1. 1 Adolescent Mental Health: Population-based Disaster Prevention Gwendolyn J. Adam, Ph.D., L.C.S.W. Assistant Professor - Department of Pediatrics Section of Adolescent Medicine and Sports Medicine MCHB-funded Leadership Education in Adolescent Health (LEAH) Program Baylor College of Medicine

2. 2 Goals & Objectives Goal: Understand critical issues in adolescent mental health as public health opportunities for population-based disaster prevention. Objectives: –Utilize key data indicators of adolescent mental health to motivate strategic action –Identify conceptual and practical barriers to addressing adolescent mental health needs –Develop strategies for improving public health cultivation of adolescent mental health

3. 3 Adolescent Mental Health Using Key Data Indicators to Motivate Strategic Action: Why We Need a Bracelet

4. 4 Key Data Indicators Demonstrate that Mental Health Issues: are prevalent among U.S. adolescents –1 in 10 children / adolescents suffers from mental illness severe enough to result in significant functional impairment - It is estimated that 20% of children / adolescents have a diagnosable mental disorder –(in 2004) 3.5 million youth (14%) ages 12-17 have experienced at least one major depressive episode in their lifetime lead to lethal thoughts and acts – suicide - 3 rd leading cause of death for adolescents –900,000 youths (3.6%) made a plan to kill themselves during worst or most recent Major Depressive Episode –712,000 youths (2.9%) tried to kill themselves during such an episode impact other behavioral health risks – e.g. drug and alcohol use have family system implications - parent mental health affects adolescent health risk behavior are not adequately addressed for adolescents - less than half of depressed adolescents receive treatment when they need it

5. 5 Key Data Indicators Demonstrate that Mental Health Issues: impact other behavioral health risks – e.g. drug and alcohol use have family system implications - parent mental health affects adolescent health risk behavior are not adequately addressed for adolescents - less than half of depressed adolescents receive treatment when they need it escalated for adolescents - between 1960 and 2000 the suicide rate among adolescents increased 128% as compared to an increase of 2% in the general population.

6. 6 Adolescent Mental Health Identifying Conceptual and Practical Barriers to Addressing Need: What to Consider in Developing our Bracelet

7. 7 Conceptual Barriers: Understanding Adolescents Myths regarding adolescents undermine parental and provider recognition of distress –Youth want to be alone –Youth don’t talk to adults –Youth behavior is consistent – if depressed will look depressed always / or at all –Sulking, minimal eye contact, no communication, sleep all day, outrageous moods, angry, violent, substance use, not eating - are normal –When in need youth just want adults to listen

8. 8 Conceptual Barriers: Understanding Adolescents Stereotypes of adolescents keep others away and reinforce the myths Adolescents are rarely the “puppy of choice at the pound” Stereotypes tend to influence adult approach to interaction – little communication, passive approach to parenting and intervention – reinforce the expected disconnect between youth and adults

9. 9 Conceptual Barriers: Understanding Adolescents Risk behaviors are meaningful and may or may not be rebellious / may be palliative Youth recognize distress in each other and go to one another for help / give feedback Youth friends are often alienated by adults when mental health issues emerge Manifestation of mental health issues in adolescents differs from adults (e.g. sadness versus irritability, overcompensation)

10. 10 Conceptual Barriers: Stigma Parents are fearful of blame in seeking help – “I love my child.” Concern regarding the records and the labels Parents sometimes choose risk of adolescent’s death over risk to their future Fear of failure or reality as a parent – “this just isn’t my kid” to “go ahead and kill yourself” Reliance upon parents to facilitate mental health care access despite above concerns Youth stigmatize need for counselors – equate with need for attention or to get out of school

11. 11 Conceptual Barriers: Public Health Expectations “There is no mental health equivalent to the federal government’s commitment to childhood immunization. ” – David Satcher, M.D., Ph.D. “Psychosocial Immunizations” –imagine “required mental health screening” for school –barriers reflect stigma around mental health issues and problems with access to care –outcomes of preventable diseases may be less lethal than mental health crises –parental expectation in responsibility differs from shots –critical impact on educational process yet not standardized

12. 12 Conceptual Barriers: Public Health Expectations Mental illnesses are “internal terrorists” –Disaster prevention versus disaster preparedness versus crisis intervention –Public awareness and motivation regarding youth mental illness are generally limited to headlines –Columbine High School Massacre (1999) – 12 homicides / 2 suicides / 24 injured versus 4,243 completed suicides in 2001 for similar age group –Opportunity to focus on impact of bullying, isolation, depression, violent media, social relationships, anger management, etc. –Response – gun control / metal detectors versus mental health screening and responses

13. 13 Conceptual Barriers: Public Health Expectations Adolescent “failure to thrive” concept missing Quality of life – “I survived.” – Daniel Symptoms are not the only thing to consider –emotional and social readiness for school –impact of staying sad or anxious for several years during key development period –impact on learning and social development Most of the treatments / services adolescents typically receive have not been evaluated to determine efficacy across developmental periods

14. 14 Conceptual Barriers: Public Health Expectations Challenges exist in identifying mechanisms by which ethnicity, race and culture account for disparities in behavioral and emotional problems and service delivery –Lack of early detection by providers and parents –Untrained and / or culturally insensitive providers –Lack of parent / provider knowledge of developmentally appropriate AND efficacious treatment –Insurance status –Settings where mental health care is delivered

15. 15 Conceptual Barriers: Public Health Expectations National measurement focus on teen suicide and teen pregnancy – “negative orientation” Asset-based measurement – screen for strengths and measure impact over time Cultivating mental health versus documenting mental illness – role of public health in shifting focus

16. 16 Conceptual Barriers: Public Health Expectations Estimating economic burden of mental health concerns in adolescents is understudied and difficult to assess: –multiple systems providing services –serious events – severe criminal acts / suicide –loss in later educational and work productivity, parental productivity –positive impact of prevention programs to decrease role of current treatment and increase productivity later –must involve multiple stakeholders

17. 17 Adolescent Mental Health Developing Public Health Strategies that Cultivate Adolescent Mental Health: Designing Our Bracelet

18. 18 Public Health Strategies: Using What Evidence Demonstrates Psychosocial intervention enhances pharmacological treatment Multi-systemic therapy promising– addresses child and child context Some forms of institutional care do not lead to lasting change when adolescent is returned home Services to delinquent youth like boot camps and residential programs – generally ineffective Some peer-group based interventions actually increase behavior problems

19. 19 Public Health Strategies: Need for Interdisciplinary Approaches Must eliminate discipline insularity Effective treatment practices must be shared across disciplines Primary care and mental health disciplines must jointly develop and utilize screening and prevention tools Research should include mental health and health disciplines

20. 20 Public Health Strategies: Making Science Accessible Development of research should begin with the context and placement of the intervention as a focus Must involve youth and family, community and treatment stakeholders, in partnership with researchers from the beginning Factors influencing ultimate dissemination must be considered during development

21. 21 Public Health Strategies: Impact is Everything Messages must be clear and organized to overcome adolescent-specific issues: –difficult to imagine the icon of adolescent mental health –many adolescent mental health difficulties by nature include resistance (depression – lack of energy or hope, substance addiction, eating disorders) –risks are behavioral – involve blame –developmental process may require that providers be vulnerable to be effective with youth

22. 22 Public Health Strategies: Impact is Everything Message must be compelling: –Enlist creative partnerships to finance interventions and outreach – who will adopt the adolescent population –Time-limited – adolescence is a “statutory offense / opportunity” –Now or later approach – untreated mental health issues in adolescents often become adult problems and / or disabilities

23. 23 Public Health Strategies: Impact is Everything Message must be effective: –Issues are life-threatening – disaster prevention –Mental illness has no lobby – or does it? –Enlist public interest, energy and outrage –Involve youth –Empower families –Encourage evaluation to measure impact

24. 24 Public Health Strategies: Impact is Everything Message must be exponential: –Maximize public health power / minimize public health expenditures –“Intentional epidemic” / outbreak / wildfire – public health expertise reversed –Involve all layers / stakeholders –Increasingly self-sustaining

25. 25 Adolescent Mental Health What will our bracelet be?

26. 26 Summary Discussed critical issues in adolescent mental health as public health opportunities for population-based disaster prevention Encouraged use of adolescent health key data indicators to motivate strategic action Identified conceptual and practical barriers to addressing adolescent mental health needs Developed strategies for improving public health cultivation of adolescent mental health

27. 27 “I survived.” - Daniel

28. 28 References Blueprint for Change: Research on Child and Adolescent Mental Health, Report of the National Advisory Mental Health Council’s Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment, Executive Summary and Recommendations (2000) DASIS Report: Adolescents with Co-Occurring Psychiatric Disorders: 2003 National Adolescent Health Information 2004 fact Sheet on Suicide: Adolescents and Young Adults. NAHIC (2004). National Survey on Drug Use and Health Report: Depression Among Adolescents. Substance Abuse and Mental Health Services Administration (2004). National Survey on Drug Use and Health Report: Mother’s Serious Mental Illness and Substance Use Among Youths. Substance Abuse and Mental Health Services Administration (2004).

29. 29 References National Survey on Drug Use and Health Report: Office of Applied Studies. Substance Abuse and Mental Health Services Administration (2003-2004). National Survey on Drug Use and Health Report: Suicidal Thoughts Among Youths Aged 12 to 17 with Major Depressive Episode. Substance Abuse and Mental Health Services Administration (2004). New DAWN Report: Disposition of Emergency Department Visits for Drug-Related Suicide Attempts by Adolescents, 2004 Preventing Child and Adolescent Mental Disorders: Research Roundtable on Economic Burden and Cost Effectiveness (2004) U.S. Public Health Service, Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. Washington, DC: Department of Health and Human Services, 2000.