14.6.1 Mental health

14.6.1.1 Adolescent onset of anxiety and depression

Emotional disorders, such as anxiety and depression, are mental health issues that affect people across the lifespan and often begin during adolescence. The symptoms of anxiety disorders include having debilitating fear, worry, and panic about perceived future threats. According to the World Health Organization, anxiety disorders are prevalent among adolescents globally, affecting about 3.6% of 10–14-year-olds, and 4.6% of 15-19 year-olds (WHO, 2021).

The symptoms of anxiety often appear alongside symptoms of depression, which include feelings of worthlessness, loss of energy, sleep problems, and difficulty concentrating. An adolescent who is depressed is more likely to have an anxiety disorder, as these two mental health issues often occur together. Depression has an early onset in adolescence, generally begins around the age of 14 and affects more females than males (Benokraitis & Buchler, 2019).

The National Institute of Mental Health found that about 4.1 million adolescents in the United States (aged 12 to 17) are reported to have had at least one major depressive episode (depressive symptoms which last at least two weeks) in 2020, with a higher prevalence among female adolescents (25.2%) than male adolescents (9.2%). It was also found that the highest prevalence (29.9%) was among adolescents who identified as being of two or more races (NIMH, 2020).

There are many and often interlinked causes of anxiety and depression during adolescence, and include factors such as genetics, trauma, stress, and environment.

For more information on anxiety and depression during adolescence, please visit this link: What to know about teen anxiety and depression.

14.6.1.2 Bipolar

Bipolar disorder is a type of depression which manifests as cycles of mania and depression, with extreme mood and energy swings. During a manic episode, adolescents may be more energetic, active, and positive than they usually are, while during a depressive episode, they may be much less energetic and active, and may have intense feelings of sadness. Bipolar disorder can be difficult to diagnose during adolescence, as the behaviors associated with the disorder, the episodes of extreme mood swings, can be mistaken for conventional adolescent behavior. Although bipolar disorder can occur at any age during the life span, it is typically diagnosed during adolescence or early adulthood (NIH, 2023). It is estimated that 2.9% of adolescents have bipolar disorder, with a higher prevalence of 3.3% for females, compared to 2.6% for males (NIH, 2007).

For more information on bipolar disorder and adolescence, please visit this link: Bipolar Disorder in Children and Teens.

14.6.1.3 Schizophrenia

Like bipolar disease, schizophrenia can be difficult to diagnose in adolescents as the symptoms can be mistaken for typical adolescent behavior and moodiness. Schizophrenia is a severe mental disorder which involves cognitive problems that result in not being able to interpret reality accurately; the symptoms can include difficulty with communication, hallucinations, thought disorder, anxiety, irritability, and social withdrawal (Mayo Clinic, 2023). Schizophrenia is usually diagnosed between 16 and 30 and is typically diagnosed earlier in males than females (NIH, 2022). Schizophrenia is a rare disorder, and is thought to be caused by a combination of genetic and environmental factors, such as living in poverty or being exposed to toxins before birth (NIH, 2022).

For more information on schizophrenia during adolescence, please visit this link: Childhood Schizophrenia.

14.6.1.4 ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is a disorder in which a person may display symptoms of inattention, symptoms of hyperactivity-impulsivity, or both.

Symptoms of ADHD include symptoms of inattention, such as having difficulty following instructions, doing tasks in sequence, and sustaining attention. Symptoms of hyperactivity-impulsivity may include fidgeting, excessive talking, interrupting, and feeling restless. ADHD symptoms can appear as early as between the ages of 3 to 6, and most children with ADHD are diagnosed during their elementary school years. ADHD symptoms need to have been present before the age of 12 for an adolescent to be diagnosed with the disorder (NIH, 2022). The symptoms of ADHD may change over developmental periods; during adolescence, inattention and impulsivity tend to remain from childhood and hyperactivity tends to lessen (NIH, 2022).

For more information about ADHD, please visit this link: Attention-Deficit/Hyperactivity Disorder.

14.6.1.5 Bullying

The Centers for Disease Control and the Department of Education released a federal definition of bullying in 2014. According to this definition, bullying involves behavior which is unwanted and aggressive, power imbalance, and the repetition of bullying behaviors (stopbullying.gov).

Bullying is prevalent in schools; around 20% of students in the United States between the ages of 12 to 18 have experienced bullying, and 19% of students in grades 9 to 12 experienced bullying on school property. About 15% of students aged 12 to 18 were bullied online or by text (NCES, 2019).

Bullying includes physical behaviors such as hitting and kicking, verbal behaviors, such as teasing, and social behaviors, such as spreading rumors (CDC, 2021). The consequences of being a target of bullying include depression, anxiety, sleep problems, and academic issues. The consequences of being bullied include being at higher risk for violence during later adolescence or adulthood and being at greater risk for substance abuse (CDC, 2021).

For more information about bullying, including risk and protective factors, please visit this link: Fast Fact: Preventing Bullying.

14.6.1.6 Peer pressure

Peer pressure refers to feeling either internal or external pressure to behave in certain ways – peer pressure can be either positive or negative. Positive peer pressure can include being influenced to do well academically, or to volunteer at a local animal shelter. Negative peer pressure can include being influenced to start smoking, or to skip classes. Peer pressure can be seen as early as elementary school and tends to increase during middle and high school as adolescents are influenced more and more by their friends and less by their family. Negative peer pressure can affect adolescents’ mental health – it can lead to an increased risk of depression and anxiety, a decrease in self-esteem and self-confidence, and an increased risk of suicide. Having supportive environments, open communication, and adult role models can help adolescents set boundaries and prevent negative outcomes from peer pressure.

For more information about peer pressure, please visit this link: Helping teens deal with peer pressure.

14.6.2 Suicide

14.6.2.1 Awareness

Suicide is the second leading cause of death in the United States for 15-to 24-year-olds (CDC).

Twenty percent of high school students in the United States have reported having serious thoughts of suicide, and 9% have reported a suicide attempt. In 2019 the rate of death by suicide was 14 per 100,000 people for 15- to 24-year-olds (NAMI, 2023). These already high rates of suicide for adolescents increased in 2020, during the first year of the COVID-19 pandemic due to the stresses of pandemic (NIH, 2022). A study by the National Institutes of Health found that overall, in the 14 states that were a part of the study, there was an increase in rates of suicide among 10-to 19-year-olds during 2020 (NIH, 2022).

14.6.2.2 Prevention

There are several risk factors for suicide, including a family history of suicide, depression, anxiety, substance abuse, and having a history of abuse or trauma (APA, 2018). In addition to these risk factors, there are warning signs that indicate a person may be considering suicide. These warning signs include social withdrawal, self-harm behavior, changes in hygiene or appearance, talking about suicide or talking about feeling hopeless (APA, 2018). Ways to prevent adolescent suicide include expressing your concern, being compassionate and actively listening, helping the adolescent maintain social connections, and trusting your intuition and getting help if you feel that something is wrong even if the adolescent denies having thoughts of suicide (APA, 2018). Ways to help prevent suicide need to include strategies at the community level as well as strategies for individuals and families (CDC, 2022). These strategies include strengthening financial security and housing stability, reducing substance abuse through community policies, having access of suicide care, promoting connection in the community, having education programs that support resilience and problem-solving skills, and identifying and supporting people at risk (CDC, 2022).

For more information about preventing suicide, please visit this link: Prevention Strategies.

Please see these video from the Mayo Clinic regarding suicide prevention in adolescence:

Figure 14.7. Teen Suicide Prevention [YouTube Video].

Figure 14.8. Reach Out – Preventing Teen Suicide [YouTube Video].

14.6.2.3 Seeking Treatment

Treatment for suicidal tendencies can vary, depending on the circumstances and degree of risk presented. If an adolescent is in immediate danger, then emergency treatment includes calling a suicide hotline number and going to a hospital’s emergency room for immediate care. In a nonemergency situation, a doctor may first conduct medical tests to see if there are any underlying physical problems that may be a root cause of the suicidal tendencies. Treatment for suicidal tendencies may include psychotherapy to help explore issues and learn coping strategies, medications such as antidepressants or anxiolytics, and family support and education.

14.6.2.4 Gender Identity

Adolescents who are questioning the sex identity given to them at birth may be at higher risk of suicide as are adolescents who are in LGBTQ youth. Studies have shown that LGBTQ youth are at an even higher risk of suicide than their peers aged 10 to 24, with some studies finding that compared to their peers, LGBTQ youth are more than four times as likely to attempt suicide (Johns et al., 2019; Johns et al., 2020). It is important to note that it is the stigma and lack of support that leads LGBTQ youth to attempt suicide, and that having at least one supportive adult can reduce the risk of suicide by 40% (The Trevor Project, 2019).

For more information on LGBTQ youth and suicide risk factors and prevention, please visit this link: Facts about LGBTQ Youth Suicide.

14.6.2.5 Disordered Eating

Eating disorders are severe mental health conditions that can lead to life-long health problems and can be fatal if left untreated. Eating disorders center around extreme focus on eating behaviors, and obsessive thoughts about eating, food, and weight. Although eating disorders can affect children and older adults, they are most frequently seen in adolescents and young adults, in females. The prevalence of eating disorders has been found to have more than doubled between 2000-2018 (Galmiche et al., 2019), and to have increased even more during the COVID-19 pandemic. This is thought to be due to the higher levels anxiety and the social isolation experienced during the pandemic (Zipfel, Schmidt, & Giel, 2022).

Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Anorexia nervosa is a mental health condition in which people are exceedingly restrictive in their food intake and have an intense fear of gaining weight. They tend to try to hide their restrictive eating from family and friends and try to appear as having eaten more than they actually have, often times by hiding uneaten food. People suffering from anorexia will see themselves as overweight even when they are significantly underweight. Anorexia nervosa is extremely dangerous and is the eating disorder that is most likely to lead to death if left untreated. Adolescents with anorexia between the ages of 15 to 24 have a tenfold increased risk of mortality compared to their peers (Fitcher & Quadflieg, 2016).

Anorexia is an emotional disorder that often has a root cause of low self-esteem; people with anorexia are so focused on restricting food and weight loss as they equate being thin with self-worth (Mayo Clinic, 2018). Anorexia has also been associated with authoritarian parenting styles, in which parents are demanding, expect strict obedience, and are not emotionally supportive (Haycraft & Blissett, 2019). It is thought that the quest for thinness seen in anorexia is a means of gaining control back from being in an environment of constant parental control.

Bulimia nervosa is an eating disorder which involves periods of binge eating and purging. During binge eating, large quantities of food are consumed in a short amount of time, followed by feelings of guilt or shame. These feelings lead to purging, which involves ways of trying to purge the food that was eaten, often through vomiting, laxative use, or excessive exercising (Mayo Clinic, 2018). Like anorexia, bulimia is also an emotional disorder that has a root cause of poor self-worth and has been associated with authoritarian parenting styles (Haycraft & Blissett, 2019). Bulimia is thought to be a reaction to parents who have unrealistic expectations of perfection.

Binge-eating disorder is another common form of eating disorders. Binge-eating disorder is similar to bulimia nervosa, in that it involves binge eating of large quantities of food, but unlike bulimia it does not involve purging. Binge-eating is often done in secret and can result in feelings of guilt and depression. People with binge-eating disorder tend to have low self-esteem and poor body self-image (Mayo Clinic, 2018). Authoritarian parenting style has been associated with binge-eating disorder (Zubatsky et al., 2015), as has trauma, with binge-eating being used as a way to manage the overwhelming negative emotions of the trauma (WebMD, 2015).

For more information on eating disorders, please visit this link: href=”https://www.nimh.nih.gov/health/topics/eating-disorders”>National Institute of Mental Health: Eating Disorders.

14.6.3 Alcohol, Tobacco, and Drug Use

Emotional disorders are often seen through alcohol, tobacco, and drug use during adolescence. Adolescence is a time of exploration and is often the time when alcohol, tobacco, and drugs begin to be used.

14.6.3.1 Alcohol Use

Forty percent of 12-to 20-year-olds have reported at least one incident of trying alcohol (SAMHSA, 2019). In a survey of high school students conducted during 2019, 29% reported drinking alcohol during the past month (CDC, 2020). While adolescents tend to drink alcohol less often than adults, when they do drink, they tend to drink larger quantities of alcohol (CDC, 2020). The majority (90%) of alcohol consumed by adolescents in the United States is through binge drinking (NIH, 2023). For more information on adolescent alcohol use and binge drinking, please visit this link: Underage Drinking.

Consequences of alcohol use during adolescence include impaired judgment which can lead to risky behavior such as unsafe sexual activity, cognitive or learning problems, increased risk of using other substances, and increased risk of death due to accidents, overdoses, and suicides (NIH, 2023).

The risk factors for alcohol use during adolescence include peer pressure, desire for increased independence, and stress (NIH, 2023). An association between adolescent alcohol use and low self-esteem has been found (Zeigler-Hill, Dahlen & Madson, 2017), as has an association between childhood trauma and alcohol use during adolescence (NIH, 2022).

14.6.3.2 Tobacco

Use of tobacco tends to start during adolescence, with the majority of adults who use tobacco having started as adolescents (NIDA, 2023). In a survey of students conducted in 2022, it was reported that 11.3% of middle and high school students used at least one tobacco product during the past month (NIDA, 2023). The nicotine found in tobacco is extremely addictive and has been found to affect emotional and cognitive functions in the brain when tobacco is used during adolescence, and that these changes in the brain may lead to continued use of tobacco (NIDA, 2023).

The risk factors for tobacco use during adolescence include peer pressure, mental health, and emotional problems. Recent negative life events and depression are also associated with the use of tobacco during adolescence (NIDA, 2023).

14.6.3.3 Drug Use

Drug use in adolescence includes the use of illegal drugs, such as methamphetamines, cocaine, heroin, and ecstasy, and the misuse of prescription medications. 15% of high school students reported having used an illegal drug at least once, and 14% reported having misused prescription medications, such as opioids (CDC, 2022).

Drug use in adolescence can lead to an increased risk of mental health problems, increase risk engaging in dangerous behavior such as driving while under the influence, and can lead to changes in the brain that affect processing emotions, decision-making, and learning (Winters & Arria, 2011).

Risk factors for drug use during adolescence include having a family history of substance abuse, peer pressure, childhood sexual abuse, rejection of gender or sexual orientation by family, and mental health issues (CDC, 2022). Low self-esteem has been found to be a critical risk factor for adolescent drug use, with child physical abuse, bullying in school, low family income, and parental marital issues all being found to be factors contributing to the low self-esteem (Ojo et al., 2013).

For more information on drug use during adolescence, including risk and protective factors, please visit this link: High-Risk Substance Use Among Youth and watch Figure 14.9.

Figure 14.9. Risk factors for drug use and drug abuse [YouTube Video].

14.6.4 Social Media Influences

We have discussed mental health disorders and various factors, such as bullying, low self-esteem, and parenting styles that can affect adolescents’ mental health. We will now look at another critical factor in mental health during adolescence – the influence of social media.

While social media platforms can have positive influences on mental health, such as building social networks and getting emotional support from those networks, social media has been found to have significant negative mental health impacts on adolescents. The negative influences of social media include disrupting sleep, distraction from important tasks, spreading of rumors, peer pressure, and unrealistic views of others (Mayo Clinic, 2022). Feelings of low self-worth in adolescence due to unrealistic social comparisons and higher rates of anxiety and depression have also been associated with the use of social media (Nesi et al., 2015).

The negative impact on adolescent mental health has been associated with the amount of time spent on social media. A study of 12-to-15-year-olds in the United States found that adolescents who were on social media for more than three hours a day were at an increased risk for mental health issues (Riehm et al. 2019).

For information on adolescents’ use of social media including information regarding specific social media platforms and amount of time spent on those platforms, please visit this link: Pew Research Center: Teens, Social Media, and Technology 2022.

For more information regarding the association between social media and mental health problems in adolescence, please watch the Fault Lines documentary (Figure 14.10).

Figure 14.10. Why social media is toxic for teen mental health [YouTube Video].