Adolescent Health and Well‐being Adolescent development and behaviour: What’s normal and when to worry? Clinical Professor David Bennett: Department of Adolescent Medicine and NSW Centre for the Advancement of Adolescent Health Part One: Understanding adolescence – a developmental change for all concerned Principles of adolescent health care: knowing what’s happening to their bodies and minds, recognising the intimate relationship between development, health and behaviour, encouraging self responsibility and self care, and providing a friendly environment and an innovative team approach. Why focus on adolescence? Adolescence is a distinct, significant and fascinating time of life where profound and rapid changes occur with potential for huge impact on both current and future wellbeing. Understanding adolescence – a struggle between inner drives and outside expectations... •
“A time of cosmic yearnings and private passions, of social concern and private agony” (Haim Ginott, Between Parent and Teenager, 1969) •
“Adolescence is a time when longings awaken with an intensity that many have misunderstood and dismissed as “hormones”. The larger questions about meaning, identity, responsibility and purpose begin to press with an urgency and loneliness we can all remember” (Rachael Kessler, The Soul of Education, 2000). Generation Y: born 1980 – 1995: Post‐1975 ‘options generation’ – people born in this generation are flexible, open to change, cooperative – and the most tribal generation we have seen. “They are world champions at establishing intimate, supportive relationships with their peers, standing by each other, and staying connected”. Generation Z: born late 1990s ‐ ? • Addicted to technology: Childhood has largely become an indoor experience for the Zs. For much of this generation, only a fraction of free time is spent playing outdoors. • Prematurely mature (‘developmental compression’): Zs are exposed to more, experience more, and experiment more at a younger age than previous generations; body image is becoming an issue of increasing concern for both boys and girls in primary school rather than early high school. The Adolescent Childhood (AC) Syndrome (Hugh Mackay) is the curious desire of parents to hasten their children’s development toward adulthood by encouraging them to act like mini‐adults plus (re girls) the machinery of modern marketing of clothes and products designed to ‘create the illusion of a precocious, premature sexuality’. The mass marketing machine is impatient with childhood. • Risk averse: “Generation Z (and to a lesser extent Gen Y) has grown up in an era where risk has become unacceptable and ‘throwing caution to the wind’ is akin to negligence” (Michael McQueen, The New Rules of Engagement: A Guide to understanding and connecting with Generation Y, Nexgen Impact, 2008; Michael Grose, XYZ: The New Rules of Generational Warfare, Random House Australia, 2005). Adolescence: While puberty is the unique set of events involving changes in physical appearance and hormones from those of a child to a mature adult, adolescence is a longer and more complex period of cognitive and psychosocial development during the second decade of life. • “A period of personal development during which a young person must establish a sense of individual identity and feelings of self‐worth which include an acceptance of his or her body image, adaptation to more mature intellectual abilities, adjustments to society’s demands for behavioural maturity, internalising a personal value •
system, and preparing for adult roles” (Ingersoll GM, Adolescence, 2nd Ed, Englewood Cliffs, NJ: Prentice‐Hall 1989). “Adolescence is a time when longings awaken with an intensity that many have misunderstood and dismissed as “hormones”. The larger questions about meaning, identity, responsibility and purpose begin to press with an urgency and loneliness we can all remember” (Rachael Kessler, “The Soul of Education”, 2000). Psychosocial goals • Psychological – acquiring independence and autonomy • Social – dealing with changing family and peer group relationships • Emotional – shifting from narcissistic to mutually caring relationships These tasks include: the formation of self‐identity, including sex‐role identity; the movement towards autonomy and, ultimately, independent living (an attenuated process in modern times); the achievement of a healthy body image; the ability to form healthy, working relationships with same sex and opposite sex peers; the development of a set of moral beliefs and standards; and acquisition of a vocation. The central developmental task of adolescence, however, is the establishment of a sense of identity and self worth. Essentially, the adolescent must work out who they are as a functioning individual, separate from the family. They need to work out their strengths and weaknesses, their likes and dislikes, what contribution they can make and a consistent way of responding to others. Erikson’s psychosocial stages: Erik Erikson was trained by Sigmund Freud’s daughter, Anna Freud. He proposed that every individual must successfully navigate a series of psychosocial stages, each of which presented a particular conflict or crisis that needs to be resolved. Erikson’s psychosocial stage model is a widely used tool for understanding human development over the life span. Erikson described adolescent development as a conflict between identity formation and identity confusion (Carlson and Buskist 1997). The process is one of active searching and involves experimenting with identities. The process is one of active searching and involves experimenting with identities. The successful achievement of identity brings autonomy, better control over impulses (largely related to neurobiological development), a decrease in self‐absorption, resistance to peer conformity and more harmonious relationships within the family. Social (and emotional) development: Much of the study of social development in adolescence focuses primarily on the changing roles of family (or adult caretakers) and friends. Adolescents participate in peer relationships at the three levels of friendships, cliques and crowds (Smetana JG et al, Adolescent development in interpersonal and societal contexts. Annual Review of Psychology, 2006:57, 255‐284). Cognitive goals: • Cognitive – moving from concrete to abstract thought • Moral – developing a set of moral beliefs and standards This is supported by brain development. According to Piaget, there are four ordered, discontinuous stages of cognitive development: • Sensorimotor (0 – 2) • Preoperational (2 – 7) • Concrete operations (7 – 11): child achieves understanding of conversation. Child can reason with respect to concrete, physical objects. • Formal operations (11 +): child develops capacity for abstract reasoning and hypothetical thinking Implications of cognitive growth: “Adolescence is a time when longings awaken with an intensity that many have misunderstood and dismissed as “hormones”. The larger questions about meaning, identity, responsibility and purpose begin to press with an urgency and loneliness we can all remember.” ‐ Rachael Kessler, “The Soul of Education”, 2000 Part Two: Adolescent behaviour: What’s normal and when to worry Infuriatingly normal behaviour: “Teenagers dominate the telephone, play unbearably loud music, never tidy their rooms, are incredibly moody, and push their parents to the limit.” ‐ Growing Pains, 1987. The period is also typified by conflict with parents, challenging of authority, a need for privacy, emotional outbursts, intense interest in peer activities, and the taking of risks. Normal adolescent behavior • Limited awareness of consequences • Open and talkative with friends • Need to be like peers • Monosyllabic with family • Sleeping in • Moodiness and flare ups • Critical and argumentative • Active striving for independence • Trying new experiences Worrying adolescent behavior • Violent/aggressive • Wild mood swings • Dangerous drug/alcohol use • Suicidal ideation • Loss of routine, excessive sleeping • Dramatic or persistent behaviour change • Withdrawn, secretive • Isolation from peers • Failing school performance or dropout Risk‐taking behaviour • “Adolescents experiment with new activities, testing their limits, exploring new skills, and enjoying the often exhilarating sense of freedom involved.” • “What adults see as problems, young people often see as solutions” (Richard MacKenzie, 1987). Neurodevelopment – new findings: a child has rapidly proliferating brain cells (4 quadrillion ‐ 16 billion); during adolescence, neurons are pruned and myelinated. This process is governed by intrinsic determinants as well as external influences and experiences. Structural changes/reorganization begin in the cerebellum and move forward – the move from awkwardness to awareness: • Pre‐frontal cortex – executive function (Dorso‐frontal lobes – centres of ‘sober second thought’; (1) impulse control, planning, emotional regulation; (2) executive functions such as decision making) • Amygdala – emotion and associated memory • Nucleus accumbens – motivation, reward and punishment • Cerebellum – co‐ordination and balance The back of the adolescent brain matures first… • Sensory and physical activities are favoured over complex, cognitive‐demanding activities • There is a propensity toward risky, impulsive behaviors, poor planning and judgment. Heavy alcohol use in young people affects brain maturation: Preliminary data suggests that binge drinking affects brain maturation; female brains may be more at risk. This imbalance leads to risk taking, low effort ‐ high excitement activities, interest in novel stimuli and impulsiveness. Psychosocial concerns: “…the prevalence of social and psychological problems has increased in young people ‐ with a fifth to a third now experiencing significant distress at any one time – and it is often higher than in older age groups.” (Eckersley R. 2005. Well & Good: Morality, meaning and happiness, 2nd ed.)These concerns are often hidden; young people are reluctant to seek services to address these needs. Worrying trends • Adolescents are involved in health‐risk behaviours earlier than past generations • Many adolescents engage in behaviour that threatens their health and well‐being • Considerable continuity of health‐ risk behaviours from adolescence into adulthood Who are the kids at risk? Those who are perceived as different, those who experience serious losses or other traumas, those in difficult external circumstances. Little social support = highest rates of ill health and vice versa (AIHW 2007). The research shows that there is an association between young people’s level of social support and the number of health problems they face; those living in circumstances where they have little social support are also those who have the highest rates of ill health (AIHW 2007). Kids in problematic families are at increased risk; children whose parents have mental health and substance abuse problems are likely to have mental health problems and children whose parents parent badly are more likely to turn out badly. Risk factors for involvement in juvenile crime include family factors, intellectual functioning and school performance, truancy, influence of delinquent peers, poverty, unemployment, substance misuse and early engagement in risk behaviours which impact on physical and mental health. Part Three: Being Healthy & Happy – Fostering Resilience and Wellbeing Social conditions and young people’s health: Young people who are living in families or communities that are fragmented, unsupportive and badly resourced are the most likely to experience health problems. “Safe neighbourhoods are associated with better psychological wellbeing and educational achievement of young people.” (Meyers and Miller 2004, quoted in AIHW 2007:94). In 1998 a higher proportion of young people aged 12‐
17 with emotional and behavioural problems lived in less cohesive families; 36% of young people with emotional and behavioural problems lived in a families with poor or fair family cohesion, compared with only 13% of those without emotional and behavioural problems. Parents of young people aged 12‐24 years who were living in the most disadvantaged areas were the most likely to report their health as fair or poor. Research shows a direct association between a young person’s level of social support and the number of health risk factors they exhibit: Around 30% of young people who lacked social support were daily smokers compared with 17% of other young people. 30% of young people who lacked social support did not participate in social activity or did less than once a week, compared to 20% of other young people. 11% of young people living in the most disadvantaged areas lacked social support compared with 5% of those living in the least disadvantaged areas (AIHW 2007:105). Health inequalities: The ‘poverty cycle’ provides a backdrop of health and social inequalities and social barriers that shape the lives and future prospects of young people. Young people’s health is a sensitive indicator of social and economic inequality. There is overwhelming evidence that young people’s health and wellbeing is directly related to the quality of the social and material resources that they are able to draw on. Recent Australian data shows that as socio‐economic status decreases there is a parallel increase in mortality, morbidity and in smoking, poor exercise and diet. The likelihood of a young person being a victim of physical or threatened assault increases with social disadvantage (AIHW 2007). Happy and healthy go hand in hand: Mental Health is a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of everyday life, can work productively and fruitfully, and is able to make a contribution to his or her community (WHO. Mental Health: New Understanding, New Hope. Geneva 2001). Mental health promotion activities imply the creation of individual, social and environmental conditions that enable optimal psychological and psychophysiological development including prevention of mental disorders.’ Hosman and Jane‐Llopis, 1999. ‘Authentic happiness’: The evidence so far indicates that meaningful and engaged lives are more important than pleasurable experiences in determining wellbeing. Healthy individuals and a healthy society strike a balance between commitment to the self and commitment to the common good (Seligman et al, 2005). The 3 routes to happiness: • Positive emotion and pleasure • Engagement – being immersed in what you’re doing at any given time • Meaning – achieved by using one’s strengths for a higher goal. (Seligman M, Steen T, Park N and Peterson C. (2005) Positive psychology progress: Empirical validation of interventions. American Psychologist, 60:410‐21) For more information on positive psychology, visit: www.authentichappiness.org Resilience: Resilience is a summary term used to refer to a range of characteristics that enhance one’s ability to bounce back from tough times. It is the process of continual development of personal competence while negotiating available resources in the face of adversity (Lyn Worsley, 2010). The word resilience comes from the Latin ‘re‐silere’: to spring back. • “Resilience is the happy knack of being able to bungy jump through the pitfalls of life. Even when the hardships of adversity arise, it is as if the person has an elasticised rope around them that helps them to rebound when things get low, and maintain their sense of who they are as a person.” (Andrew Fuller, 1998) • “What seems important is to approach life’s challenges with a positive frame of mind, a confidence that one can deal with the situation, and a repertoire of approaches that are well‐adapted to one’s own personal style of doing things.” (Michael Rutter, 1993) • “Resilience is not only an individual’s capacity to overcome adversity, but the capacity of the individual’s environment to provide access to health enhancing resources in culturally relevant ways...” (Ungar et al, Family process, 2007; 43(1):23‐41) • “Building resilience is a never‐ending upward spiral of coping with and taking charge of problems, solving them one at a time, and transforming failures into strategies that can be used to cope with and take charge of the next problem.” (Michael Blum, 2006) The Resilience Doughnut: Connecting strengths to thrive. Three factors are needed to build resilience: • resourcefulness (I have) • self esteem ( I am) • self efficacy (I can) These internal characteristics interact with seven different contextual factors. The Resilience Doughnut is a model for building resilience in children and young people. This model is being used by practitioners all around Australia, and is quickly spreading to other countries, including Japan, South Africa and the UK. The seven factors that resilient young people and adults have in common are illustrated in the shape of a doughnut. Ways of helping a young person through stressful times and building their resilience are shown using the simple common sense formula: “If something is working, do more of it”. Lyn Worsley has created this model as a resource that can be used for anyone experiencing the difficulties that life inevitably brings. Children as young as 5 years old have used the Resilience Doughnut and understood what makes them strong! For more information on the Resilience Doughnut, contact Sue on 0408 164 785 or email [email protected] www.theresiliencedoughnut.com.au Protective factors for adolescents: • Personality characteristics such as autonomy, self esteem and a positive social orientation • Family cohesion, warmth and an absence of discord • External support systems that encourage and reinforce a child’s coping efforts and ‘hold them to high expectations’ (Masten and Garmezy, 1985) “Young people will be more resilient if the important adults in their lives believe in them unconditionally and hold them to high expectations; young people live up to or down to the expectations we set for them.” (Ginsberg). Resilient children have various strengths or internal assets which, when coupled with environmental or external strengths, can be described as protective factors. Typically, resilient children are recognised by their high self‐
esteem, internal locus of control, optimism and clear aspirations, achievement and goal‐orientation, reflectiveness and problem‐solving capacity, respect for autonomy of themselves and others, healthy communication patterns, and the capacity to seek out mentoring adult relationships (Rutter, 1987; Fuller, 1998). Personal resilience is a foundation for positive development throughout childhood, and is thought to derive from the accruel of both internal and external protective factors in a variety of settings, which themselves may be described as ‘resilience‐
promoting’ (Rutter, 1990; Gilgun, 1996; Coll et al, 1998). Part Four: Implications for parents and teachers The family at adolescent transition: Like a living organism, families seek to adjust to natural changes that occur across the family life cycle. 40% of parents report an increase in distress (especially mothers) in the early adolescent years including lowered self esteem, diminished life satisfaction, increased anxiety and depression and more frequent rumination about middle age. Australian parents are worried • Parents lack confidence and believe they could be better parents (60%) • Parents do not believe that parenting comes naturally • Parents want more information and support to achieve better outcomes for their children • 78% of parents seek advice from family and friends; 25% are concerned about being judged for seeking help. • 71% are struggling to find time to enjoy activities with their children. (Tucci, Goddard and Mitchell, The concerns of Australian parents, Australian Childhood Foundation, 2004) • ‘The amount of time parents spend with their children/week has decreased by 20 hours per week over the last generation, substantially due to both parents now working.’ (Dr David Dossetor). Strong Families have several things in common: appreciation, open communication, time together, a commitment to promoting happiness and welfare, spiritual wellness, and ways to cope effectively with stress. (The Secrets of Strong Families, Nick Stenett & John De Grain) Parenting style: “The rules regarding child‐rearing are not primarily about making children feel good, but about making children into good people ‐ resilient, self‐reliant, compassionate and ethical.” (Wendy Mogel, The Blessing of a Skinned Knee: Using Jewish Teachings to Raise Self‐Reliant Children, 2001). Competent parenting is about adaptability (Azar 2002). Three themes have emerged: perceptiveness, responsiveness and flexibility. Authoritative parenting (high warmth, high regulation) • Warm, involved and responsive • Firm and strict and demanding of maturity • Fosters and encourages psychological autonomy (Diana Baumrind, 1971, 1991) Adolescents from authoritative homes achieve more in school, have better self‐reliance and self‐esteem, less depression and anxiety, more positive social behaviour, self‐control, cheerfulness and confidence and are less likely to engage in anti‐social behaviour (Lawrence Steinberg, 2001). Authoritarian parenting (low warmth, high regulation): “…parenting styles of low warmth, high use of punishment and low monitoring of the child’s behaviour were associated with externalising behaviours and with substance use.” (Australian temperament Project, 1983‐2000 Australian Institute of family Studies, Pathways from Infancy to Adolescence). Essentially: (i) Show love – accept that your children are both special and ordinary (ii) Expect respect – a democratic system doesn’t work well for dogs or children; it just makes them feel insecure (iii) Encourage self‐reliance – teach them to be resilient, self‐reliant and courageous. Participation and responsibility: “The lessons we instil by insisting that our children do mundane tasks may very well be the ones that stay with them longest, helping them to become self‐reliant adults, responsible community members, and loving parents.” (Wendy Mogel, The Blessing of a Skinned Knee). Above and beyond generating a general sense of connectedness to family members, eating meals as a family benefits young people. Additionally, the frequency of family meals is inversely associated with tobacco, alcohol and marijuana use, depressive symptoms and suicide involvement, particularly among adolescent girls (Eisenberg et al, 2004) Is discipline a dirty word? Plan ahead, make rules clear, make sure there are clear and immediate consequences for unwanted behaviour, be consistent (as much as possible), handle rule‐breaking calmly, catch them doing something right and be precise. Parents often dramatically underestimate the prevalence and variety of risk‐taking behaviours among their children in early teen years (i.e. middle school). Parents who keep a close eye on their children’s whereabouts and activities are less likely to have children involved in risky behaviours; monitoring and supervision is crucially important as a protective factor. In the National Longitudinal Study on Adolescent Health, a selected sample of adolescents in grades 7 through 12 was drawn from an initial survey of 90,118 teenagers across the US. These teens and their parents completed interviews in their home. Significant findings: parent‐family connectedness and perceived school connectedness were protective against nearly every risky behaviour except pregnancy. Parents who disapproved of early sexual intercourse produced teens who had later intercourse. Five pointers for keeping communication lines with our children open: • Persevere – don’t give up • Talk to them in proper conversations, ask about the music they like, films, their friends…Would you say to a friend, ‘Have you done your homework? Don’t leave the wet towels on the doona?’ • Listen to what they say – show them the respect they deserve. • Watch how they behave – know what is normal and when to worry. • Hug them. Just get in there and hold on. (Bronwyn Donaghy) The three Ps • Keep it in perspective • Don’t take it all personally • It won’t persist – keep your eye on the longer term goal School and resilience: Recognition of the role of the school environment in promoting the development of mental health and psychological resilience in children and young people is increasing worldwide. Schools provide a critical context in shaping children’s self‐esteem, self‐efficacy and sense of control over their lives. In addition to promoting adoption of a curriculum in which health is specifically integrated, the Health Promoting Schools approach recognises the significance of school‐based health policies, links with health services and partnerships between the school, the family and community. Recent evidence supports the contention that the HPS approach successfully creates an environment rich in social capital. The organisational and social factors inherent in the HPS approach foster children’s emotional or psychological resilience by building resilience at an organisational level, such that resilient schools are healthy schools (Stewart et al, 2004). An important element is youth participation: involving young people in decision‐making about issues that affect their wellbeing at school A good school feels positive and safe • Having good friends • Having good teachers • Believing you fit in • Feeling respected • Having an adult take an interest in you • Perceived school connectedness Parental involvement: The most effective interventions are those where parents and educators work together; the exchange of information is effective in managing behaviour and school‐related problems. What can parents/teachers and health professionals do to help? • Show love and expect respect • Teach by example – stress management, conflict resolution, problem solving • Reduce risk and minimise harm • Intervene early and seek the right help • Persevere when problems arise NSW Centre for the Advancement of Adolescent Health (CAAH) The centre was established in 1998 as a technical support agency to implement an organised, multi‐sectoral approach to improving the health of young people in New South Wales. Goal: Better health outcomes for young people Our key focus areas are: • Developing information and resources to increase knowledge and understanding of youth health issues • Capacity building to increase organisational skills and confidence in addressing young people's health needs • Supporting applied research and promoting better practice in youth health care • Supporting advocacy and policy development to increase leadership and action for adolescent health www.caah.chw.edu.au