Mental Health: The First Step to Well Being

Photograph of healthy, happy young people.

When a young person experiences homelessness, abuse, pregnancy, or other dangers, we can often see the results. Whether it’s malnutrition or lack of dental care, the most glaring physical effects can usually be recognized and treated. The psychological effects, however, can be trickier to identify.

For this issue of NCFY Reports, we take a look at three of the more widespread mental health issues facing at-risk young people and their providers. First we learn five important things all family and youth workers should know about post-traumatic stress disorder. Then we hear from different youth programs about the risks and uses for psychotropic medications in traumatized young people. And last, we hear from experts about how to recognize and prevent postpartum depression in teen mothers.

But mental health is a huge field, and we want to hear from you about how you handle the biggest psychological challenges facing the young people you serve. Tell us on Twitter and Facebook about these and other issues, and share your best treatment practices as well.

A Storm After the Calm: Post-Traumatic Stress Disorder in At-Risk Youth

Terri Weaver cuts right to the chase when describing the effects of trauma. “Your whole life has been put through the blender of traumatic experience and your ability to live life is colored by that trauma,” she says. As professor of psychology at St. Louis University in St. Louis, MO, Weaver knows that when young people experience trauma, their whole world changes. Their outlook on themselves and the world, their attention span, even their ability to connect with and trust other people. 

At their worst, these difficulties can be symptomatic of post-traumatic stress disorder, or PTSD, a mental health condition with wide-ranging symptoms that include flashbacks, numbness and self-destructive behavior. PTSD occurs after the fact in people who have experienced or witnessed a traumatic event such as rape, child abuse, domestic or community violence, natural or manmade disasters, or the sudden death of a loved one.

A Harvard Medical School study estimated that only 5 percent of young people have experienced PTSD, but other research has found that the disorder occurs in street youth at nearly six times that rate. Young people who have gone through physical or sexual abuse or intimate partner violence are also at high risk. With that in mind, here are five things family and youth workers should know about PTSD:

  1. Not all youth who’ve experienced trauma will develop PTSD. In a recent study on trauma and street youth, researchers found that 78 percent of youth had experienced a traumatic event, while only 28 percent met criteria for PTSD.
  2. Young people in the midst of trauma might have symptoms of PTSD—but it’s not PTSD. The disorder is diagnosed at least one month after the traumatic experience ends. That’s because when young people are in the midst of trauma, their reactions, such as becoming passive so an abuser won’t attack them, can be considered “adaptive,” Weaver says. It’s also because a young person can’t heal from trauma until its source is removed.
  3. PTSD may be preventable. “The more stable one’s environment following a trauma, the better one is likely to do,” says Christopher Sarampote, a program officer with the National Institute of Mental Health’s Child Trauma Program. Offering predictability and stability, keeping youth safe from an abuser, and meeting their basic needs for food, housing and safety may protect them from later developing PTSD.
  4. PTSD is treatable. “Getting help is important,” Sarampote says. Not treating PTSD, or traumatic responses in general, can impair young people’s recovery and even lead them to be victimized again, he says. A mental health professional can provide a diagnosis, prescribe medications if appropriate, and offer therapy. Evidence-based approaches that may help include Trauma Focused Cognitive Behavioral Therapy and Psychological First-Aid for Youth Experiencing Homelessness (PDF, 1.5MB).
  5. PTSD often co-occurs with other mental health problems and with substance abuse. “It’s important not to have tunnel vision and only think about PTSD” when screening a young person, Weaver says. Depending on the source of the young person’s trauma as well as personal factors, they may also have depression, suicidal thoughts, drug or alcohol addiction, or physical ailments such as injuries or gastrointestinal problems. Knowing a young person’s other struggles can help a mental health team tailor treatment and avoid therapies that might help with PTSD but hinder recovery from other conditions—or vice versa. For example, Sarampote says, anti-depressive medications may increase a teen’s risk of feeling suicidal, and teens with PTSD are already at high risk.

Psychotropic Medication: A Family and Youth Worker’s Guide

You’ve probably seen the pill bottles yourself. Young people living in residential settings like foster homes, homeless shelters and transitional living programs are often prescribed psychotropic medications to address psychological symptoms and behaviors such as depression, anxiety and aggression. The Administration for Children, Youth and Families has made it a priority to link young people to the treatment they need to heal and recover from adverse experiences, including medication when appropriate. But such prescriptions should be administered with great care and as part of a comprehensive treatment plan, according to Commissioner Bryan Samuels.

As the director of Youth Move Maine, a youth leadership and advocacy organization in Portland, ME, Ryun Anderson has met with youth prescribed psychotropic medications as well as the doctors writing those prescriptions.  Young people often wished for more information so they could make better medical decisions, she says, but psychiatrists say they are too rushed to go into great detail—especially when it comes to medication alternatives.

“The people who needed to give youth this informed consent simply didn’t have the time to be working with young people in a developmentally appropriate way,” Anderson says. “We really look to [youth workers] as resources who could have those relationships and more in-depth conversations with young people, recognizing that the prescribers weren’t able to do that.”

Better Information, Better Choices

Aided by advocates around the state, Anderson and her team worked with six youth ages 17 to 23 to create “Making a Choice: A Guide to Making a Decision About Using Antipsychotic Medication” (PDF, 917KB). The guide, Anderson says, is intended to help youth workers engage young people in age-appropriate conversations about everything from their medical rights to helpful follow-up questions.

Before they can have those conversations, family and youth workers need to educate themselves on commonly prescribed medications and their side effects, says Steve McCrea, supervisor at CASA for Children in Portland, OR. That task can be made less daunting by dividing prescriptions into five main categories: stimulants, antipsychotics, mood stabilizers, antidepressants and anxiety agents.

McCrea also encourages youth workers to talk to young people about their goals and interests, a step that can help shift the conversation from a youth’s problems to what they want to achieve in life.

“Then, you can start talking about possible interventions that will get them there and that’s where the medication may come in as being seen as helpful,” he says.

Developing Connections Before Youth Can Connect the Dots

Dianna Walters, policy associate at Jim Casey Youth Opportunities Initiatives, has seen firsthand the impact a youth worker can have on a young person’s relationship with psychotropic medication. Walters recently brought a young man she met working at a youth shelter in Lewiston, ME, to a federal working group on the topic.

The young man, who often refused to take his medication and bounced around from placement to placement, is now living in his own apartment and has cut all the medication from his life.

“I attribute [the change] to that caseworker and the fact the he built a relationship with someone that really listened to him and was able to really work with him on the things that he wanted, so it wasn’t really someone else’s plan for his life,” Walters says.

She offers the following tips for youth workers looking to develop relationships with young people and to help them make decisions about psychotropic medications.

  • Get to know young people better before talking to them about their treatment options. Playing video games together, for example, might get the young person talking more freely than if a youth worker simply follows a checklist.
  • Check in with youth taking medication regularly to see how they’re feeling and if there are any noticeable side effects.
  • When giving young people information, make sure the language is easy to understand, and that it explains both short-term and long-term consequences.
  • Avoid rewarding or punishing a young person based on whether or not they take their medicine.
  • Whether or not a young person is taking medication, devote the time to helping them think positively about their lives. Improving self-esteem by building personal goals “is the best medication we can give them,” she says.

The Hardest Adjustment: Recognizing Postpartum Depression in Teen Mothers

Anxiety, helplessness or anger might not seem like the typical experience of a new mother, but postpartum depression afflicts between 12 and 20 percent of moms in the United States. Symptoms usually appear within two months of giving birth, and it’s still hard for doctors to predict which women will suffer from them.

What’s more, teen mothers are almost twice as likely as adults to experience postpartum depression, according to the Centers for Disease Control and Prevention. Family and youth workers should therefore be able to recognize and treat postpartum depression in their pregnant or parenting clients.

Many of the risk factors for the condition overlap with those for teen pregnancy. “The risks associated with teen pregnancy are often associated with social circumstances and the complicated lives that teens live,” says Maureen Phipps, a lead researcher and obstetrician-gynecologist at Women and Infants Hospital in Providence, RI. Young women who become pregnant tend to have poor bonding with their own parents, limited access to health services and less-than-ideal medical care when they do obtain services. All of these are risk factors for postpartum depression.

Prevention and Warning Signs

Since 2007, Phipps has been leading Project Reach, a research program aimed at finding ways to prevent postpartum depression in this high-risk population. Trained interventionists meet with pregnant teens for five weekly sessions of interpersonal therapy, discussing topics such as communication, support networks, how to solicit support from friends and family, and goal setting.

Only 12.5 percent of participants receiving specialized counseling experienced postpartum depression during the program’s pilot period, Phipps says, compared with 25 percent in the control group. A second study is currently underway.

This approach rings true for Kelli Strickland, a facility social worker at Mary’s Shelter in Santa Ana, CA. During their intake process, Strickland and her colleagues try to attain psychological and medical histories from clients’ past providers and screen for existing depression. For any maternity group homes looking for an evidence-based screening tool, Phipps recommends the Edinburgh Depression Scale (EPDS).

Strickland and her colleagues look out for a few common symptoms of postpartum depression:

Lack of maternal attachment: “We look for how quickly they get up to help their baby in the night. And more generally, the depressed girls have a harder time meeting the needs of their baby.”

Isolation: “If they’re staying in their bedroom, that’s a concerning sign. If the girls start to insist that they want to feed in their rooms, it can be an indicator.”

Utilize the Group Setting and Teenagers’ Natural Resiliency

Indeed, Strickland says that the group setting and social activities in a maternity shelter can help ward off postpartum depression symptoms. Mary’s Shelter staff push the following activities:

Social Parenting:  The organization builds in several practices to help young mothers build comfort and confidence in their parenting skills. For example, “The girls have to come out to the living room to feed their babies to make sure that the babies are being fed often enough and correctly,” Strickland says. “They also take part in parenting classes together every week in addition to individual weekly therapy sessions.”

Resiliency: Strickland also praises the young mother’s ability to balance parenting with school, all while looking ahead to the life they hope to create for their family. “They keep hoping and planning for the future even when nothing about their childhood has been what a childhood should be,” she says. “And so many of them are such naturally wonderful moms, before they’re developmentally ready.”

Maureen Phipps agrees, saying that her goal with Project Reach is to build on teenagers’ emotional resiliency. “Pregnancy adds another dimension of risk for depression,” she says.  “But in teens, there’s a lot of resiliency there. We’re trying to help them build a social support network to lean on when things get hard.”