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WHO’s Take on Adolescent mental health

Adolescence (10–19 years) is a unique and formative time. Whilst most adolescents have good mental health, multiple physical, emotional and social changes, including exposure to poverty, abuse, or violence, can make adolescents vulnerable to mental health problems. Promoting psychological well-being and protecting adolescents from adverse experiences and risk factors which may impact their potential to thrive are not only critical for their well-being during adolescence, but also for their physical and mental health in adulthood.
Mental health determinants
Adolescence is a crucial period for developing and maintaining social and emotional habits important for mental well-being. These include adopting healthy sleep patterns; taking regular exercise; developing coping, problem-solving, and interpersonal skills; and learning to manage emotions. Supportive environments in the family, at school, and in the wider community are also important.

Multiple factors determine the mental health of an adolescent at any one time. The more risk factors adolescents are exposed to, the greater the potential impact on their mental health. Factors which can contribute to stress during adolescence include a desire for greater autonomy, pressure to conform with peers, exploration of sexual identity, and increased access to and use of technology. Media influence and gender norms can exacerbate the disparity between an adolescent’s lived reality and their perceptions or aspirations for the future. Other important determinants for the mental health of adolescents are the quality of their home life and their relationships with their peers. Violence (including harsh parenting and bullying) and socio-economic problems are recognized risks to mental health. Children and adolescents are especially vulnerable to sexual violence, which has a clear association with detrimental mental health.

Some adolescents are at greater risk of mental health conditions due to their living conditions, stigma, discrimination or exclusion, or lack of access to quality support and services. These include adolescents living in humanitarian and fragile settings; adolescents with chronic illness, autism spectrum disorder, an intellectual disability or other neurological condition; pregnant adolescents, adolescent parents, or those in early and/or forced marriages; orphans; and adolescents from minority ethnic or sexual backgrounds or other discriminated groups.

Adolescents with mental health conditions are in turn particularly vulnerable to social exclusion, discrimination, stigma (affecting readiness to seek help), educational difficulties, risk-taking behaviours, physical ill-health and human rights violations.

Mental health conditions in adolescents
Worldwide, it is estimated that 10–20% of adolescents experience mental health conditions, yet these remain underdiagnosed and undertreated. Signs of poor mental health can be overlooked for a number of reasons, such as a lack of knowledge or awareness about mental health among health workers, or stigma preventing them from seeking help.

Emotional disorders
Emotional disorders commonly emerge during adolescence. In addition to depression or anxiety, adolescents with emotional disorders can also experience excessive irritability, frustration, or anger. Symptoms can overlap across more than one emotional disorder with rapid and unexpected changes in mood and emotional outbursts. Younger adolescents may additionally develop emotion-related physical symptoms such as stomach ache, headache, or nausea.

Globally, depression is the ninth leading cause of illness and disability among all adolescents; anxiety is the eighth leading cause. Emotional disorders can be profoundly disabling to an adolescent’s functioning, affecting schoolwork and attendance. Withdrawal or avoidance of family, peers or the community can exacerbate isolation and loneliness. At its worse, depression can lead to suicide.

Childhood behavioural disorders
Childhood behavioural disorders are the sixth leading cause of disease burden among adolescents. Adolescence can be a time where rules, limits and boundaries are tested. However, childhood behavioural disorders represent repeated, severe and non-age-appropriate behaviours such as hyper-activity and inattention (such as attention deficit hyperactivity disorder) or destructive or challenging behaviours (for example, conduct disorder). Childhood behavioural disorders can affect adolescents’ education, and are sometimes associated with contact with judicial systems.

Eating disorders
Eating disorders commonly emerge during adolescence and young adulthood. Most eating disorders affect females more commonly than males. Eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder are characterised by harmful eating behaviours such as restricting calories or binge eating. Anorexia and bulimia nervosa also include a preoccupation with food, body shape or weight, and behaviours such as excessive exercise or vomiting to compensate for calorie intake. People with anorexia nervosa have a low body weight and a heightened fear of weight gain. People with binge eating disorder can experience feelings of distress, guilt or self-disgust when binge eating. Eating disorders are detrimental to health and often co-exist with depression, anxiety and/or substance misuse.

Psychosis
Disorders which include symptoms of psychosis most commonly emerge in late adolescence or early adulthood. Symptoms of psychosis can include hallucinations (such as hearing or seeing things which are not there) or delusions (including fixed, non-accurate beliefs). Experiences of psychosis can severely impair an adolescent’s ability to participate in daily life and education.  In many contexts, adolescents with psychosis are highly stigmatized and at risk of human rights violations.

Suicide and self-harm
It is estimated that 62 000 adolescents died in 2016 as a result of self-harm. Suicide is the third leading cause of death in older adolescents (15–19 years).  Nearly 90% of the world’s adolescents live in low- or middle-income countries but more than 90% of adolescent suicides are among adolescents living in those countries. Suicide attempts can be impulsive or associated with a feeling of hopelessness or loneliness. Risk factors for suicide are multifaceted, including harmful use of alcohol, abuse in childhood, stigma against help-seeking, barriers to accessing care, and access to means. Communication through digital media about suicidal behaviour is an emerging concern for this age group.

Risk-taking behaviours
Many risk-taking behaviours for health, such as substance use or sexual-risk taking, start during adolescence. Limitations in adolescents’ ability to plan and manage their emotions, normalization of  the taking of risks that have an impact on health among peers and contextual factors such as poverty and exposure to violence can increase the likelihood of engaging in risk-taking behaviours. Risk-taking behaviours can be both an unhelpful strategy to cope with poor mental health, and can negatively contribute to and severely impact an adolescent’s mental and physical well-being.

Harmful use of substances (such as alcohol or drugs) are major concerns in most countries. Worldwide, the prevalence of heavy episodic drinking among adolescents aged 15-19 years was 13.6% in 2016, with males most at risk. Harmful substance use in adolescents increases the likelihood of further risk-taking such as unsafe sex. In turn, sexual risk-taking increases adolescents’ risk of sexually-transmitted infections and early pregnancy – a leading cause of death for older adolescent girls and young women (including during childbirth and from unsafe abortion).

The use of tobacco and cannabis are additional concerns. In 2016, based on data available from 130 countries, it was estimated that 5.6% of 15–16 year olds had used cannabis at least once in the preceding year [1]. Many adult smokers have their first cigarette prior to the age of 18 years.

Perpetration of violence is a risk-taking behaviour which can increase the likelihood of low educational attainment, injury, involvement with crime, or death. Interpersonal violence was ranked the second leading cause of death of older adolescent boys in 2016.

Promotion and prevention
Interventions to promote adolescents’ mental health aim to strengthen protective factors and enhance alternatives to risk-taking behaviours. Promotion of mental health and well-being helps adolescents in building resilience so that they can cope well in difficult situations or adversities.  Promotion programmes for all adolescents and prevention programmes for adolescents at risk of mental health conditions require a multilevel approach with varied delivery platforms – for example, digital media, health or social care settings, schools, or the community.

Examples of promotion and prevention activities include:

* one-to-one, group-delivered, or self-guided online psychological interventions;
* family-focused interventions such as caregiver skills training, including interventions which address caregivers’ needs;
* school-based interventions, such as:
* organizational changes for a safe, secure and positive psychological environment;
* teaching on mental health and life-skills;
* training staff in detection and basic management of suicide risk; and
* school-based prevention programmes for adolescents vulnerable to mental health conditions;
* community-based interventions such as peer leadership or mentoring programmes;
* prevention programmes targeted at vulnerable adolescents, such as those affected by humanitarian and fragile settings, and minority or discriminated groups;
* programmes to prevent and manage the effects of sexual violence on adolescents;
* multisectoral suicide prevention programmes;
* multilevel interventions to prevent alcohol and substance abuse;
* comprehensive sex education to help prevent risky sexual behaviours; and
* violence prevention programmes.

Early detection and treatment
It is crucial to address the needs of adolescents with defined mental health conditions. Avoiding institutionalization and over-medicalization, prioritizing non-pharmacological approaches, and respecting the rights of children in line with the United Nations Convention on the Rights of the Child and other human rights instruments are key for adolescents.
Interventions for adolescents should consider:

* The importance of early detection and provision of evidence-based interventions for mental and substance use disorders. WHO’s mental health Gap Action Programme (mhGAP) provides evidence-based guidelines for non-specialists to enable them to better identify and support priority mental health conditions in lower-resourced settings.
* Transdiagnostic interventions – for example, those which target multiple mental health problems.
* Delivery by supervised staff who are trained in managing adolescents’ specific needs.
* Engaging and empowering caregivers, where appropriate, and exploring adolescents’ preferences.
* Face-to-face and guided self-help methods, including electronic mental health interventions. Due to stigma or the feasibility of accessing services, unguided self-help may be suitable for adolescents.
* Psychotropic medication should be used with great caution and should only be offered to adolescents with moderate-severe mental health conditions when psychosocial interventions prove ineffective and when clinically indicated and with informed consent. The treatments should be provided under the supervision of a specialist and with close clinical monitoring for potential adverse effects.