9 Chapter 9 – Adolescent Mental Health

In the late 1800s, seven disorders of the mind were recognized by the medical community.  These were recognized mostly for administrative purposes and was not used for treatment.  It was not until the 1920s that the medical community wanted to organize a classification system for the purpose of treating patients in psychological distress.  After World War II, the American Veteran’s Administration engaged in its own attempt at classification and introduced 17 categories to respond to veteran’s need for psychological services.  In 1952, the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was completed for clinical use.  In 1978, the third edition of the DSM was completed and, unlike the earlier versions, emphasized the precision of the categories and eliminated specifying the causes of various illnesses (Zachar et al, 2019).  The third edition was one of the largest undertakings in the history of the DSM, and the version was explicitly biomedical in its framework; it was hoped by the editors that this would satisfy critics of psychiatry (Shorter, 2015).  The DSM IV was completed in 1994 and this used new evidence to tighten the language around the categories of mental illnesses.  In 2000, a fifth major revision of the manual was initiated where there was renewed effort to identify mental illness categories using new data and frameworks (Bandini, 2015; Scott, 1990; Schacht, 1985; Stein et al, 2010).

From its inception, the DSM process has been influenced deeply by politics.  In the first iteration of the DSM in 1974, homosexuality was defined as a mental abnormality, but it has been removed in further editions because of the pressure exerted by homosexual rights activists (Drescher, 2015).  Similarly, trans-people were diagnosed as having a gender identity disorder in the earlier versions of the manual while the fifth edition identifies them as having gender dysphoria to better represent their experiences.  However, members of the trans community continue to criticize this classification as still being stigmatizing and call for non-pathologizing their experiences (Cosci & Fava, 2016).  The more recent versions of the manual have been criticized for obfuscating differences between symptoms exhibited as responses to natural events and conditions of life, and enduring psychopathology.  The manual has been accused of having too many categories and hence being too difficult to use.  Many of the recent classification schemes in the DSM are also aimed at fulfilling and ensuring the ease of communication with insurance companies, which health activists have pointed out is counter-productive to good health care delivery (Davy, 2015; Stein et al, 2010; Stein et al, 2019).

The DSM 4 identifies a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”  Disorders are often identified by the cluster of syndromes or symptoms that characterize a problem.  The latest iteration, DSM 5, defines mental illness as the following,

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.  Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above” (American Psychiatric Association, 2013, p. 20).

In having all these qualifying events, the editors were responding to critics within the community who complained that the categories were problematic and lacked external validity since the illnesses were not tied to specific causes (Paris & Phillips, 2013; Whooley, 2014; Whooley, 2016).

Several of these disorders that seem to occur more often in children, are not appropriately defined and their prevalence seems to vary enormously from one decade to another (Merikangas et al, 2010).  In a study conducted in 2014, it was estimated that almost 21% of youth ages 9 to 18 were diagnosed with a mental health disorder (Leaders, 2019). American children consume almost 4 times the number of psychotropic drugs as the rest of the world combined.  Almost one in five youth is prescribed mood-altering medicines (Bachman et al, 2017).  During the first decade of childhood, there has been a sharp rise of people being referred for mental health issues (Healthcare Cost Institute, 2012).   As many critics point out, medications are being prescribed at earlier ages with little scientific knowledge of the long-term consequences of psychotropic drugs on children’s lives.  It is also unclear how efficacious these medicines are in treating disorders that manifest in children (Conroy, McIntyre, Chumara & Stevenson, 2000; Wong et al, 2015).  When children are impulsive and non-cooperative, the adverse effects of medical interventions multiply since usage is erratic and often not compliant with the prescribed regimen (Ninan, 2014).

There are some disorders that are more commonly diagnosed among North American children.  Mental health experts typically classify these psychopathologies into Internalizing and Externalizing disorders and have a third category that consist of others that cannot be classified as either of the first two.  Internalizing disorders are the result of harmful thoughts and actions turned inward; this category includes mood disorders and anxiety.  Externalizing disorders are associated with defiance, impulsive, destructive and rule breaking behavior; this category includes Attention Deficit/Hyperactivity disorder and Conduct and Oppositional Disorders.  Other illnesses that are not classified in the first two are schizophrenia, congenital developmental disorders, trauma and eating disorders (Farmer et al., 2016; Cicchetti & Toth, 2014).   While these disorders may be discussed as if they were separable, they in fact often co-occur (exhibit comorbidity) and a single individual may be diagnosed with multiple disorders.

Any kind of intentional self-harm is classified as an internalizing disorder.   Suicide is the 3rd leading cause of death among adolescents, the first being accidents and the second homicides.  Almost a quarter of adolescents have considered suicide at some point in their high-school years, 17% have come up with specific plans to carry it to fruition, while 8% attempt it (Hedegaard, Curtin & Warner, 2018).   Ninety percent of adolescents who end up committing suicide exhibit signs of depression (Beck, Brown, Berchick, Stewart  & Steer, 2006).  Many youths consider suicide for the first time during their adolescence.  The most common suicide attempts undertaken by adolescents are overdosing on potentially lethal drugs, hanging, using firearms and using sharp objects.  Most adolescents who do attempt to end their lives plan their suicide actions.  It is also important to distinguish youth who may only want to self-harm but not end their lives but whose attempts may end in fatality, and youth who have suicidal ideation and aim to end their lives (Cha et al, 2018; Klonsky & May, 2014; Klonsky, May & Saffer, 2016).  Suicidal ideations often precede attempts to end one’s life; it involves the person spending significant amounts of time thinking about the act of ending one’s life.

Suicide deaths are preventable when addressed in a timely fashion and this age group provides a space to explore ways to treat internalized mental disorders like those related to mood.  Studies show that youth who report at least one suicide ideation are 12 times more likely to commit suicide than those who do not express suicide ideation (Reinherz, Tanner, Berger, Beardslee, & Fitzmaurice, 2006).  Similarly, almost one-third of adolescents who report suicide ideation go on to committing suicide (Nock et al., 2013).  As adolescents get older, the rates of suicide attempts go up (Turecki & Brent, 2016).

Demographics is a big factor in adolescent suicide; girls are much more likely to have suicide ideation and attempts while death is more likely for boys (Scott, Pilkonis, Hipwell, Keenan & Stepp, 2015).  By adulthood men commit suicides 2 to 3 times more than women do (Bertolote & Fleischmann, 2015).  Indigenous youth are far more likely to commit suicide than youth from any other ethnic group; this can be attributed to extreme poverty and unemployment, accessibility to lethal means, trauma and loss of cultural identity (Wexler & Gone, 2012).  Among other historically underrepresented groups and among immigrants, the geographical location where the family lives has a huge impact on youth suicide rates.  When families from marginalized groups live in neighborhoods dominated by other families from their backgrounds, suicide rates are much lower than if these families lived in a dominant community with mainstream characteristics (Zammit et al., 2014).  Similarly, youth from LGBTQ+ communities experience more barriers to finding a wholesome identity in their youth leading to higher rates of suicides (Smith, Sanchez & Lopex, 2019).  Several studies show that where they live has significant mental health implications for LGBTQ+ youth – living in a state that has legalized homosexual marriages, neighborhoods that have more registered Democrats, and having supportive school districts lead to lower levels of depression and suicidal ideation among this population (Hassing, 2019; Marx & Kettrey, 2016).  Discrimination and stigma are related to rates of suicide attempts.

Gosnell, Fowler & Salas (2019) found that adolescents who exhibited suicidal thoughts had abnormal hippocampus (this regulates emotions) and the dorsolateral prefrontal cortex which is involved in planning behaviors.  Reduced levels of serotonin, lowered levels of cortisol and inflammation has been cited by several researchers as a precursor to suicide attempts (Courtet et al, 2016; Pandey, 1997).  Some studies point to a genetic component to suicide behaviors though the relationship may be indirect in terms of susceptibility to environmental stress (Buchman-Schmitt et al, 2017).

At the psychological level, low self-esteem and hopelessness is related to suicide behaviors (Extremera et al, 2018; Wilburne & Smith, 2005).  Anhedonia (the inability to experience pleasure and happiness) has been increasingly correlated with suicidal ideation (Auerbach et al., 2015; Winer et al, 2016).  Experts have noted that suicide attempts are correlated to a lack of capacity for emotional regulation accompanied by inflexibility of emotional strategies, i.e., a tendency to engage in angry rumination when facing problem situations (Bonanno & Burton, 2013).  The risk factors for suicide have not been well explored but bullying (especially cyberbullying) and child maltreatment exhibits significant correlation to rates of suicide (Castellvi et al., 2017; Britton, Van Orden, Hirsch, & Williams, 2014).  In the case of bullying, surprisingly, both perpetrators and victims of bullying are more likely to attempt suicides and the length of the bullying incidence is related to suicidal ideation (Holt et al, 2015; Winsper et al, 2012).  Peer influence is significant as well; having a friend or acquaintance who has attempted suicide leads to a higher probability of attempting suicide.  This can explain why suicides occur in clusters among teens (Borowsky, Ireland and Resnick, 2001; Haw, Hawton, Niedzwiedz & Platt, 2013).  At the social level, explorations around social belongingness and loneliness have been correlated with suicidal ideation.

Treatments involve addressing individual, psychological, group and social factors that influence suicide behaviors and thoughts.  Family and individual therapy as well as school group therapy strengthen belongingness and increase the conflict resolution capacities of students (Kaz et al, 2013).  One particularly helpful therapy has been the Integrated Cognitive Behavioral Therapy that aims to change internal monologues of affected individuals while at the same time addressing family dynamics (Spirito & Esposito-Smythers, 2011).  Dialectical Behavior Therapy that facilitates individuals’ tolerance of distress and pain has also been shown to be effective in reducing suicidal ideation (Mehlum et al, 2014)).  At the school level, one effective model is to address all preventive programs for all youth regardless of suicide risk (Wasserman et al., 2015; Zalsman et al, 2016).  Conducting regular mental health assessments to identify youth who are at high risk of suicide attempts has been shown to be only moderately effective.  Gatekeeper programs that train youth in identifying and referring youth who might be at higher risk has not shown significant effectiveness in reducing incidence (Wasserman et al, 2015).  Similarly, the efficacy of crisis lines has not been studied extensively and needs to be explored more to substantiate its efficacy in reducing suicide behaviors (Surgenor, Quinn & Hughes, 2016).

Until the 1980s, teens and children were not thought capable of suffering from depression; mood imbalances were often looked at as being normal for that age group.  In 1987, the drug Prozac was introduced to the market and for the first time; adolescents began to be diagnosed with the disorder in increasing numbers (Lawlor, 2012).  However, despite the relative newness of the diagnosis, clinical depression and anxiety among adolescents and young adults have skyrocketed in recent decades (Thapar et al, 2012).  Girls are more than twice as likely to suffer from the disorder as boys.  The rates range from 9% of all teens to 36% (Moffitt et al, 2010).  Most teens who are diagnosed with mood disorders have other comorbidities like ADHD, conduct disorders and anxiety (Wichstrøm et al, 2012).  Depression and other mood disorders tend to persist and re-occur over the long term and there is significant but only moderate correlation into adulthood (Goodyear-Smith, 2006).  This might be related to the interaction between the social context, experiences and the impact of the mood disorder.  In many cases, the diagnosis of a mood disorder may set forth a chain of events that lead to experiences that reinforce and strengthen the symptoms that lead to the diagnosis in the first place (Langa & Gone, 2019; Patten, 2019).

Experts have identified symptoms that constitute depression; some of the signs of full-blown depression are, persistent irritability (especially among children and youth) and sadness, loss of interest in normal activities, changes in appetite or body weight, insomnia or excessive sleepiness, psychomotor agitation, loss of energy, and feelings of worthlessness and guilt, outbursts of emotions, loss of friends, substance abuse and physical symptoms of illness (Monti & Rudolph, 2017; Price et al., 2016).  Experts recognize that for youth who may be predisposed to melancholy, encountering stress at school, home or among their peers may heighten the chances of experiencing a major clinical depressive episode (Löfving–Gupta, 2015).

Anxiety and depression are deeply connected through the lifespan and anxiety often precedes depression (Turner, Mota, Bolton & Sareen, 2018).  Similarly, depression seems to demonstrate a connection to substance abuse and conduct disorders; experts surmise that depressed individuals often use alcohol as a medication to treat their depression (Hussong et al., 2011).  Depression often runs in families; this may reflect both a genetic basis as well as commonly shared experiences that is passed on from one generation to another (Riglin et al, 2018).  Several neurocognitive and neuroendocrine bases for depression have also been identified, though it is difficult to say if the former causes depression, or if depression leads to these changes (Forbes & Dahl, 2005).

The major form of treatment for depression in the USA is psychotropic medications, chief among them being the anti-depressants (aan het Rot, Matthew & Charney, 2009).  Antidepressants work to increase the absorption of certain neurotransmitters like serotonin in the brain.  Some experts believe that when there is a deficiency of these neurotransmitters a person is likely to exhibit the symptoms of depression.  However, the results of studies exploring the connection between neurotransmitter deficiency and major depression have been mixed (Lacasse & Leo, 2005; Schildkraut, 1965).  There are several gaps in the evidence that critics have written about.  The drugs are more likely to work in cases of severe depression than in mild cases of depression (Fournier et al, 2010).  The efficacy of these medications ranges from about 40% to 60% of those taking them.  Efficacy rates refer to the percentage of users who benefit from the drug and can diminish the symptoms over time.  For others, the medications are not effective while a few others may improve with time even with no intervention. About 50% of those taking antidepressants experience uncomfortable to disabling side effects.  Thus, compliance with the medication regimen is often a problem with those taking antidepressants (Arroll et al, 2009; Geddes et al, 2003).

In addition to medication, talk therapy, especially in the form of Cognitive Behavioral Therapy has been shown to be effective (Van Hoorhees, Smith & Ewigman, 2008).  Some experts believe that counseling and therapy are more effective for treating depression than are medicines.  They claim that talk therapy is typically more expensive than pharmacological medicines and many insurance companies may refuse to cover the costs of extended therapy; the result is often over-medication in people suffering from both depression and anxiety (Harris, 2011; Wilens & Hammerness, 2016).

Experts describe anxiety as a diffuse uneasiness over some anticipated ill that might befall the sufferer or their loved ones (Bernstein, Borchardt & Perwien, 1996; Tuma & Maser, 2016).  It often co-occurs with depression and is the most common mental illness in children and youth.  Almost 31% of youth in the USA suffer from anxiety disorders and only 18% of sufferers get the help they need (Bandelow & Michaelis, 2015).  Anxiety could be a generalized state, or it could be a response to a specific situation (Guildford & Miller, 2015).  Its impact can be manifested directly in the body or it could be hidden while still affecting the person’s functioning. Children often manifest anxiety in the form of physical symptoms like stomach pain, headaches or expressing a need to withdraw from stressful situations.  Generalized anxiety disorders are the most common among children, especially among students who worry about their performance.  This is often manifested in high levels of restlessness, difficulty concentrating and experiencing tension (Henningsen, Zimmerman & Sattel, 2003; Spencer, 1998).

Social anxiety disorder is a form of anxiety that manifests in social situations.  Social anxiety is exhibited in avoiding eye contact or showing little interest in reaching out to other people.  Youth with social anxiety are easily embarrassed and humiliated and hate calling attention to themselves (Stein & Stein, 2008).  Anxiety is one of the most treatable mental-illness if diagnosed accurately (Byrne, Lebowitz, Ollendick & Silverman, 2018; Seligman & Ollendick, 1998).

OCD tends to manifest its symptoms in childhood and adolescence.  The disorder is manifested as a compulsive need for excessive structure and order as well as the tendency to hoard objects or engage in repetitive thoughts that might obstruct productive work.  For clinicians to classify this as a disorder, the symptoms need to last for two weeks (Mataix-Cols, Nakatani, Micali & Heyman, 2008).  OCD can be distinguished from other disorders like autism spectrum disorders and tic disorders by the awareness displayed by the patient (Holzer et, 1994).  People who are diagnosed with OCD recognize that their obsessive thoughts are senseless and disruptive.  They have unsuccessfully tried to resist these thoughts (Krebs & Heyman, 2015).  Approximately 4% of teens are affected by it and their symptoms can be very disruptive to normal functioning.  Some studies have implicated the overactivity of the orbitofrontal cortex in the disorder (Pauls, Abramovitch, Rauch & Geller, 2014).  Environmental factors like social isolation, physical abuse and negative emotionality co-occur in many cases of OCD (Stein et al, 2010).

Cognitive Behavior Therapy (CBT) has shown to be highly effective in treating mood disorders and OCD in adolescents.  Children with depression often engage in highly negative self-talk accompanied by irrational thoughts and expectations.  They have unrealistic standards of behavior and over emphasize the impact of the capabilities and actions of both themselves and others around them.  CBT attempts to bring to the surface these thoughts and modify them in a gradually positive manner Olatunji, Davis, Powers & Smits, 2013).   Family dynamics can be addressed by engaging the entire family in therapy (Geller, March & AACAP Committee on Quality Issues, 2012).  Other ways of addressing these disorders might be to include exercise and dietary changes in the regime and providing a supportive environment in the school (Nosratmirshekarlou, Shafiq, Goodarzi, Martino, & Pringsheim, 2019).  Progressive muscle relaxation leads to better adaptability in stressful circumstances.  Including imagery in the form of systematic desensitization has been demonstrated to be successful in reducing some of the symptoms of many mental illnesses.  Systematic desensitization involves introducing a stressful situation with therapeutic support, in a gradual manner until the client is no longer triggered by the elements of a situation (Luber, 2015).  While psychotropic medicines are helpful in the short term, there is increasing skepticism by experts about using medication without also including talk therapy to address symptoms of OCD (Franklin & Foa, 2011; Schwartz, Schlegl, Kuelz & Voderholzer, 2013).

Many youths engage in self-harm behavior not intending to commit suicide, these behaviors are often referred to as non-suicidal self-harm.  They may include cutting, scratching, burning or minor overdosing.  Like with other internalized mental disorders, these behaviors often co-occur with symptoms related to depression and other trauma (Nixon, Cloutier & Janssen, 2008).  Surveys have demonstrated that self-harm affects youth at a high rate from about 13% – 45% of young people reporting to engage in it; about half of those affected seek help and this has been correlated to the severity of their self-harm behavior.  The more severe the self-harm, the more likely individuals are to seek professional help. That leaves out many young people whose quality of life may be affected by the disorder but who may not think it important to seek help.   Women and LGBTQ+ youth reported more self-harm behaviors than boys and straight youth (Laye-Gindhu & Schonert-Reichl, 2005).  It is important that advocates of youth be vigilant for self-harm behaviors when young people come in with other issues associated with depression or they profess to feeling bullied or discriminated against (Liu & Mustanski, 2012; Ougrin et al., 2015)

Increasingly, youth who come from a variety of persistent stressful situations have been diagnosed with PTSD – Post-Traumatic Stress Disorder.  The symptoms can mimic other illnesses but youth with PTSD have marked reexperiencing of the problem situation over and over again and exhibit hyper-arousal during situations that might trigger certain negative emotions.  Children who have experienced sexual abuse are particularly susceptible to PTSD. Youth with PTSD may avoid certain stimuli, be hyper-aroused under similar circumstances as when the past trauma happened, express disorganized behavior or may dwell on the situation excessively (Dyregrov & Yule, 2006).  As with other mental health issues, the symptoms may occur with other illnesses as well.

Attention Deficit/Hyperactivity Disorder (AD/HD) is an externalizing disorder and is commonly diagnosed among children and youth.  As its name suggests, youth with AD/HD have trouble focusing on tasks, are distracted and have trouble following through with school work.  They have trouble paying attention when spoken to, are forgetful in daily activities and unrelated thoughts intrude when performing specific activities.  Teachers report that students who may have AD/HD fidget or talk excessively in class, are disruptive and inappropriately active.  There are a set of 18 symptoms that are specified by the DSM; children would have to exhibit at least 12 of them for a period of 6 months in order to be classified as AD/HD (Hudziak, Copeland, Stanger & Wadsworth, 2004).  As with other mental disorders, AD/HD is also thought to be caused by a combination of genes and the environment (Nigg, 2006).  In particular, two neurotransmitters have been implicated in AD/HD – dopamine which is responsible for the feeling of being rewarded after engaging in an activity, and norepinephrine which is responsible for attention and arousal.  Some researchers believe that low levels of both these hormones cause the symptoms of AD/HD (Thapar Cooper, Eyre & Langley, 2013).

Treatment for AD/HD involves behavioral psychotherapy and medication.  Children and youth may be taught better time management and organization skills while occasionally using rewards judiciously (Nigg, 2006).  Parents and teachers can be taught to help these children negotiate their environment by introducing firm structures within their homes or schools (Evans Schiltz, deMars & Davis, 2004; Klassen, Miller, Raina, Lee & Olsen, 1999; Trout et al, 2007).  The principal medications tend to be stimulants since it is believed that lower than normal levels of neurotransmitters are responsible for the disorder.  The medications resemble other illicit stimulants like methamphetamine; unlike their illicit counterparts, experts claim AD/HD medicines are slow release and do not cause the euphoria that methamphetamines cause (Chacko, Newcorn, Feirsen, Uderman, 2010).

The group of behaviors and symptoms that lead to the diagnosis of ODD/CD are usually observed in childhood and include being uncooperative, defiant towards authority figures and hostile towards peers, caregivers, teachers and other authority figures (Matthys, Cuperus & Van Engeland, 1999).  ODD/CD is sometimes the result of an inability of young people to separate appropriately from their caregivers and may also involve a history of negative consequences for infractions that models aggressive behavior for youth (Bezdjian et al, 2011).   In many cases however, there is a strong association between being diagnosed with AD/HD and the occurrence of conduct disorders.   While the behaviors that constitute ODD/CD may occur in children without AD/HD, they tend to occur consistently in those diagnosed with AD/HD and pose significant challenges to adjustment to school or connections with peers (Michanie et al, 2017; Oosterlaan, Scheres & Sergeant, 2005).

The treatment for ODD/CD involves talk therapy that facilitates a child learning to control their anger and aggression as well as to increase their capacity to engage in nonviolent communication and conflict resolution (Webster-Stratton, Reid & Hammond, 2001).  Family therapy that helps increase better communication between parents and siblings of youth with the disorder and helping the adults at home learn better discipline and management techniques have been found to be effective (Drugli, Larsson, Fossum, & Mørch, 2010).  School-based programs that teach social skills and conflict management, address issues of bullying and harassment, and teach emotional regulation are useful in facilitating growth in all children including those with ODD/CD.  The disorder often co-occurs with other mental illnesses like ADHD and therefore it is important to have appropriate diagnosis to best help those affected (Pine et al, 1997).

While a majority of adolescents experiment with substances (both illicit and legal), only a small minority transition into abusing substances.  The criteria that distinguishes a disorder from recreational use of mind-altering substances is that a disorder creates a significant problem in the daily functioning of the individual, a loss of interpersonal relationships, increasing tolerance to the drug and withdrawal when the drug is unavailable to the person (Cole, Sprang & Sillman, 2019).  SUD involves both dependence and abuse – the former refers to the physiological processes that keep the person consuming the drug while the latter is the more complex interactions between the individual, the drug and the larger social context in (Rhemtulla et al, 2016).  Often, substance abuse co-occurs with other mental illnesses like depression or ADHD which adds additional stressors to a teenager who is predisposed to substance abuse (Priester et al. 2016).

Recent surveys indicate that teen drug use frequency of most substances like tobacco, alcohol, cocaine, ecstasy, heroin and prescription drugs have come down in recent years; marijuana use has stayed stable (Sarvet et al, 2018).  Almost a quarter of high school students report having used marijuana in the previous month and 6% report using it daily.  While attitude towards marijuana has softened, the rate of use has not spiked.  About 5% of 12th graders used opioid painkillers in 2016; it was over 9% in 2004.  Over 7.5% of 12th graders used Ritalin and Adderall in a non-medical manner.   A significant number of high schoolers used over the counter medicines like those for cough, for non-medical purposes.  Younger teens are more likely to use inhalants like household cleaners, glue and pens while older teens use marijuana and less often, synthetic marijuana.  High school seniors use and abuse prescription medications like opioids and Adderall more than other substances (Das et al, 2016; Schepis, Teter & McCabe, 2018).

Alcohol and tobacco are the most commonly used drugs by adolescents in the USA. Since both are legal for adults, they are often viewed as a rite of passage for youth and part of their attempts to try on adult roles with their peers.  With the use of alcohol, most adolescents report that their primary motive was curiosity about what it felt like to be intoxicated.  Inexperience contributes to unintentional overdoses and other negative consequences (Hennessy & Tanner-Smith, 2015).  Using any substance inappropriately and for non-medical purposes pose some level of risk; however, in recent years the rise of opioid and heroin addiction has been characterized as a public health epidemic in several states where youth die from overdose regularly (Manchikanti et al, 2018).  Opioid pills are typically crushed, injected or snorted leading to an immediate euphoric experience.  Many young people graduate from opioids to heroin because the latter is much cheaper, resulting in similar but sometimes deadly consequences (Maxwell, 2015).  ADHD medications like Adderall are similarly abused by high school students; most students use these drugs to increase focus and concentration, but the consequences are very similar to the high produced by amphetamines.  Regular use leads to long term negative physical consequences (Smith et al., 2017).  Another major substance used by youth, mostly by men, are performance enhancing steroids.  When steroids are abused, it can lead to severe physical problems and even irreversible organ damage.  There is also evidence that steroid use may lead to increased aggression (Sagoe, Mentzoni, Hanss, & Pallesen, 2016).  When youth stop using these steroids after overuse, withdrawal symptoms like depression can impair the person’s health and functioning (Yates, 2016).

Genetic predispositions have been implicated in SUDs (Hodgson et al, 2017).  Having parents who abuse substances significantly increases the likelihood of children abusing drugs (Koob & Volkow, 2016).  Taking highly addictive drugs in one’s teen years, being a male, being under the age of 25, not having adequate familial support and suffering from other mental health illnesses are all factors that are associated with a higher probability of developing a SUD (Koskela et al, 2017).  Older adolescents are much more likely to engage in drug use than younger adolescents.  Many experts believe that the instability in emotions that often accompanies being an adolescent is related to the higher incidence of drug use among older adolescence.  Youth use drugs to self-medicate; this is called the self-medication hypothesis.  However, once these substances are used regularly, their psychotropic effects begin to feel ‘normal’.  When the drugs are withdrawn, the carefully maintained stability under the influence of these mind-altering substances begins to dissipate leading to drop in the feelings of mental well-being.  In addition, the inappropriate use of these drugs can lead to anxiety and depression (Khantzian, 1997; Mayes & Suchman, 2015).  Thus, it is important to tease out the various issues that might be affecting an adolescent’s normal functioning before beginning a treatment regimen.

As in the case of other mental illnesses, both psychotherapy and medication can be used in combination for optimum outcomes.  With the spike in heroin overdoses and deaths across the US, there is a fierce debate raging around appropriate ways to address the issue of addiction.  Since the late 1980s, the flow of drugs from the Global South has been viewed as the principal problem leading to addiction.  The War on Drugs conceived of by successive administration was meant to cut off supplies of illicit drugs to the American consumer.  This policy did not work as intended and led to the largest expansion of the US prison system in history, with most of the prisoners being young, male and often from vulnerable and marginalized groups (Inciardi, 2008).  Instead of helping reduce drug use and abuse, the war on drugs and other punitive policies implemented added to the stigma of those who suffered from addiction and hardened public opinion towards this vulnerable population.  Today, there is a new push to legalize some of the less harmful drugs along with decriminalization of marijuana in several states.  Criminal justice reform advocates argue for a removal of the mandatory sentencing laws that force judges to mete out harsh sentences; advocates recommend that the criminal justice system treat the problem of SUD as one involving mental health (Ferrazzi, 2018; Hoffman, 2001).

In the US, over the last few decades, there has been much written about the instability in adolescent life.  Youth are susceptible to a host of mental issues because in industrialized societies, this is the time when there are immense pressures to choose their life trajectory and values.  Lightfoot (1997), for instance, explores the issue of adolescent risk-taking as a space for an adolescent to take meaningful action to negotiate their connections with the larger world. During adolescence, the cultural artifacts of childhood are thrown over for those that attempt to better reflect one’s relationship with society.  To Lightfoot, adolescents are in a transitional space which is playful, speculative and fanciful and which help youth articulate their identities in the present and for the future.  She points to the fact that much of the risk-taking that adolescents engage in take place in the company of other teens.  Many of the risks that adolescents take is also aimed at rebelling against authority.

Adults in the US have historically viewed youth risk-taking as both trouble and opportunity and the ambivalence towards the phenomenon has made any societal response disorganized and ineffective (Koot & Garde, 2013).  However, an alternative constructive response might be to highlight the moments of opportunities that risk-taking offers to grow and form adult identities.  Educational philosopher John Dewey and psychologist Stanley Hall spoke about the enormous possibilities for self-exploration and identity that adolescent spaces offered (Pajares, 2006).  Erikson wrote about the adolescent need for locomotion both physically and ideologically; he proposed that this propelled youth towards change (Arnett & Cravens, 2006).  For Erikson, youth tendency towards experimentation, while sometimes extreme, serves to help them push boundaries and try new identities.  Preventing youth from these experimentations might sometimes inhibit the achievement of the development tasks for the period, one of the main ones being the achievement of one’s identity.

Some researchers emphasize the need for adult advocates of youth to differentiate the normative risks that many teenagers take and ones that often are pathological and are likely to result in self-harm.  Smoking an occasional joint with friends is a normative risk that many teens take, while heroin addiction is something that needs to be attended to right away (American Psychological Association, 2007).  The behavior that is under study needs to be situated in the appropriate social contexts within which it is happening.  In addition, it is important for advocates to understand the meanings that adolescents themselves give to the behaviors (Goodman et al, 2015).  For instance, anti-social activities by gang members is a way for individual members to show their solidarity with the group and it has powerful personal significance for the members even as law enforcement and the adults in teens’ lives may implement negative consequences for these associations (Pyrooz & Densley, 2016).

When it comes to childcare, young parents are often engaged in what one sociologist calls ‘intense cultivation’ of their children.  Parents spend more time engaging with their children now than at any time in the since the industrial era.  Much of this increase in time spent with children is in the form of interactive activities to maximize their children’s chances of success – this is true of mothers and fathers (Bianchi, 2005).  Families thus seem to be responding to the extreme instability of the workplace and the markets.  When both paid and unpaid work are counted, parents put in about 10 hours a day, every day of the week in work.  In one recent survey, most men and women say that balancing work and caregiving is highly stressful.  This stress is more highly felt in the upper echelons of the social ladder because more parents work, and they work many more hours at higher pay.  As a result, couples today spend far less time socializing with friends or extended family, enjoy activities or engage in projects together leading to lower quality of marriage (Evenson & Simon, 2005).  For the almost 50% of American adults who also engage in caregiving activities towards their own parents, work, family and childcare can be exceedingly stressful leading to stress and depression (Evensan & Simon, 2005; McLanahan & Adams, 1987; 1989).  The happiness gap between parents and non-parents is larger in the USA when compared with other industrially advanced countries and many emerging economies.

Since families work long hours in the USA, there is an acute need for good quality childcare programs.  The evidence however demonstrates that childcare facilities are ill equipped when compared to other industrially advanced countries (Laughlin, 2013).  More than three quarters of American children spend time in day care settings, many for more than 35 hours and yet unless a family is wealthy, most children who do attend daycare get substandard care.  The evidence that early childcare improves wellbeing for individuals for years after is proven (Campbell, 2012; Yoshikawa, 2013).