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Cape Byron Medical Centre

PSYCHOLOGIST EXPERT OPINION: CHILDREN & TEENAGERS MENTAL HEALTH

Mental illness is affecting an alarming and growing number of our children and teens. In fact, one in seven Australians aged four to 17 are experiencing a mental health condition, according to beyondblue(1). That’s more than half a million children and adolescents.

A Mission Australia Youth Survey, in 2017, suggested the figures may be even higher. Around one quarter (23.7%) of 15 to 19 year olds were either extremely concerned (11.1%) or very concerned (12.6%) about depression.

Shockingly, suicide is the biggest killer of young Australians and accounts for the deaths of more young people than car accidents. In 2015, 391 young Australians aged 15-24 died by suicide compared with 290 in 2005 (2).

Here, our psychologists Mee Hee Douglas and Elizabeth Margules answer the most asked questions in relation to mental health and suicide in children and teenagers.

1. AT WHAT AGES ARE CHILDREN MOST VULNERABLE TO DEPRESSION OR ANXIETY?

Mee Hee: From the time we are born, any of us are vulnerable to depression and anxiety throughout our lifespan. Depression and anxiety can be viewed in a developmental context so individuals may be more vulnerable during developmental transitions or challenges where a person’s capacity to cope is largely predetermined by the personality strengths built up earlier in development.

Elizabeth: Children, from birth to eleven years, are particularly vulnerable to environmental influences. When mental health problems occur these are often a direct response to what is happening in their lives in the context of childhood development and needs being realised within developmental stages. So for example, chronic stress can occur for an infant where needs to develop trust are not able to be met within their environment. And the accumulation of risk factors in the absence of protective factors may increase the likelihood of a mental health issue like depression or anxiety. Studies show, for example, that a vulnerable temperament with early stressors can predict onset of depression in children (Buffered et al 2014)

Further, major life changes are known to increase risk at any age. Adolescence for example, anywhere from 10-24 years (Aus. Med Assoc), is a period of great change and emotionality. Some children are approaching adolescents earlier, as early as seven years old, on average around 12 years old. The stages of childhood development have shifted in recent history, with an earlier onset of puberty. There was a stage in between childhood and adolescence called latency. A period that was a valuable time for acquiring problem solving, decision making, communication skills that is now rushed through by wider systemic changes in culture driven by the digital world which we now live in. Stress on developmental stages within these wider cultural changes are further impacted by diet nutrition, increased rates of family separation.

2. WHAT ARE SOME OF THE REASONS THESE CONDITIONS START, OR SOME OF THE THINGS BEHIND THEM?

Mee Hee: Our capacity to manage our emotional lives begins from our earliest experiences with our primary care-giver, which is usually the mother.  It is ordinary for mothers to not be attentive to all of her baby’s needs and for babies to be easily upset, stressed, and frustrated, for example, waiting too long for the breast or the breast comes too early or comes off too quickly etc.  Many mothers are able to respond more often than not and this is the beginnings of the baby learning to contain and to manage their anxieties. If however the baby is upset or frustrated for too long and too often, the baby is overwhelmed with anxiety and may develop defences to protect himself, for example, vomiting (can’t take in anymore), oversleeping (first defence of denial), distress crying (protest).

The first year of life is paramount for developing a capacity to contain anxiety.  This forms the foundation from which later development occurs.
Developmental transitions that are too abrupt or where a child has been carrying anxiety or frustration for too long, without enough assistance, or too much assistance, from parents to help them to manage, may set that child up for difficulties later in their development.

Elizabeth: Mental health issues emerge from a combination of factors that include vulnerabilities of children and care-givers, in the developmental context. And problems can be intergenerational, so even if it is early in life the issues can be quite sustained. So the child and family, and their wider system are taken into consideration when considering the cause of a mental health issue.

Issues like depression and anxiety in children could be triggered by illness, a stressful situation or a loss for example. Normal depressed states may result from attachment loss, or grief, pain and sadness during a state of moving on or change. While sometimes these depressive states are more reactive, a normal response to loss or unmet expectations, a trauma that may be painful or difficult but not so much pathological, (too much stress for too long) will lead to a reactive state with more going on with the brain.

Adolescents today are facing a shock within wider changes to society. There’s been a steady rise in an increasing number of adolescent depression, with each decade, alongside; nuclearisation of the family against the tribe, confusing rites of passage, the then breakdown of the nuclear family as well, increased pollution, increased technology, disconnection from nature. A journal article from Roger Walsh (2012) talked about how the pharmaceutical industry kind of sidelined a body of research around things such as exercise, time in nature, cooperative tasks, doing things together, service to others, spiritual involvement and other therapeutic lifestyle changes that protect against anxiety and depression.

3. HOW MUCH OF A ROLE DOES SOCIAL MEDIA PLAY?

Mee Hee: Adolescence is a time of transitioning from childhood to that of adulthood through the world of their peers. It is a time when adolescents are working out how they want to be in the world and to find their place in society and culture.  This is why young people absorb cultural change in a very rapid and powerful way.

Culture has historically marked changes in the life cycle of human beings, such as birth, death, marriage, and entry into adulthood by providing rites of passage.  Contemporary society however does not offer such rituals and young people are left to create or invent them for themselves in an effort to shake off the label of child and go on to become part of the adolescent community.

Rituals, created by young people, are reminiscent of the tests of courage we often find in socio-cultural history.  They may require having sex with someone just met, drinking alcohol until loss of consciousness, smoking marijuana, or trying harder drugs.  However, some teenagers feel that these newly created rites are “too much” for them and they may show difficulties in entering the adolescent world and to progress from there into the adult world.

The support offered for adolescent transition was a role traditionally filled by family and schools but now includes information technology. Teenagers spend much of their time on social networks where media determines the criteria of their existence.  Young people spread their focus and attention on a number of things at the same time.  They can watch TV, instant message, watch a video on YouTube, go on Facebook, Instagram, Snapchat, WhatsApp, SMS, Tumblr, and read Blogs.  Their existence and meeting space can be reduced to the mobile phone.

Issues related to the care and protection of privacy and intimacy become real considerations, especially that of adult sexuality, which has been significantly affected by technology and become a spectacle itself.  It has become increasingly challenging for young people to be aware of, and to value, the existence of a space in the mind where emotional relations take place and from where emotional and intimate commitment to another over an extended period of time can take place.  This is often abandoned for quick-fire solutions where the cultural context demand that they interact with it and cope with the pressures that come from it.

Elizabeth: Technology presents a major issue for mental health, with so many different platforms to communicate through, around 60-90% of the communication adolescents do will be digital. So, digital peer pressure is enormous – the pressure for credibility and staying relevant among peers.

As we know cyberbullying is a health concern, as plenty of literature would suggest. We know that cyberbullying also strongly influences other unhealthy behaviours such as young people becoming more likely to abuse drugs and alcohol, and other forms of self-medication or self-harm. The forms of cyberbullying that hurt adolescents most are social media online posts, emails, and photos, that have a greater impact than text message and phone call bullying.

Resilient Youth survey data lets us know that 68% of year 7 to 12 students report that they are using technology between 10pm and 6am. We know from this data that attachment to devices is strong and according to Dr Seaton, a leading pediatric sleep physician, screen time for children is highly addictive. In addition, we’re dealing with other risk factors like for example video games and apps that are designed with addictive qualities, like the hugely popular Fortnight, whereby children’s lives are being compromised by excessive playing of these games.

4. WHAT ARE THE SIGNS OF MENTAL ILLNESS AND WHAT IS JUST “BEING A TEENAGER”?

Elizabeth:
Knowing the difference between warning signs and normal behaviour is not necessarily easy, and many are not able to accurately assess the state of their own mental health. It is important explore noticeable changes in your child, and to pay attention to their perception of life rather than how they appear to be coping. Things like suddenly loses interest and pleasure in activities that once really gave them joy, a loss of appetite or over eating, controlling eating, difficulty sleeping.  Some other key signs of a teenage mental health issue include; longstanding feelings of unhappiness, moodiness, and in particular irritability accompanied by a sense of emptiness or numbness for two to three weeks. This type of presentation is deserving of more assessment than to be considered normal adolescence. Other signs to look for are the self-critical and self-blaming type behaviour, difficulty making decisions, or a pre-occupation with dark and gloomy thoughts and that includes thoughts of suicide.

Mee Hee:

Transitioning from childhood to society and finding one’s place in the world is a very precarious thing, especially for today’s teenagers who are confronted with an external world that is threatening and uncertain.

Their fear is not just a fear of the unknown but today’s adult world is frightening and dangerous.  Young adults must cope with high levels of violence and the risk of unemployment.
And there remains the core adolescent task which parents need to survive. In the words of Winnicott: “If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results.  If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving.  There will be this long tussle which you will need to survive” (Playing and Reality, 1971, p. 193).

In normal adolescent development, the young person must take the place of the parents, and for this reason, growing up is an inherently aggressive act and personal triumph is inherent in the process of acquiring adult status.  As Winnicott said, “You sowed a baby and you reaped a bomb” (Playing and Reality, 1971, p.196).

The onset of puberty is a powerful psycho-biological force in which the body matures sexually and physically, bringing with it an upsurge of feelings which may overwhelm the adolescent.  There is a huge thrust of sexual and aggressive feelings that they need to face and manage.  Loving feelings can now be incorporated into fully sexual urges and if the teenager is to achieve psychic maturity, their loving ties toward their parents must be detached and displaced to other persons.  This is achieved through a process similar to mourning and in some adolescents this process feels like an unbearable loss, and many go through significant periods of depression.

This task of mourning is linked to the task in adolescence of separating, of finding a separate identity apart from that of a child or of their parents.  Life and growth means emotional separation from parents.  Many of the comforts of childhood have got to be given up.  Responsibilities have to be faced, decisions about career, life directions, and the capacity to work are all tested.
In normal development, teenagers have conflicting needs for security, guidance and limits, versus the need and demand for independence and freedom. Conflicted and ambivalent feelings and contradictory needs are prominent. The human psyche always reacts to emotional conflict with anxiety and so adolescence is inherently an anxiety provoking time.
The new sexually mature body is unfamiliar and can be feared and even hated, as can be the sexual feelings.

Facing the reality of independence can lead the adolescent to find new leaders, idealise the peer group or new leader, and project their feelings of failure and helpless incompetence into the parents.

However, at the same time, dependent needs are vital and if unacknowledged or rejected, adolescents may act very violently, even suicidally. The pressures both internally and externally to deny this dependent need can confuse the adolescent, parents and other adults involved.

Anxiety about coping as a separate person is considerable and predominantly manifest in hypersensitivity to belong to the group, to merge with the group or with a sexual partner. The teenager feels deeply wounded when rejected and yet actually sensitive to being infantilised.  When the teenager turns to an adult for help, their need to be understood is often urgent and intense and if he feels disappointed, vengeance, in the form of acting out may be quick, serious, and overwhelming.

Defences belonging to an earlier life may be activated – extreme splitting, black and white view of the world, manic omnipotence, idealisation, and feeling persecuted – which is why adolescence is a time of risk for the development of psychosis and borderline behaviours.

Adolescence need support through their adolescence and to have parental figures to help them deal with the realities of life.  If parents abdicate, the worst scenario will develop as adolescents have yet to become capable of taking responsibility for their cruelty, hostility and psychological pain.

The capacity to cope in adolescence, as mentioned earlier, is to a large extent, determined by the developmental strengths build up earlier in development.  Hence, difficulties transitioning through adolescence is an opportunity to re-work earlier developmental deficits and/or arrests.

The complexity and intensity of adolescence, as described above, is why it is a time that individuals are vulnerable to depression, suicide, and psychosis.  Mental illness in teenagers occurs when they have trouble working through the adolescent task of separation and how they want to be in the world.  This is often marked by developmental collapse in the form of school refusal, eating disorders, panic disorder, social anxiety, anti-social behaviour, and other forms of severe refusal syndrome.

5. HOW IMPORTANT IS IT TO ALLOW TEENAGER’S TO EXPRESS THEIR ANGER/VOLATILITY, AND NOT TRY TO TURN THEM INTO ‘THE PERFECT CHILD’?

Mee Hee: Although reinforced in present day, trying to control teenage behaviour may either lead to increased defiance and anxiety through pseudomaturity or developmental arrest. Teenagers who are pushed or want to skip over adolescence, and driven by parental or external pressure or by their own ambition, and enter ruthlessly into adulthood often suffer a breakdown around the time they reach forty. On the other end of the spectrum, in cases of protracted childhood where parents and/or young person are fixated on the world of children and family, remain in a state of “expectancy”, waiting for their parents or other adults to introduce them to the realm of adulthood.

Childhood is messy and children are not meant to behave. Parents have a messy and difficult and complex 20 year project in helping children to manage their emotional life before setting them into society!

6. ARE THERE ANY SIGNS TO LOOK FOR THAT INDICATE A TEENAGER MAY BE CONSIDERING SUICIDE?

Elizabeth: Some of the more typical symptoms that accompany thoughts of intentions of suicide are again withdrawal from friends and family, increase in reckless behaviours such as using drugs and alcohol or behaving in ways that compromise physical safety. Other behaviours include, giving away significant possessions or overspending, talking about suicide, being pre-occupied with ideas of death.

If you are concerned, try to create opportunities to talk. Asking about suicidal thoughts or ideas will not increase the likelihood of any action being taken. The main thing in suicide prevention is belief that others help and identifying, knowing who to go to, who/where are your supports, and that those supports can foster hope.
Children or young people at immediate risk of suicide or self-harm should be referred to the emergency department of a hospital or relevant acute mental health service, or a child/youth psychiatrist.

Mee Hee: Adolescence, in addition to individuals with depression, alcoholism, schizophrenia, psychosis, borderline personality disorder and panic disorder, have a high risk of suicide. Thankfully, the vast majority of those who fall in these categories are not suicidal. Suicide is not a symptom of an underlying diagnostic condition that goes away if the condition responds to treatment. Knowledge of the affective and cognitive components of the meaning of suicide helps distinguish which person with any given diagnosis are at risk for suicide, though prediction of suicidality, especially in the longer term, is notoriously difficult.

Suicide, especially in the young, is usually an escape from an intolerable affective state. The nature and intensity of the following affects are indicators that distinguish those who are suicidal from those who are not:

Rage: Hostility and rage distinguishes those who are depressed who are suicidal from those who are not. This may be conscious or observable hostility, or it may be unconscious and less visible, for instance, in seemingly compliant young people with eating disorders. In youth suicide, only about a 1/4 have histories of major depressive disorder whilst just under half have a history of aggression.

Hopelessness, despair and desperation: These feelings can arise from aloneness, murderous hate, self-contempt, and any state that leads to the individual’s inability to maintain or imagine any human connections of significance. Desperation is felt when there is a hopelessness about change and that life seems impossible without that change. Sometimes what the person is hopeless about is not in their awareness but gives rise to a huge amount of anxiety. Anxiety as part of this affective state is a strong predictor of short term risk of suicide.

Guilt: When guilt is linked to conscious or unconscious hate and anger that leads to anxiety, this can be a risk factor for suicide.
Cognition and meaning: When we are trying to determine the meaning of any behaviour, including suicide, we can’t be limited to information the person volunteers or their responses to questions. The meaning of suicide is often unconscious. Suicidal youth give death a special meaning and may actually or in fantasy, use their own deaths in an effort to control others or to maintain a sense of control over their own lives.

Some of the common meanings given to death by young people who have committed suicide are death as reunion, death as rebirth, death as retaliatory abandonment, death as revenge, and death as self-punishment or atonement. In the case of self-punishment or atonement, we often see adolescents who failed to meet their own or their families’ academic, vocational, or social aspirations, or matching those of siblings or peers. They have a sense of humiliation or failure and suicide is an expression of self-hate and the need for punishment.

Although this all sounds within the young person’s awareness, it often isn’t and the young person feels pushed into their own death by forces beyond their control or understanding. What the meaning of suicide in young people have in common is that they are responses to loss, separation, and abandonment whilst feelings of rage may be repressed, projected or expressed from the experience of loss or loss of self-esteem.
Rejection of life usually includes a rejection of the parents from whom life originated. The young person is likely to feel in a deep way that they were the ones to have been abandoned first.

As mentioned previously, life and growth entails emotional separation from parents.Painful feelings are an inevitable part of development but for suicidal youth, loss, separation and death are often equated.

7. WHAT CAN PARENTS DO IF THEY THINK THEIR CHILD IS STRUGGLING WITH THEIR MENTAL HEALTH?

Mee Hee: Everyone will experience disappointments and painful losses. The capacity to bear these feelings derive from a baby’s earliest relationship with his mother. If she has been able to be responsive with her baby in an empathic way, she can contain the baby’s and later, the child’s, pain and the baby will, in time, internalise this capacity to contain or manage their own painful, frustrating, anxiety-provoking, and disappointing feelings without having to resort to extreme defences to avoid feelings.
It’s this capacity, or not, that is brought to bear in adolescence, as it is in later adult life. It is this capacity that is tested when children are struggling with their emotional life, what is now called, mental health.

Parents can understand and accept the child they have and help them to manage their feelings rather than “fixing” or trying to control the behaviours.
Helping children with their emotional development is the most important thing, without this, all other areas of development become derailed.

Elizabeth: Try to engage in a genuine way; giving young adolescents your full attention, ask questions, be interested and give them feedback or paraphrase back what you are hearing. Understanding the developmental perspective and improving emotional literacy help with communication. Adolescents are operating mostly of the amygdala, a structure of the brain, which operates well off feedback, short sentences and humour. You are also providing an opportunity to clarify what they thought they were expressing. And young people are responsive to positive feedback and keeping things upbeat. Look for positives in their lives. Their brains are not yet fully developed. The pre-frontal context is not fully developed until the early twenties. The capacity for forward thinking and to weigh up consequences is a work in progress. Therefore, the role other caring adults play is pivotal in supporting limits and boundaries over the things that matter in particular around health and safety.

However, in understanding mental health issues and mental illness, it is important to consider that while there are common symptoms that we could understand to be a syndrome like depression or anxiety – that the consequences of these are wide ranging. So, it is important that we try not to give advice or generalise. Around technology, skills, knowledge and strategies around using technology in a safe way need to be supported. You can, for example set up a random wifi password generator or use programs like, Family Zone, where you control and see apps and games being used.

Importantly though, setting limits and restrictions on devices does not address the underlying issues for use or over use of technology. Avoidance of addressing other issues may need exploring as suddenly restricting devices can exacerbate underlying anxieties. Equally as important is taking the time to understand the complexities of your child’s situation.

 

8. WHAT CAN FRIENDS DO?

Mee Hee: Friends can listen and provide support, but if the difficulties are severe, friends can encourage the young person to make an appointment with their school counsellor or inform the parents.

Elizabeth: A friend can be there to listen, to ask what may help. Acknowledge and validate how they are feeling, offering emotional support. Offer practical support and let them know about other support services. And take care of yourself. It can be difficult for people with mental health issues to ask, to accept help, and to make decision so offering practical support is really helpful. For example, check in, suggest a time and a place to catch up. And the village aspect is really important, to try and recreate opportunities to connect.

9. ARE THERE “PROTECTIVE” FACTORS FOR YOUNG CHILDREN TO PREPARE THEM FOR TEENAGE HOOD?

Mee Hee: Protective factors are related to previous developmental building blocks having been established. These are to do with focus, attentiveness, capacity to learn, capacity to be alone, capacity to separate and find a place within a group, and to tolerate frustration.  These can be established in relationship with parents but also through early childhood play. It also involves having parents who have a capacity to tolerate their child’s strong feelings, including anger and hate, without retaliating.

Elizabeth: We know that four out of five kids in high school are doing really well. Six out of seven kids in primary school are doing really well. That is because they have caring loving adults in their lives, who have made them feel safe and valued and listened to. Perhaps these parents have read a little of what the literature says about builds resilience. While we can’t control a lot of the social factors like these battle of the selfies on Instagram and snapchat, we can support the kids in having the capacity to withstand what is happening to them as well as enable kids to experience responsibility for their choices. And support them to develop resilience, which is the capacity to face, overcome, and be transformed by that adversity. Things like, if in life you can’t change something, you and you alone can change the way you think about it. So, we can practice the way we think about things. Or, see life as it is but focusing on the good bits.
Or, recognise that the greatest predictor of wellbeing for your children is not being good looking, is not having a lot of money, it is not even having more good things happen than bad. It is actually having a rich repertoire of friends and that we as parents can support our children in this way. Having close relationships, doing things together, team sports, and cultivating a sense of living in a benevolent society.

These are just some of the strategies that have an evidence base that can really prepare our children’s well-being.

Therapeutic lifestyle changes can also help protect against anxiety and depression include; such as getting out in nature. A study by Nanda et al (2011) showed that by simply increasing symbols of nature (images, sounds) reduced intensity of medication was needed for depressed patients.
Getting a good night’s sleep – deep level four deep sleep for cleaning out the cytokines, sleep for working out the emotional issues though dreams, no blue light after dark, no alcohol, include vitamin D in the diet.

Practicing relaxation such as diaphragmatic breathing; creating pressure in the abdomen is both massaging the airways and stimulating the vagus nerve in your thorax (around your guts) and there’s a subsequent flow of electricity up the right side of the neck into your brain releasing the GABA. And exercise, we know that the neurotrophic factor from exercise will help the adolescent with depression.

10. WHEN SHOULD A CHILD OR TEENAGER SEE A PSYCHOLOGIST?

Mee Hee: If parents are confused or feel that they do not know how to help their child to manage their feelings and/or if the child or teenager are finding their development too much to bear, a qualified child and adolescent psychotherapist can be sought.

Elizabeth: While psychologists typically deal with mental health issues, it can be helpful to engage with psychological therapy when needing support navigating any issue that may seem challenging. Psychologist provide focused psychological therapies in both a preventative and management sense. Going to see a psychologist isn’t about being labelled or getting a diagnosis but about being more deeply understood so that through the process, changes can be generated.

We need to make sure the child is willing to be there, to be clear and simple enough in fully explaining what kind of service is provided. In accessing a psychologist it is equalling important that the child’s care-givers are provided with opportunities to fully understand the service and participate as well as have their expectations or concerns addressed.

Who else can help?

 

–             Your GP

–             Kids Helpline 1800 55 1800 or www.kidshelp.com.au

–             Headspace 1800 650 890

–             The Black Dog Institute www.blackdoginstitute.org.au

–             beyondBlue on 1300224636