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Learning objectives
After studying this chapter, you should be able to:
describe influences on the development of internalising and externalising behaviour and their relationship to health
describe factors associated with adolescents’ help-seeking behaviour
describe the relationship between factors contributing to homelessness, and their impact on later health and wellbeing
identify public health approaches designed to address adolescent substance use
use your understanding of risk factors and public health approaches to develop effective responses to bullying perpetration and victimisation.
Carolyn first ran away from home at 15 years old, after being assaulted by her mother and told to leave and not return. She was living with foster carers for a year, but after her 16th birthday she was asked to move into independent living, and moved to a share house with four other young people. From this point, Carolyn had to live her life as a responsible adult. She managed to get a casual job, but the income she received was not enough to cover her cost of living. To earn more money, Carolyn left school at the end of Year 11 and moved from casual to part-time employment. However, the money Carolyn earned from part-time work was still not enough to cover the cost of living. She was unable to obtain full-time work and, after missing several rental payments, Carolyn was forced to leave the share house and became homeless. She was then 18 years old. During her time homeless, she slept rough (on the streets), and at times did not sleep at all out of fear for her safety. She also regularly went for several days without anything to eat or drink.
While homeless, Carolyn regularly had experiences when she would get angry, often threatening or hitting other people. Carolyn had to find a way to manage these difficulties and often engaged in behaviours that were not socially acceptable to obtain money or a place to stay for a night. Carolyn experimented with alcohol and drugs to try to make herself feel better about who she was and what she was doing on the streets.
Carolyn is now 20 years old. She currently lives in crisis accommodation. Her caseworker has just advised her that this accommodation will only be available for a ‘few’ months and then she will need to find somewhere else that is more stable to move to. Living in this accommodation provides Carolyn with a home to go every day, a bed to sleep in, a small kitchenette, bathroom and laundry facilities. Carolyn tells her worker she likes this setting as it provides her with her own space rather than being in someone else’s home or having nowhere to go. Carolyn has been in crisis accommodation for almost six weeks.
Introduction
Recent estimates suggest young people (10–24 years of age) comprise 27% of the global population (Gore et al., 2011). Adolescence is a time when young people are vulnerable to the emergence of mental health problems (particularly depressive and anxiety symptoms), suicidal behaviour, substance use and engagement in antisocial behaviours. These problems and behaviours are among the top causes of mortality and disability adjusted life years (a measure of the years of healthy life lost due to ill health, disability or premature death) for adolescents today (Gore et al., 2011). Adolescence results in changes to the way young people interact with their families, peers and wider society. With increased emphasis placed on peer relationships, adolescents’ experiences of traditional and cyber-bullying perpetration and victimisation become prominent. For some adolescents, family-based problems may be associated with entry into homelessness. Although not all adolescents experience these types of problems, most face challenges in making adult transitions (for example, completing school, beginning employment), making the availability of support and help-seeking behaviours all the more important in the context of addressing a growing burden of disease due to common health and behavioural problems. The challenging context of adolescence may result in a reluctance to seek help; however, this can have positive benefits for the abovementioned health concerns and behaviours.
While old public health approaches were embedded within biomedical paradigms focusing predominantly on education as a means of improving health, new public health approaches acknowledge the impact lifestyle and lifestyle choices have on health and take a proactive approach to dealing with health concerns (see also chapters 1 and 2). Many approaches aiming to improve adolescent health have been underpinned by a determinants approach to health aimed at understanding the social, economic, environmental and political factors influencing health (see chapters 5, 6 and 7). In developing public health approaches aimed at addressing adolescent health concerns and behaviours, it is important to understand the factors that contribute to these concerns and behaviours, and whether there are particular factors that lead to specific concerns for certain groups of adolescents (for example, those experiencing homelessness).
This chapter explores some of the common health concerns experienced by adolescents (internalising and externalising problems, homelessness, substance use, and traditional and cyber-bullying perpetration and victimisation), help-seeking behaviour, and the individual characteristics and environmental factors (herein referred to as risk factors) that increase the likelihood these health concerns (Catalano & Hawkins, 1996). Risk factors can be categorised by the social context of the adolescent including peer group, family, school or community, and characteristics of the adolescent. Each section provides an overview of the abovementioned health concerns and discusses risk and protective factors influencing their development. Public health-based prevention and intervention approaches used by practitioners and researchers will be described.
Internalising and externalising problems
Internalising and externalising problems among adolescents affect not only their immediate health and wellbeing, but also school engagement, psychological and social development, and achievement of developmental tasks. The Australian Institute of Health and Welfare (2008) found that approximately 10% of adolescents between 14 and 19 years of age and 10% of those 15–19 years reported an internalising or externalising problem. Suicide remains a leading cause of death for Australian youth, accounting for 22% of deaths among 15–19-year-old males and 33% of females of the same age (Australian Bureau of Statistics, 2012). Internalising problems are of concern given their association with adverse health outcomes (for example, adult mental health problems, suicidality) and association with externalising problems.
- Internalising problem
an emotional problem including the inability to regulate emotions (for example, anxiety and depressive symptoms).
- Externalising problem
a socially unacceptable behaviour such as fighting, damaging public property, stealing, illegal activity, carrying a weapon, school truancy and substance use.
Factors contributing to internalising and externalising problems
Internalising problems (including suicide) are influenced by a range of family, school and community factors. Consistently reported risk factors for internalising problems are family factors including violence, poor communication, high conflict and low parent–adolescent problem solving (Shortt & Spence, 2006). Low levels of school connectedness are associated with depressive symptoms (Bond, Toumbourou, Thomas, Catalano & Patton, 2005), while school-based programs aimed at reducing behavioural problems have positive effects on student–teacher relationships, school connectedness and academic achievement (Freiberg & Lapointe, 2006). Community-based factors including violence and poverty increase risk for depressive symptoms, while higher numbers of school transitions and community crimes are linked to internalising problems (Shortt & Spence, 2006).
Risk factors for externalising problems are similar to those for internalising problems. At an individual level, adjustment problems, low impulse control, aggression and interpersonal difficulties (Smart, Vassallo, Sanson & Dussuyer, 2004) are risk factors. At a family level, coercive and inconsistent disciplinary strategies are associated with child and adolescent-onset externalising problems (Smart et al., 2004). Poor parental supervision, low levels of family interaction, violence and conflict, and parental attitudes favourable to violence also pose risks for externalising problems (Loeber & Farrington, 2000). Interaction with delinquent peers is a risk factor for externalising problems (Smart et al., 2004). At a community-level, risk factors include neighbourhood disadvantage and crime, lower perceived risks of punishment, unemployment and social disorganisation (Wikstrom & Sampson, 2013).
The relationship between internalising and externalising problems and health
Adolescent internalising problems can lead to the disruption of developmental pathways and achievement of adult milestones, while also increasing subsequent risk for other health conditions such as adult internalising problems (Hankin et al., 1998), suicidality (including suicidal ideation, attempt and self-harm) (Beautrais, 2000), externalising behaviours (Galambos, Leadbeater & Barker, 2004), substance use, lower academic achievement and unemployment (Stice, Ragan & Randall, 2004)
Negative developmental, health and social outcomes are reported for externalising problems and include substance use, continued engagement in antisocial behaviours, relationship problems, school failure and involvement with the criminal justice system (Smart et al., 2004). Researchers have argued that the developmental consequences associated with externalising problems are more severe when the onset of these behaviours occurs in childhood compared to adolescence, with studies of Australian adolescents showing early adolescent externalising problems are associated with increased contact with the criminal justice system in mid and late adolescence (Smart et al., 2004).
Public health approaches to addressing internalising and externalising problems
The prevention science paradigm has commonly been adopted in devising approaches to address and reduce rates of adolescent internalising and externalising behaviours. Public health approaches to address these behaviours often adopt multi-sectoral partnerships between community organisations. For instance, initiatives including the MindMatters Mental Health Promotion Project and National Youth Suicide Prevention Strategy actively demonstrate the implementation of suicide and self-harm prevention approaches. Other approaches include mental health campaigns distributed through mass media and designed to modify cultural norms and perceptions, while increasing knowledge of common mental health problems, and where help can be sought. The need for multifaceted approaches targeting multiple risk and protective factors have been addressed through universal prevention approaches, including programs designed to increase adolescents’ social and problem-solving skills. To address family-related risk factors, many programs have been developed and trialled, aiming to reduce the onset of externalising behaviours through increasing parental supervision and positive family interactions, while decreasing family violence, conflict and parental attitudes favourable to these behaviours.
- Prevention science
a research approach characterised by examining risk and protective factors across individual, family, peer and community environments, and how these can be modified to improve or reduce behaviour.
Jennifer is a social worker specialising in family resources. Services provided by the organisation are delivered using a developmental framework (a framework classifying risk and protective factors and their influence on growth and behaviour according to defined developmental periods) with an emphasis on improving health. Using this framework permits the organisation to build their public health strategies in a way that matches the developmental needs of their clients, and to implement these strategies at key periods in development where they likely to have the most benefit.
Jennifer has been asked to present a whole-day workshop to colleagues and clinicians from community-based organisations in her local government area, focusing on the development and prevention of internalising and externalising behaviour, and provision of treatment. Also to be explored through the workshop are areas for mental health service development and delivery, to adolescents, their families and local schools, in further developing the organisations’ services.
Consider the main issues addressed in this section. Identify the main components that Jennifer could present in her workshop, including the range of factors that could be considered in addressing internalising and externalising problems. Also devise strategies for service provision to ensure organisational approaches respond to the diverse and changing health needs of adolescents, families and schools within the local community.
Help-seeking behaviour
Help-seeking behaviours have commonly been studied within the contexts of coping and social support. More recently, it has been suggested that help-seeking behaviour may be a distinct behaviour and not simply a component of social support or coping (Heerde, Toumbourou, Hemphill & Olsson, 2014). Social science researchers have commonly examined help-seeking behaviour as seeking assistance through formal avenues of support (for example, medical or psychological services). Data from the Australian National Survey of Mental Health and Wellbeing (Sawyer, Miller-Lewis & Clark, 2007) shows that for adolescents 13 to 17 years of age who met the clinical definition for mental health disorder, help was most commonly sought from school counsellors (14%), family doctors (13%), and paediatricians (11%). For adolescents, examining the sources of support available through informal avenues (for example, family, friends, teachers) may be a more inclusive approach, in conjunction to the adolescents’ ability to access these supports. This may be because the period of adolescence is one of many changes and challenges, as cited at the beginning of this chapter. Research indicates that adolescents are more likely to turn to family and peers for support with health concerns and behaviours, with 56% and 48% of adolescents reportedly seeking help from their parents and friends, respectively (Sheffield, Fiorenza & Sofronoff, 2004).
- Help-seeking behaviour
the initiation of specific and direct behaviours intended to mobilise assistance from formal (for example, counsellor) and/or informal sources (for example, family members).
- Social support
the actions of other people (for example, family members or peers) to provide support to the adolescent.
Factors contributing to help-seeking behaviour
Many factors contribute to the development of help-seeking behaviour. Individual psychological factors include stereotypes associated with help-seeking (for example, those associated with masculinity and weakness), confusion about confidentiality, fear, anxiety, shame, embarrassment, and low confidence in individuals being able to provide assistance (Cardol et al., 2005). Families remain important social networks for adolescents, despite peer relationships becoming increasingly important. Family factors contributing to help-seeking behaviour may relate to the family environment and the ways in which (or not) family members model help-seeking behaviours. For instance, weak or unsupportive family relationships and reduced opportunity for participation in family activities or decision-making may reduce an adolescents’ likelihood of seeking help from these people. Confiding relationships with peers are important influences on adolescents’ help-seeking behaviours. It has been estimated that up to 90% of adolescents confide in their peers, rather than professionals or other individuals, when experiencing distress (Ciarrochi & Deane, 2001).
The relationship between help-seeking behaviour and health
Many projects aimed at determining ways in which mental health problems can be reduced (such as through promoting help-seeking behaviour) have been trialled. Help-seeking is generally considered a healthy behaviour, and seeking help from reliable and informed sources may bring adolescents into contact with a range of important resources capable of reducing risk for mental health and behavioural problems. Family factors associated with help-seeking behaviour, such as parental support, and quality of family relationships (including positive communication, parent attachment) reduce tendencies for internalising and externalising behaviours (Shortt & Spence, 2006).
Public health approaches to addressing help-seeking behaviour
Schools remain a key setting for implementing public health approaches addressing help-seeking behaviour. These approaches seek to develop and promote positive mental health and emotional wellbeing. The aim of such approaches is to reduce risk factors and enhance protective factors, while building skills which result in proactive approaches to dealing with problems.
In Australia, the development and implementation of National Mental Health Policies gave rise to the inclusion of mental health and life skills programs within the school curriculum. Such programs, ranging from individual programs to components of broad-based mental health promotion programs (for example, ‘MindMatters’), are widely available (Wyn, Cahill, Holdsworth, Rowling & Carson, 2000). These programs aim to strengthen the development of life skills, as well as foster supportive school environments; however, little evaluative literature exists on the appropriateness, credibility, and effectiveness of such programs, although the importance of building life skills within school environments has been widely established (Glover, 1998; Wyn et al., 2000).
Melanie is 16 years old and in Year 10 at her local rural high school. She lives with her mother and younger sister. Although her parents recently separated, Melanie shares a close relationship with her mother and father. Five weeks ago, Melanie attended a party with a group of friends. At this party, Melanie consumed several alcoholic drinks and had unprotected sex with a male who was in Year 11 at her school. Through her Health and Physical Education class at school, Melanie and her classmates have been studying a unit on sex education. Following this class, Melanie realises she has been experiencing some symptoms that may indicate she is pregnant.
1 Identify and explain some of the risk factors that may be influencing Melanie’s behaviour.
2 As a school teacher, consider some approaches within the classroom setting that could be implemented to assist in developing students’ knowledge about safe sex, unplanned pregnancy and sexual health.
3 As a health worker, how can you apply some approaches to health promotion planning within the school setting to assist other students (male and female) who may find themselves in a situation similar to Melanie?
Homelessness
Homeless young people are a heterogeneous population group who commonly report experiencing many difficulties in their daily lives. For many homeless young people, the experience of family violence and abuse, unemployment, lack of affordable housing or transitioning from out-of-home care settings contributed to their being unable to live at, being kicked out of or forced to leave their place of residence. Australian Census data estimated that 26 238 youth aged 12–24 years (approximately 25% of the total number of homeless people) were homeless in 2011 (Australian Bureau of Statistics, 2012). The difficulties young people face while experiencing homelessness require them to find ways to manage these obstacles on a daily basis, which often requires engagement in behaviours that are not commonly considered to be socially acceptable (for example, violence). Likewise, being homeless embeds young people within an environment, and lifestyle, associated with increased susceptibility to victimisation and oppression. Homelessness is a severe form of social exclusion. For homeless people, the negative health and social outcomes associated with the entry into and the course of homelessness do not occur in isolation from one another.
Factors contributing to homelessness
Relationships between factors influencing transitions into and out of homelessness are complex and not unidirectional. Risk factors encountered while homeless frequently compound the influence of risk factors experienced prior to homelessness.
Childhood abuse, as well as transitions from out-of-home care, youth justice settings or migration from another country, are commonly cited individual factors. Further, individual factors encountered by young people while homeless, such as victimisation, influence the health of these youth. Characteristics of family environments, such as parental loss of employment and lack of housing stability, have been identified as influences on youth homelessness, and are also implicated in a young person’s reluctance to return to the family environment following periods of homelessness. Social factors known to influence homelessness include a lack of access to suitable, affordable and safe housing options; few employment opportunities; and a lack of collaborative health programs. Further, homeless youth often engage with peers in social networks that face similar risk factors.
The relationship between homelessness and health
Homeless adolescents display a number of serious health concerns, including but not limited to internalising problems, substance use, injury resulting from victimisation and physical health problems (for example, sexually transmitted infections, malnutrition) (Bearsley-Smith, Bond, Littlefield & Thomas, 2008). For homeless young women, unplanned pregnancy is often the result of survival sex (consensual or non-consensual exchange of sexual practices for money, food, shelter, alcohol or drugs), unprotected intercourse and sexual assault (Little, Gorman, Dzendoletas & Moravac, 2007). These health problems are often compounded by the experience of childhood abuse, parental substance use, and family breakdown prior to entering homelessness. Experiencing homelessness does not afford individuals the opportunity for rest and recuperation from illness or injury because of lack of access to safe accommodation, appropriate nutrition, purchase and storage of medication, and hygiene and sanitation. The transient nature of homelessness, financial instability and barriers to seeking health care (for example, prior negative experiences with and low trust in health and support services, insufficient knowledge of access to and navigating the health systems, fear of potential contact with authorities, and personal circumstances (shame, embarrassment)) also negatively affect an individual’s ability to obtain consistent medical care.
Public health approaches to addressing homelessness
How to increase health service utilisation among homeless youth has been the focus of many public health approaches. Multi-sectoral approaches between community-based organisations are required to prevent, address and reduce the health and social costs associated with homelessness. Intervention and prevention programs within these approaches need to be designed to address the complex needs of homeless people. Given the relationships between factors influencing homelessness are complex and derived from circumstances experienced both prior to, and during homelessness, it is not sufficient for service sectors to work in isolation from one another to address the health status, housing instability, psychological functioning and interpersonal skills of homeless people. Integrated service provision has the potential to increase the capacity of health and support services in assisting homeless people.
