FACTORS ASSOCIATED WITH MENTAL ILLNESS AMONG YOUTHS

Introduction Worldwide 10-20% of children and adolescents experience mental disorders. Half of all mental illnesses begin by the age of 14 and three-quarters by mid-20s. Neuropsychiatric conditions are the leading cause of disability in young people in all regions. If untreated, these conditions severely influence children’s development, their educational attainments and their potential to live fulfilling and productive lives. Youths with mental disorders face major challenges with stigma, isolation and discrimination, as well as lack of access to health care and education facilities, in violation of their fundamental human rights. Many mental health problems emerge in late childhood and early adolescence. Recent studies have identified mental health problems - in particular depression, as the largest cause of the burden of disease among young people (DALYs). This presentation explores the factors that are associated with mental health illness among youths ADOLESCENCE AS A CRITICAL PERIOD IN THE LIFESPAN The situation of young people is rapidly changing across the globe. The group of young people is less homogenous than the group of school aged children, and the life trajectory for young adults is not as predictable or as homogeneous as in previous generations (Rowling 2006). Transition into adulthood is a period which is determined by many changes. Adolescents and young adults are in a key phase of establishing independent identity, making educational and vocational decisions and lifestyle choices as well as forming interpersonal relationships. All of these have major long-term influences on the individual, particularly in terms of factors that influence mental health and well-being. Young people are particularly vulnerable to social exclusion, notably in the transition stage between education and employment. For example leaving school early without access to full time work can lead to disconnection economically and socially and failure to develop a sense of the future. These young people form a specific category of “invisible” young people, as their possibilities and rights to a minimum income or health insurance are in many countries only minor (Policy paper on the health and well being of young people 2008). FACTORS ASSOCIATED WITH MENTAL ILLNESS AMONG THE YOUTHS • Biological factors • Psychological factors • Environmental factors Biological Factors Some mental illnesses have been linked to abnormal functioning of nerve cell circuits or pathways that connect particular brain regions. Nerve cells within these brain circuits communicate through chemicals called neurotransmitters. "Tweaking" these chemicals -- through medicines, psychotherapy or other medical procedures -- can help brain circuits run more efficiently. In addition, defects in or injury to certain areas of the brain have also been linked to some mental conditions. Other biological factors that may be involved in the development of mental illness include: • Genetics (heredity): Mental illnesses sometimes run in families, suggesting that youths who have a family member with a mental illness may be somewhat more likely to develop one themselves. Susceptibility is passed on in families through genes. Experts believe many mental illnesses are linked to abnormalities in many genes rather than just one or a few and that how these genes interact with the environment is unique for every person (even identical twins). That is why a person inherits a susceptibility to a mental illness and doesn't necessarily develop the illness. Mental illness itself occurs from the interaction of multiple genes and other factors -- such as stress, abuse, or a traumatic event -- which can influence, or trigger, an illness in a person who has an inherited susceptibility to it. • Infections: Certain infections have been linked to brain damage and the development of mental illness or the worsening of its symptoms. For example, a condition known as pediatric autoimmune neuropsychiatric disorder (PANDA) associated with the Streptococcus bacteria has been linked to the development of obsessive-compulsive disorder and other mental illnesses in children. • Brain defects or injury: Defects in or injury to certain areas of the brain have also been linked to some mental illnesses. • Prenatal damage: Some evidence suggests that a disruption of early fetal brain development or trauma that occurs at the time of birth -- for example, loss of oxygen to the brain -- may be a factor in the development of certain conditions, such as autism spectrum disorder. • Substance abuse : Long-term substance abuse, in particular, has been linked to anxiety, depression, and paranoia. • Other factors: Poor nutrition and exposure to toxins, such as lead, may play a role in the development of mental illnesses. Psychological Factors Psychological factors that may contribute to mental illness include: • Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse • An important early loss, such as the loss of a parent • Neglect • Poor ability to relate to others Environmental Factors Certain stressors can trigger an illness in a youth who is susceptible to mental illness. These stressors include: • Death or divorce • A dysfunctional family life • Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness • Changing jobs or schools • Social or cultural expectations (For example, a society that associates beauty with thinness can be a factor in the development of eating disorders.) • Substance abuse by the person or the person's parents EFFECTS OF MENTAL HEALTH PROBLEM ON YOUNG PEOPLE In spite of the fact that most youths perceive their health to be good, there is a sizeable minority of young people reporting their health to be either “fair” or “poor” and experiencing a number of recurring health complaints (Morgan et al. 2008). Worldwide, up to 20% of children and adolescents suffer from disabling mental health problems (WHO 2001). As mental health problems in adolescence tend to be under-recognized and undertreated (Sourander et al. 2004), estimates of psychological problems and disorders may therefore be higher than is reported in studies. On an individual level, mental health problems can have deteriorating effects on young people’s social, intellectual and emotional development and consequently on their future. At its worst, they can lead to loss of life. Suicide is one of the three leading causes of death in young people and a public health concern in many European countries (WHO 2001). Besides the negative effects on an individual level, mental illness affects also many other spheres of life – family, friends and society at large – causing costs not only in health care system. In fact, the costs of mental illness among children and adolescents have indicated to fall to a very large extent on sectors outside the health care system – only 6% of costs fall on the health system (Suhrcke et al. 2007). Furthermore, there are close links between child and adult mental illness – the presence of mental illness during childhood may lead to up to 10 times higher costs during adulthood (Suhrcke et al. 2007). HOW DO WE MEASURE THE MENTAL HEALTH STATUS OF YOUTH? This report presents data from studies using nationally representative samples only. While community and regional studies have yielded useful data, variation in study methodologies limits their generalizability to the national level. Local studies vary in the sampling, age groupings, disorder definitions, and analysis. For example, one review of 52 studies found estimates of the psychopathology rate among children and adolescents ranging from 1% to nearly 51%. The national studies reviewed for this report use various methodologies for assessing mental health status. Findings may be biased due to misrepresentations. For example, findings understate the prevalence of problems if respondents attach a strong stigma to mental health problems. Alternatively, problems may be overstated if respondents desire benefits that may accompany certain diagnoses. Approaches to assessing mental health status can be categorized as follows: • Positive indicators such as well-being and resiliency. As indicated above, few nationally representative data are available using this approach. • Broad questions to measure symptoms of well-being or emotional distress. This approach includes research that measures limitations in functioning due to mental health problems. Several national surveys of youth and parents offer this type of data, such as the Youth Risk Behavior Surveillance System (YRBSS), National Health Interview Survey (NHIS), National Survey of America’s Families (NSAF), and the National Survey on Drug Use and Health (NSDUH). • Formal assessment techniques, including standardized scales or interview schedules. These scales are usually linked to psychiatric classification systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of theAmerican Psychiatric Association. Examples of studies using these techniques include the NHIS, the National Co-Morbidity Study, and the National Longitudinal Survey of Adolescent Health (AddHealth). It should be noted that, over time, the criteria for inclusion of some disorders has changed and the criteria for defining some disorders has been revised. Consequently, data collected at different points in time may be problematic for monitoring trends. • Data about receipt of services for mental health related problems. NSDUH asks about receipt of counseling services as well as substance use services; the Medical Expenditure Panel Survey (MEPS) conducts interviews regarding health care use and analyzes billing records related to services;25 and, the Pediatric Research in Office Settings and Ambulatory Sentinel Practice Network (PROS/ASPN) asks health care providers about services performed. HEALTH EDUCATION NEED FOR YOUTH MENTAL HEALTH Mental health promotion strategies need approaches that are also associated with the prevention of child and adolescent problems within communities with low Socio-economic Status (SES). Low SES can be measured in different ways including low levels of education and/or income or definitions that combine several variables. This is mainly because the factors associated with low SES are also associated with the development of violence and crime, substance abuse and child health problems. Interventions that address underlying determinants of low SES show strong efficacy in decreasing adolescent crime and violence and effectiveness in improving child health outcomes. Infact there are programs designed to improve educational pathways that show some efficacy in reducing aspects of adolescent substance use. Such interventions could also be supported in mental health promotion policy as they may assist in preventing related problems that undermine mental health. Following areas need attention for promotion, prevention, identification and intervention: • Promoting Health and Well-being, Identifying Needs and Intervening Early • Supporting Parenting • Child, Adolescent and Family-centered Services • Growing Up into Adulthood • Safeguarding and Promoting the Welfare of Children and Adolescents • Children and Adolescents who are Ill • Children and Adolescents in Hospital • Disabled Children and Adolescents and those with Complex Health Needs • The Mental Health and Psychological Well-being of Children and Adolescents • Medicines for Children and Adolescents • Antenatal, Peri-natal and Postnatal Services ‘Primary care’ is of crucial importance and includes all first line services that have contact with children and their families. Nation's attempt to address the issues The major national policies and legislations formulated in the country to ensure child rights and improvement in their status include: • National Policy for Children, 1974 • National Policy on Education, 1986 • National Policy on Child Labour, 1987 • National Nutrition Policy, 1993 • National Health Policy, 2002 • National Charter for Children, 2004 • National Plan of Action for Children, 2005 However, there is a wide gap between identifying needs, planning, developing policies and effective implementation to bring a difference. But there is hope when concerned authorities continue to take the matter seriously and address the preliminary rights that aid in child mental health issues. ACTION PLAN Prevention Effective prevention programs have been identified which may help to reduce the risk of youths developing a mental problem or disorder. Some prevention programs are even more effective than later treatments, particularly in the area of conduct disorders. Significant advancements can be made when both the early years of life and the early stages of disorders are targeted. Mental health prevention and early intervention are relatively new fields in mental health. Progression of these initiatives involves supporting health and related staff and the community in the acquisition of the knowledge and skills needed to meet the challenges of new service directions and programs, including the provision of resources to assist implementation. Youth’s mental health may be affected by events such as death of a family member, marital discord or separation, environmental disasters and economic disadvantage. Children and adolescents may require interventions to ameliorate the effects of abuse or neglect, parental substance abuse or mental health problems or domestic violence. Lack of appropriate stimulation in the early years may result in language delay and together with inappropriate child-rearing practices, especially if characterised by neglect or inconsistency, may lead to emotional or behavioural disorders. Appropriate parenting styles are fundamental to caring for children's mental health. Early attachment and bonding between parents and their babies is important and needs to be supported. Many children, adolescents and their families who could benefit from mental health services for assessment and treatment are not accessing services. There are a variety of reasons for this: a lack of trust in statutory services; a wish to solve problems themselves; a lack of recognition and agreement that a problem exists; a fear of being teased and stigmatised; a fear of confidentiality being broken and a belief that nothing can be done. These can all affect the take-up of help. Children and adolescents rarely present with single disorders but rather with a range of problems. A large proportion of the available evidence does not reflect the co-morbidity issues which present in day-to-day clinical practice. In addition, services have to rely frequently on either extrapolating research findings from abroad or from adult literature. When it comes to prevention, one must give necessary attention to genetic causes, environ -mental factors and the interaction between the two that can cause several childhood disorders, as some of these are preventable. Advancement of genetic techniques aid in prenatal diagnosis and have importance in counseling including premarital counseling. For e.g. early identification of PKU would prevent mental retardation. Cretinism, Iodine deficiency and malnutrition are also easily correctable and preventable conditions. Promotion All children, adolescents and their parents or carers require access to information and supportive environments to ensure that the child or adolescent's mental health is promoted. Specific activities such as tackling bullying, provision of education to increase awareness of mental health issues and to improve the recognition of children's emerging needs, and provision of support for those children with particular needs, have a vital role to play in improving the chances for children and adolescents. Everyone in a community has a role to play in ensuring that the environment in which children are growing up promotes their mental health. For children with learning difficulties and their parents or carers, the provision of special education, training and promoting need for early intervention may make a significant difference in overall development. One should invest time and resources in refocusing of services that will be necessary to meet their needs. This will include ensuring that there is a strong focus on vocational and social issues in order to ease adolescent's transition into adulthood and reduce the likelihood of social exclusion, so often a secondary consequence of mental illness. Assessment of local needs may identify other groups of children and adolescents for whom service development is required e.g. looked after children, where there has been recent significant improvement in provision, children with conduct disorder or severe behavioural problems, children and adolescents who are homeless, adolescents in young offenders institutions and asylum seeking children, where expertise is not readily available. Given that some forty per cent of children with learning disabilities have a diagnosable mental disorder and this rate is even higher in those with severe learning disabilities, the low level of resources available to the children and their families represents serious inequity and a significant challenge for the development of appropriate services. There is normally a wide variation in the age when adolescents achieve maturity and independence, especially for those with learning disability and other impairments. A degree of flexibility is clearly required to ensure that adolescents receive treatment in an environment that promotes their engagement and responds to their developmental needs. A nurturing social environment in childhood, good early education and academic success in school are related to protecting the mental health of young growing generation. The influence of peers is also critical. For good mental health services, the following five sectors are important: • Early years • School years • Community based activity • Additional and support needs • Children in need of special care Child mental health services at district level should incorporate the following programs: • Liaison • Consultation • Training • Supervision • Intervention • Planning and development • Research and development Training should aim to consolidate existing knowledge through experiential learning, enabling staff to promote good mental health and recognise and manage children and adolescent's mental health problems at an early stage. Training should be appropriate to the developmental level and cultural context of the children and adolescent's population. Primarily educative, supervision should aim to improve the ability of professionals to promote and support children and adolescent's mental health more effectively by improving their skills, knowledge base and facilitating reflection on attitudes towards mental health, thus enabling more effective practice. Supervision can take the form of individual or group support and can also act as a means of consolidating multi-agency training. Children in most sections of Nigerian society are traditionally and conventionally not consulted about matters and decisions affecting their lives. In the family and household, the neighbourhood and wider community, in school or in work place, and across the settings of social and cultural life, children's views are mostly not given much importance. If they do speak out, they are not normally heard. The imposition of restrictive norms is especially true for a girl child. This limits children's access to information and freedom to choose, and often to the possibility of seeking help outside their immediate circle. Youth mental health is a shared responsibility, and for any intervention to be effective there should be a synergy between efforts being made by different stakeholders to address the issues. There is a need to create a mechanism that will make such a synergy possible. These may include child mental health prevention and promotion mechanisms at village, block, district and state levels which involve parents, elected representatives of urban and rural local bodies, teachers, anganwadi workers, medical practitioners, police and social workers and responsible members of public among others. The media should be productively used to spread awareness on child mental health. Debates and discussions with participation of children can be a regular feature on electronic media in order to enhance people's knowledge and sensitivity on child mental health issues. We also need appropriate and updated prevalence and incidence database from all the possible agencies for planning and implementation. Children's voices need to be heard by everyone. All for addressing issues of child mental health should have adequate children's representation with the opportunity for them to express their views. For example, school curricula should be developed with the active participation of children; children should be involved in development of the district child protection plan, children should be involved in management of schools and institutions, etc. It is mandatory that peer education, peer training and peer participation should be part of each and every school mental health program. WHAT IS NEEDED IS TO SEE THAT • All children and adolescent get best and improved mental health. • Multi-agency services, working in partnership, promote the mental health of all children and adolescent, provide early intervention and also meet the needs of children and adolescent with established or complex problems. • All children, adolescent and their families have access to mental health care based upon the best available evidence and provided by staff with an appropriate range of skills and competencies. All children and adolescents, from birth to their eighteenth birthday, who have mental health problems and disorders, need to have access to timely, integrated, high quality, multi-disciplinary mental health services to ensure effective assessment, treatment and support, for them and their families. IN ORDER TO ACHIEVE WE MUST ENSURE THE FOLLOWING AT DISTRICT LEVEL • All staff working directly with children has sufficient knowledge, training and support to promote the psychological well-being of children and their families and to identify early indicators of difficulty. • System of referral, support and early intervention are well worked out. • Professionals provide a balance of direct and indirect services and are flexible about where children and families are seen. • Children and adolescents are able to receive urgent mental health care when required. • Children and adolescents with both a learning disability and a mental health disorder have access to appropriate child and adolescent mental health service. • Arrangements are in place to ensure that specialist multidisciplinary teams are of sufficient size and have an appropriate skill-mix, training and support to function effectively. Recommendation Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. Promotion of mental health contributes towards overall health and should form an essential component of health promotion. The scope for promoting mental health is identified by analogy with physical health promotion successes. Mental health is a community responsibility, not just an individual concern, just as many countries and communities have realized for heart health, tobacco control, dental health, and in other areas. The social and economic costs of poor mental health are high and the evidence suggests that they will continue to grow without community and government action. The following key recommendations can be drawn from the material presented in this Seminar. These are especially relevant to health policy planners and public health professionals in low and middle-income countries. 1 Promotion of mental health for the youth can be achieved by effective public health and social interventions. The scientific evidence base in this area is relatively limited, but evidence at varying levels is available to demonstrate the effectiveness of several programmes and interventions for enhancing mental health of populations. These include: • early childhood interventions (e.g. home visiting for pregnant women, pre-school psychosocial interventions, combined nutritional and psychosocial interventions among disadvantaged populations); • economic and social empowerment of youths (e.g. improving access to education, micro-credit schemes); • social support to the young populations • programmes targeted at vulnerable groups such as minorities, indigenous people, migrants, and people affected by conflicts and disasters (e.g. psychological and social interventions during the reconsolidation phase after disasters); • mental health promotion activities in schools (e.g. programmes supporting ecological changes in schools, child-friendly schools); • mental health interventions at work (e.g. stress prevention programmes); • housing policies (e.g. housing improvement); • violence prevention programmes (e.g. community policing initiatives); and • community development programmes (e.g. Communities That Care, integrated rural development). 2. Intersectoral collaboration is the key to effective programmes for mental health promotion. For some collaborative programmes, mental health outcomes are the primary objectives; however, for the majority these may be secondary to other social and economic outcomes but are valuable in their own right. 3. Sustainability of programmes is crucial to their effectiveness. Involvement of all stakeholders, ownership by the community, and continued availability of resources facilitate sustainability of mental health promotion programmes. Conclusion The country has to take care of an enormous number of children. While articulating its vision of progress, development and equity, Nigeria has expressed its recognition of the fact that when our children are educated, healthy, happy and have access to opportunities, they are the country's greatest human resource. This will require commitment to the integrity of programs, their adaptation for and engage-ment with local communities, and the incorporation of evaluations of program effectiveness. More attention is now being given to the need for programs to provide quality norms for good practice that are determined by theory, evidence based outcomes, cost effectiveness and feasibility of widespread implementation. We must assist the implementation of innovative and effective mental health initiatives in this relatively new field in mental health services for children and adolescents across Nigeria. Nigeria presents a unique case in terms of the sheer size of its population and 46 percent of them are children; characterized by heterogeneity in respect of physical, economical, social and cultural conditions. Its population of 1.12 billion constitutes 16 percent of the world population, with 74 percent of them living in rural areas. Nigeria is a secular state with various languages, cultures and religions. This kind of complex and multifaceted country makes formulation of National policies, programming and planning quite a challenging task. Each and every one of the 600 districts of Nigeria is unique in many ways. Each district will need its planning at local level. For such a diversified country it is difficult to envisage a national program that fits all and even of all are considered in reality it may fit none. The incidence of youth needing mental health services is high. Even after fifty nine years of independence, resources to meet the mental health needs of children, manpower, as well as preventive, diagnostic and treatment services are extremely limited. Who is resp -onsible for this gap in demand of such crucial child mental health services and meeting the need? Is it inadequate government policy and/or unaroused citizenry and/or insufficient resources and/or the lackadaisical attitude of people towards the needs of children? We must urgently introspect this in order to achieve future positive outcomes. One thing is certain. Single window operation for child mental health, education and welfare will surely go a long way in successful implementation of various child legislations providing right control, quick results and ensuring justice for successful mental health programmes.