys die of suicide.1,10,11

Behavioral disorders such as attention-deficit/hyperactivity disorder more commonly begin in children and younger adolescents. Characteristics are excessive activity and trouble paying attention, with disregard for consequences. These children may also have conduct disorder, which is characterized by a repetitive and persistent pattern of behavior that violates basic rights of others or major societal norms or rules.15

Eating disorders can also be a precursor to chronic or debilitating mental illness in adulthood. Eating disorders are more common in females than males and encompass binge-eating, anorexia, and bulimia.9 Less common disorders are psychosis, somatization disorders, and borderline personality disorder.

Any family history of mental illness can be a risk factor.16 Nurses should be aware of any unusual behaviors such as hallucinations or delusions, obsessive preoccupation with body image or food intake, substance abuse, and sudden extreme behaviors. Alert the patient's healthcare provider if the patient demonstrates any of these behaviors.

Assessing vulnerable populations

Many in the adolescent age group do not have access to mental health services or may be unwilling to admit they have a problem, such as depression, due to the stigma associated with mental illness.17 Assessment practices need to be changed to identify at-risk youth and ensure early prevention and intervention because they are likely too scared to seek help.

Although any adolescent can be at risk, nurses need to consider some lesser-known vulnerabilities. For example, early menarche in girls has been found to be an antecedent of mental health disorders such as depression, anxiety, eating disorders, and substance abuse. Extensive changes in physical and psychological well-being present challenges to all adolescents, and particularly girls who mature ahead of other girls their age.18 In a recent study, Mendle and colleagues supported findings from past research showing that, even after accounting for other vulnerabilities associated with mental health, girls who experience early-onset puberty are at a higher risk for antisocial behaviors and psychological issues.16 Past studies have also found that girls with early-onset puberty are more likely to engage in early sexual relationships, use drugs and alcohol, and experience more psychological stress overall than boys and girls who do not experience early-onset puberty.19 Further, Owens describes how the onset of menses in adolescence associated with fluctuating hormones can be a risk factor for suicidal thoughts and behaviors, no matter the age of onset.12

Exposure to school violence can also have an ongoing impact on mental health. Violence in schools is a broad concept that encompasses physical and verbal harm, bullying and threats, and sexual and ethnic harassment.20 Victims of violence and bullying have an increased risk of poor psychological health in adulthood.21 Bullying cannot be stopped entirely, but early intervention for the victim can prove beneficial for future mental health.

How well the family unit functions is also important to consider. Dysfunctional families in which a young person's environment is consistently adverse and abusive is a significant risk factor for suicidal behaviors.13

Family violence can take many forms within the family unit. Sibling violence is one common example, as well as physical and sexual abuse from another person related to the adolescent. These instances are rarely isolated, and victims can experience more than one type of violence.22

Family violence can be complicated, creating relational trauma for the entire family. This violence may not be easy to assess; family violence is often generational and the caregivers in the household may have also experienced violence.

Sexual orientation, gender identity, and gender expression are identified in populations that are considered vulnerable regarding mental illness and suicide attempts.23 Recent studies confirm that LGBTQ+ adolescents experience high levels of peer victimization, violence, rejection, harassment, and sexual abuse contributing to mental illness and suicidal behaviors.24

Social factors

Adolescence is a time of developing self-identity and self-confidence. Adolescents place great importance on peer groups and relationships. Peer rejection, conflicts, and school stress can contribute to anxiety and depression.8,13

Romantic relationships are another factor. Adolescents are changing both physically and emotionally. Teens begin to feel intense emotions toward others and experience intimacy. Relationship stressors and breakups can undermine mental well-being.8,15

The internet and social media also can play a role in mental illness and suicide in young people. Cyberbullying and problematic social media use can jeopardize mental well-being.1

Another potential risk and precursor to suicide is experiencing losses, such as another teen or close relative committing suicide or another tragic life event. Poor social support, either parental or otherwise, can also compound risks to mental health in young people.8

Assessment strategies

Mental health assessment is an integral part of every evaluation, even when the patient has no remarkable health history, presenting signs and symptoms, or complaints. Adolescents who present with physical complaints may not be willing to share their mental health issues. Knowing the characteristics and experiences of vulnerable patients and the questions to ask can identify youth at risk.10

Although adolescents are typically healthy, a thorough health history that addresses past and present acute illnesses, chronic health disorders, hospitalizations, and social history must be obtained to identify potential risks.7 The focused interview should be structured to include fewer questions that obtain the most information. Adolescents may be uncomfortable asking questions. Consider the following assessment strategies:

  • Adolescents may communicate better with peers or adults other than parents or guardians, such as nurses, so engage in informal conversations with the patient to gain information. Ask questions that show interest and build rapport such as, “What hobbies and interests do you have?”
  • Try to get them alone. Assessing adolescents one-on-one without a parent or caregiver allows them to speak freely.
  • Use open-ended questions such as, “Tell me about your friends,” and employ silence to give the adolescent time to answer questions thoroughly.
  • Interview family members separately when possible to gain a clearer picture of the situation.

Adolescence is a time of heightened self-consciousness and associated uncertainty. Fear of others' opinions and a need for privacy is typical. A teenager's willingness to openly share with a nurse depends on his or her perceptions of the relationship and comfort level. The nurse should be aware that first attempts at interaction may be met with rejection. It is vital to communicate in a genuine, respectful, and honest way.14

When to seek further evaluation

Older children and adolescents may benefit from an evaluation for mental health disorders if they meet any one of the following criteria:

  • loss of interest in things that they used to enjoy
  • low energy
  • too much or too little sleep, or sleepiness throughout the day
  • spending more and more time alone, and avoiding social activities with friends or family
  • fear of gaining weight, or dieting or exercising excessively
  • engaging in self-harm behaviors, such as cutting or burning their skin
  • smoking, drinking alcohol, or using drugs
  • engaging in risky or destructive behavior alone or with friends
  • thoughts of suicide
  • having periods of highly elevated energy and activity and requiring much less sleep than usual
  • saying they think someone is trying to control their mind or that they hear things that other people cannot hear.7,14,16

Intervention

Early intervention improves outcomes.5,11 Nurses must be able to recognize normal variations in adolescent development and behaviors. If a nurse suspects an adolescent is at risk for mental illness or the adolescent shares feelings of depression, the nurse should first interview the patient alone and further assess for suicide risk. Initiate conversations with statements such as, “I know it may not be easy to talk to someone you don't know,” and follow with open-ended questions such as, “Have you ever thought about killing yourself or wished you were dead?”16 Also, communicate that patient safety takes precedence over confidentiality and sharing information with family and the primary care provider may be needed.

Patients who have potential mental illness without suicidal concerns can be educated on resources available and referred to the primary care provider for further assessment. The nurse must contact the child's primary care provider to ensure close follow-up and further assessment and referral if needed.16

If suicidal thoughts or ideation are identified through assessment, or the nurse has significant concerns, the nurse must determine if the adolescent has a plan. Share with the parent that the adolescent is suicidal and plan to keep him or her safe. A plan should include an immediate evaluation by a mental health professional and potentially inpatient hospitalization. In all cases, safety is a priority. It is important to note that adolescents who do not have a high number of risk factors can still be vulnerable.16

The risk of suicide is exceptionally high in the time directly after a nonfatal self-harm event. This risk is significantly higher in instances of young people who used more violent self-harm methods such as hanging or a firearm.25

Esposito suggests that the internet is a risk factor for suicide due to social media and the potential for bullying.16 It allows the teen to identify different means to attempt suicide. Therefore, identification of precipitating factors and ongoing assessment to assure safety should be a priority. All potential weapons, prescription and over-the-counter medications, and any toxins or illicit substances must be removed immediately, and the child placed in a safe space with supervision.16

Intervention for mental health illness in adolescents usually requires an interdisciplinary approach that includes a thorough mental health assessment, education for the parent and teen, the involvement of teachers and school counselors, and treatment specific to the mental illness. Treatment often includes pharmacotherapy and cognitive therapy.14

Suicide prevention

The association between suicidal behaviors and mental health disorders is strong in the adolescent population. Nurses should be knowledgeable about the warning signs of mental illness and impending suicide. Teach the patient's family and friends the potential warning signs of an impending suicide attempt. These include reckless behavior, increased incidence of alcohol and/or drug abuse, seeking out information on suicide methods, changes in sleep patterns, panic attacks, anxiety, agitation, giving away treasured personal belongings, expressing feelings of worthlessness or hopelessness, contacting people to say goodbye, social withdrawal, and dramatic changes in mood.7

Be the change!

Knowledge of risk factors, assessment, and detection of high-risk adolescents can prevent suicide. Learn about mental illness and assessment and know when to seek further evaluation and the appropriate interventions. Choose to implement it into everyday practice. If your area of nursing does not have a mental health assessment protocol for adolescents, implement a validated tool. There are many tools and checklists readily available for healthcare providers to use. (See Mental health resources.) Never underestimate the role nurses can have in creating a safe and open environment to support at-risk adolescents. Do not be afraid of having difficult conversations and always be genuine, kind, and willing to listen. These interactions can save lives.

Mental health resources

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Keywords:

adolescence; behavioral health; mental health; suicide; vulnerable populations

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