Conclusion: Successes Since the First Edition and Pressing Issues for the Future of Adolescent Mental and Behavioral Health

Despite improvements in the delivery of care for adolescent mental and behavioral conditions since the first edition of this book, many challenges remain. This concluding chapter highlights some of the most pressing issues. These include the need for more mental health care practitioners, a greater evidence base for the treatment of adolescent conditions, and more focus on reducing family poverty. Given the high rates of gun violence, including homicides and suicides, efforts are needed to reduce access to these weapons. Promising directions in research and the need for a national youth development strategy are also discussed.

Defining Youth Suicide

This chapter looks at suicide among adolescents and young adults. Although true suicide causation is difficult to empirically establish, an accumulated body of research points to a number of individual and environmental factors that have been closely and fairly consistently associated with youth suicidal behaviors. These risk factors are identified and briefly discussed here. The chapter looks the behavioral and environmental factors for suicide. The main aim of this chapter is to examine current youth suicide prevention strategies and interventions with an eye towards identifying what works, what does not appear to work, and what research needs to be undertaken to move the field forward. Given the multiplicity of risk and protective factors that have been related to youth suicide, it is understandable that many different approaches have been taken in the attempt to prevent this behaviour.

Research Agenda for Eating Disorders

The concluding chapter of this section outlines several gaps in current knowledge that will be critical to address in future research. DSM-5 introduced a number of changes in diagnostic criteria for eating disorders, and it is crucial to determine the utility of these revised criteria in addressing the needs of adolescents with clinically significant eating problems. More large studies are needed to understand the frequencies of eating disorders and disordered eating in the general population, and risk factors for their development, including psychological and biological factors. It will be important to improve knowledge of the benefits and risks of psychological and pharmacological treatment interventions, and to clarify the most effective methods of involving the family. Continued research on prevention is critical to understand how efforts to prevent eating disorders can be integrated with interventions to prevent other psychological disorders and obesity.

Prevention of Eating Disorders

This chapter examines risk factors for the development of eating disorders and efforts to prevent them. A number of variables are considered to be risk factors; however, extant research has notable limitations, including the low prevalence of these conditions within the general population, which complicates the identification of reliable risk factors. The impact of culture on eating disorders is reviewed, as well as social and biological factors thought to exert complementary impact and to contribute synergistically to risk. Considerable progress has been made in developing and evaluating models for prevention since the publication of the prior edition of this book. These advances include the publication of several large effectiveness trials, the development of models to prevent the onset of anorexia nervosa and combined eating disorder prevention and weight maintenance/loss programs, and the availability of interventions for both boys and girls.

Treatment of Eating Disorders

This chapter focuses on treatments for adolescents with eating disorders, using information derived from randomized controlled trials and evidence-based treatments for eating disorders in adults. Available data provide some guidance in selecting treatments, but there are significant limitations in research on psychological and pharmacological interventions. Family-based treatment is effective for adolescents with anorexia nervosa, especially for those with a short duration of illness. For adolescents with bulimia nervosa, both family-based treatment and guided self-help based on cognitive-behavioral therapy are empirically supported interventions. At this time, there are no randomized controlled trials on the treatment of adolescents with binge-eating disorder, and, despite the widespread use of psychotropic medications, there is little empirical information about the utility and safety of such interventions for adolescents. Additional large well-controlled systematic studies with adolescents are needed to inform best care practices.

Prevention of Anxiety Disorders

This chapter begins by introducing current thinking on the rationale for preventing anxiety disorders in youth. It explains risk and protective factors in youth and examines symptoms exhibited. An important set of impediments to developing successful prevention intervention is the lack of knowledge about the complex interrelations among the various risk and protective factors for the development of anxiety disorders. Much is known about some specific factors but little is known about how they interact, which leaves the field bereft of a strong theoretical foundation upon which to build prevention programs. This may be why prevention research has continued to languish relative to treatment. There are a number of practical considerations that have stunted the development of prevention programs as well. The chapter outlines these. Therefore, new sources of funding must be identified to generate knowledge that will inform the development of anxiety disorder prevention programs.

Treatment of Depression and Bipolar Disorder

This chapter reviews the current status of the adult literature on mood disorder treatments for both psychosocial and psychopharmacological treatments. This is followed by an appraisal of the same treatment for adolescents. The chapter finds that there are only limited data from methodologically rigorous trials in pediatric bipolarity. Evidence suggests that monotherapy using certain drugs may be useful in the treatment of young patients with mania and related mood states. A consistent theme from the extant literature is that a substantial number of patients do not respond to all types of monotherapy. Therefore, investigators have begun to explore combination pharmacotherapy. It seems that simultaneous treatment with more than one agent may be a rational form of intervention for some patients. Pediatric bipolarity is a chronic condition associated with substantial dysfunction and suffering. There are few methodologically sound pharmacological treatment studies, thus more research on this topic is sorely needed.

Stigma

Stigma occurs when a person or group is negatively stereotyped and is treated as socially unacceptable. The stigma surrounding mental disorders poses significant barriers to identification, treatment, and recovery from these conditions. Stigmatizing beliefs about mental illness emerge prior to adolescence and are reinforced by both entertainment and news media. These widespread beliefs can promote self-stigma in persons with symptoms of mental illness. This chapter reviews the community and psychological processes that contribute to stigma and strategies that seek to reduce its harms in adolescents. It also highlights examples of successful stigma-reduction programs that emphasize the efficacy of treatment, correction of negative stereotypes, and exposure to persons with mental illness who have been successfully treated.

Adolescent Gambling

As a result of gambling’s general social acceptability, increased availability, and new online accessibility, and gambling has increased among youth. Adolescents represent a high-risk, vulnerable group for developing gambling problems. While youth with gambling problems typically do not present in the same way as adults, they nevertheless experience a host of negative consequences associated with excessive gambling. This chapter reviews risk and protective factors, screening, and treatment strategies for gambling problems among adolescents and highlights the importance of harm minimization through prevention strategies. Education and social policy implications are provided.

The Positive Perspective on Youth Development

This chapter covers positive youth development, positive psychology, and positive education, which suggest that mental health is more than the absence of mental illness and involves proactively supporting the mental well-being of young people. The assets of youth that protect against problems and allow young people to do well include both individual psychological characteristics and aspects of their social context. Positive approaches aim to maximize the potential of young people by encouraging both personal and environmental assets. Research findings over the past three decades have brought empirical support for key premises of positive youth development and have provided important insights into individual and contextual factors that underlie youth thriving. Future studies will continue to refine measures, improve interventions, and use empirical findings to understand and influence the processes that give rise to positive development.