Our Challenged World — How Can Law and Medicine Respond The Challenge for Youth
HER EXCELLENCY PROFESSOR MARIE BASHIR AC CVO
GOVERNOR OF NEW SOUTH WALES
My thoughts are with you as you gather on beautiful Samos, the home of Aesop, Pythagoras, and so many others who have contributed richly to the legacy of Greece and our continuing enlightenment into the 21st Century.
Pythagoras, — philosopher, mathematician (and even described as the first influential figure to espouse the principle of equal opportunity) — once noted, that “concern should drive us into action, and not into a depression”1. After leaving Samos in 518BC, Pythagoras established a school for young men and women at Crotone in Italy in the hope that they would achieve “a purification of the mind by scientific study”2. That hope endures today in our commitment to evidence-based enquiry, as we seek solutions to our challenged world.
So now I ask, what can we — Law and Medicine in this 21st Century — do to meet the challenges facing youth.
Having had the privilege of working with young people over a professional lifetime in the field of mental health, I shall relate my presentation essentially to young people, — adolescents and young adults across the world who bear our hopes for a better 21st Century, a century which might harness and apply its technological advances in the service of humankind; a century in which we may identify and address those factors which impede young people as they journey towards realising their potential and reaching a valued, productive place in their societies.
Disraeli reminded us in 1845, “The Youth of a Nation are The Trustees of Posterity”3. But whilst quotations abound from poets and philosophers commenting on youth, not all would agree with Disraeli’s glowing and confident assertion.
Perhaps the most widely quoted comment is that attributed by Plato to Socrates, “Our youth now love luxury. They have bad manners, contempt for authority, they show disrespect for their elders and love chatter in place of exercise; they no longer rise when elders enter the room; they contradict their parents, chatter before company, gobble up their food and tyrannize their teachers.”4
And in the light of contemporary neuroscientific research, perhaps Joseph Conrad was extraordinarily accurate in 1902 when he wrote “….I remember my youth, and the feeling that it will never come back any more — the feeling that I could last for ever, outlast the sea, the earth and all men; the deceitful feeling that lures us on to joys, to perils, to love, to vain effort — to death; the triumphant conviction of strength, the heat of life in the handful of dust, the glow in the heart that with every year grows dim, grows cold, grows small, and expires — and expires, too soon, too soon — before life itself.”5
What challenges then face 21st Century youth, before that glow in the heart — for which Conrad yearned — begins to grow dim? The initial challenge for us surely is first to ask our youth what are their concerns and how might they be addressed.
Whilst my comments are predominantly based on Australian data, information and experience, these impressions may have applicability to young people across the world, particularly in developed countries.
In Australia, efforts have been directed to gain these important insights from young people through the Australian Youth Forum, a Commonwealth Government initiative launched in 2008 in recognition of the fact that this generation are facing new and unique challenges.
Their responses cited issues of employment, of tertiary education affordability, of the impact of climate change, of health including mental health, together with social acceptability and wellbeing. These last two issues must be appreciated in the context of Australia’s considerable ethnocultural diversity, where pressures from within family and from the mores of the traditional culture may still be traversing a phase of adjustment to a new culture, and their perception of acceptance by the wider national community. This particularly applies to more recent arrivals, such as asylum seekers from substantially different cultures, — individuals who may have also experienced considerable trauma over time.
Young people in turn want to be heard and should be heard, for wise governments and those in positions of executive authority will know — or will soon learn — that the voices of young people cannot be ignored.
These voices are eloquent, and can be powerful in their dissent, in their distress and anger, whether anger against a family or a community which they believe ignores or rejects or abuses them. Negative emotions can be aroused, including self-blame, negative behaviour, alcohol and drug abuse, and eventually depression, with the risk of suicide.
Are these pessimistic or alarmist considerations from a relatively affluent, unthreatened and stable land? And what does contemporary research tell us about these young people?
A national survey of young people (11 – 24 years) conducted in 2008 by the Research and Social Policy Unit of Mission Australia (a 150 year-old non-denominational Christian community service organisation) has provided further insight into issues which young Australians consider most important.6
This was the 7th consecutive annual survey undertaken by Mission Australia, and therefore enables comparison of data over time. The response rate of almost 46,000 (45,600) in 2008 represented an increase of more than 50% over the previous year (2007), and responses revealed a significant national consistency.
Around 85% indicated English as the family language and among the remainder, (about 6,800), 75 languages other than English were spoken between them in the home. The majority lived with family, some at boarding school, 467 were in a juvenile justice centre or a prison, and 375 revealed homelessness or insecure housing. There were 2,500 responses from indigenous young people and around 2,350 young people registered as having a disability.
These disabilities included Attention Deficit Disorder, Mental Illness, Intellectual Disability, Autism Spectrum Disorder, Dyslexia and Learning Disability.
Valued most across all age groups and across all genders were family relationships (75%), and friendships (62%), followed by physical and mental health, being independent, feeling needed and valued, and getting a job.
Of most concern were body image (their appearance), drugs, family conflict, bullying and emotional abuse, suicide, — and a new entry for 2008 — personal safety. Indeed, physical and sexual abuse rated as important concerns for almost 27% of the female respondents.
It is noteworthy that in the older group depression and coping with stress took the 2nd and 3rd positions of most significance after body image.
A separate survey of students attending an Australian university7 primary health care service (that is, a service for mostly physical health issues), revealed that more than one half were experiencing mild to very high levels of psychological distress. And of the ‘very high psychological distress’ subgroup, only 36% had received assistance for this.
Perhaps co-location of a specialist mental health counsellor within the university primary care facility, and the provision of preventive and self-help interventions including availability of Fact Sheets and e-Health strategies would be worth considering.
In the Mission Australia survey, the young people have nominated parents, family and friends as the preferred source of encouragement and advice. This was followed by information from the internet, which indicates an important avenue through which to provide valuable information regarding mental health education and appropriate services.
Given the high priority of trust which the young people have accorded family and peers, it is valid to examine situations where such trust becomes endangered. I refer to the traumatising environments created by domestic violence, and by bullying, both of which may contribute to stress and mental health problems.
Domestic violence affects many Australian households.
It is the single largest cause of homelessness in Australia for women. One survey has found that 23 per cent of women in Australia who have ever been married or in a de facto relationship have experienced violence by a partner at some time during the relationship.8
The aftermath of abusive, often physically violent interactions can exact continuing trauma on young family members. A number of fatal outcomes together with the considerable dimensions of the physical and psychological effects of domestic violence in the community are now producing a determined response from government.
In-depth interviews with victims and families have taken place to formulate a strategy to protect women and children from violent menfolk. This has resulted in the implementation of a new scheme in a number of urban and rural locations. “Staying Home Leaving Violence” is now assisting women and child victims to remain in, rather than flee from, the family home, neighbours, schools and social supports.
After response by police to an emergency call and an appropriate assessment, community workers follow with empathic counselling, and speedily arrange for house locks to be changed, and a new telephone number to be allocated. They also assist with essentials for the children when there is no access to independent financial support.
Local courts, police and community services and locksmiths work together to bring about peace and empowerment for the mother and children, and to place accountability in the domain of the perpetrator who may in some cases face conviction and time in gaol. Outcome assessment indicates at this stage that two thirds of women involved in this program have been able to remain at home and experience no further violence.
Attention has also been drawn in recent months to the growing extent of bullying across a range of schools, causing considerable anxiety, depression and other sequelae among young people. One authority in adolescent development considers that “more than half of all students have been bullied at detrimental levels each week or more frequently.9
Some children may be more vulnerable to selection as victims of bullying. For example, atypical children who are shy, artistic and sensitive; those who may be identified within the autism spectrum disorder category, including Asperger’s Syndrome, and even occasionally those who stand out because of exceptional sporting ability or exceptional beauty.
Bullied children may become stressed and depressed and have low self-esteem, thus attracting further bullying and a downward spiral.
Some preliminary research studies have suggested that bullying, especially repeated bullying of vulnerable young people can predispose to the development of psychotic-like symptoms in adolescents10. Further longitudinal research is required.
A recent report of the tragic suicide by hanging of two male students attending the same rural high school several years apart (2001 and 2008) both of whom had experienced sustained bullying prior to their descent into depression, has reinforced a determination by authorities to bring about change.
To identify and take action against this unacceptable phenomenon, for which some schools have now adopted a clear policy of zero tolerance, a National Centre Against Bullying (NCAB) whose chairman is a former judge of the Family Law Court of Australia, has been established.
Bullies have been described as having low levels of empathy and high levels of social manipulation.
It is critical that parents be aware that their own aggressive behaviour can be internalised by their children who then act it out on others.
Considerable negative publicity in recent months has identified rising incidents of cyber bullying, using both direct texting and anonymous website communication to attack and spread defamatory material. Students responsible for this psychologically destructive behaviour now face school exclusion, and parents have been instructed to speak to their children about cyber-bullying and to be as aware as possible of their on-line and mobile telephone communications.
The Australian Communications and Media Authority data indicates that “at least 90% of 15-year olds now have a mobile telephone.
Earlier it was noted that youth surveys had listed ‘mental health’ as a top priority concern.
The National Youth Mental Health Foundation of Australia founded in 2006 has issued a statement to say that Mental Health is the single largest health issue facing young Australians, and that 60 – 70% of the burden of disease of 15 – 24 year-olds is due to mental health and substance abuse disorders.
This Foundation has now established Mental Health Centres in 20 communities across Australia, including 14 in rural and remote areas. It has also established a web-based interactive newsletter, ‘Headspace’.
1 in 4 young people aged 12 – 25 years will experience a mental health problem in any 12-month period, and as noted earlier, mental health issues are in the Top 3 areas of concern as identified by young people themselves. (Mission Australia Youth Survey 2008). Further, it notes that only one in four of this group receives professional assistance for their problems.
A subdivision of age groups reveals that
- 14% of 12 – 17 year olds, and
- 27% of 18 – 25 year olds
are experiencing these difficulties (mental health and substance misuse disorder), and further, that up to 50% of drug and alcohol problems have been preceded by mental health problems, often depression.
This has intensified efforts in research, and the development of preventive and early intervention programs, as well as strategies to refine diagnostic accuracy and more effective treatment of depression.
The World Health Organization’s statements on the mental health of young people have given similar cause for concern.
At the WHO European Ministerial Conference on Mental Health at Helsinki in January 2005, Dr Hans Troedsson, former WHO Director for Child and Adolescent Health stated “The international health community is concerned about the mental health status of our young …… it is a time bomb that is ticking and, without the right action now, millions of our children growing up will feel the effects.”
The briefing issued from that Conference, whilst drawing attention to the worrying statistics that worldwide up to 20% of children and adolescents suffer from disabling mental health problems, also emphasised (and I quote) that “child and adolescent mental health is essential for the building and maintenance of stable societies…..”, and that “new challenges require enhanced efforts to meet the needs of the 21st Century. Immigration, migration, changes in family structure, alterations in future opportunities for employment and the continuing stresses of conflict”, (ie Domestic Violence and Bullying), “….all impact on child and adolescent health and, ultimately, on the health of the nations…”.
The fear of stigmatisation regarding referral for mental health services may be an important issue with young people, as has been noted with young military personnel. Despite an excellent mental health strategy formulated by the Australian Defence Forces in which a 2-stage screening test after returning from active service is mandatory, there is nevertheless reluctance on the part of the young soldier to be seen to undertake treatment which may reflect negatively on image and identity. Mental health education in general health briefings for military personnel may be valuable in reducing attitudes of stigma.
In recent decades, the problem of conduct disorder in young people has challenged families, educators, psychiatrists, sociologists, welfare and law enforcement professionals.
WHO research indicates that over the past 70 years, the prevalence of this disorder has increased five-fold.11 This may be related to a significant increase in environmental risk factors, or even to the diagnostic preference of the investigators.
It is important to identify those young people initially assigned a label of conduct disorder where the primary condition of major depression may have been overlooked, and where there has been a secondary development of problematic behaviour which now attracts attention. That is, ‘a plea for help’, unlike an underlying non-conspicuous depression. A persistent depressive mood may have gone on to involve risk-taking, and/or delinquent behaviour, alcohol and/or drug misuse. Indeed all four of these problems may coexist.
Schools and legal authorities become involved to divert this self-destructive journey, aware that the condition of conduct disorder may have later deleterious consequences. Poor physical health, dangerous risk taking, problematic employment and graduation to more serious crime may follow. Drug and alcohol use is commonly involved.
Indeed, public health research, educational authorities and the media are drawing attention to the increasing extent of alcohol use among young people. This has led to a revision of guidelines initially established by the National Health and Medical Research Council. Australia’s official guidelines now state that the safest option is to drink NO alcohol below the age of 18 years in light of the risk for early drinkers to develop alcohol–related disorders in subsequent years.12 The research demonstrated that this particularly applied to young males, but females were not exempt from such risk in later years. A similar concern applies to marijuana use.
Although the majority of young people attending Australian educational institutions are law-abiding, focussed on traditional pursuits, and working towards age-appropriate goals, a number of worrying trends are emerging.
State police statistics reveal an increase in negative incidents such as bomb threats, possession of prohibited weapons or dangerous articles, as well as incidents associated with drugs and alcohol.
Young people who become involved in criminal activity however, comprise a relatively small proportion of the Australian population, around 1.16% (2006 figures).
Significant factors noted to be common to most young offenders include —
- poor parental supervision
- difficulties in school and employment
- negative peer associations (such as gang membership)
- poor personal and social skills
- alcohol and substance abuse
- homelessness, neglect and domestic abuse
These factors give clear signposts for the development of preventive programs and early intervention.
A cause for ongoing concern has been the over-representation of Aboriginal and Torres Strait Islander (that is, Indigenous) young people amongst those who offend. Culturally respectful and empathic approaches in rehabilitation have been developed by the Juvenile Justice Department with this in mind.
Many preventive programs for indigenous youth are now underway to provide greater encouragement and opportunity into educational pathways through scholarships to quality schools and supportive mentoring relationships which also involve the parents. These continue into tertiary education streams including university studies in law and medicine.
Young people with significant mental health problems are also an over-represented group in the juvenile justice system. Approximately 88% of young people in custody are indentified as having mental health problems, and 40% of young people in community juvenile justice programs have symptoms consistent with a psychiatric disorder.
Treatment in both settings is provided by Justice Health who have identified depression, self-harm and suicide issues, as well as drug-related problems, as the most frequent requiring intervention.
An innovative and encouraging legal intervention and quasi-treatment approach was introduced during my time as Chair of the Juvenile Justice Advisory Council of New South Wales. Known as Youth Justice Conferencing, this model, now employed across Australia, redirects young offenders to confront their behaviours which have impacted negatively and harmfully upon a victim.
A meeting is convened between offender and victim in the presence of an appropriate member of the community. Together at this meeting they agree on a suitable outcome which could include —
- an apology
- a reasonable reparation to the victim
- specific steps to reconnect the young person back with the community.
This third goal is important in initiating in the young offender some sense of social inclusion upon which to grow responsibility and self esteem, and to reduce the sense of alienation and rejection which these young people commonly feel, and have converted to destructive and self-destructive anger.
Some categories of offence cannot, understandably, be managed by this model of intervention, — for example, sexual assault, serious drug offences, offences causing death, and breaches of apprehended violence orders.
Outcomes of this Youth Justice conferencing process have been carefully monitored and technique continuously improved. Approximately 90% of all young offenders referred, complete the required task of their outcome plans.
The Juvenile Justice Department is sensitive to the ethnocultural diversity of their target population and accordingly recruits convenor-representatives for Youth Conferencing from all community groups, including indigenous and culturally and linguistically appropriate representatives. Specific training in this model is provided for convenors. It is important to prevent a misperception of victimisation or even racial prejudice towards individual ethnic groups.
In Australia, young people are not infrequently involved in extraordinary, life-threatening behaviours, often with tragic outcome. Motor vehicle fatalities of alcohol affected, inexperienced young drivers in powerful cars continue to occur, despite repeated community education campaigns and harsh penalties for traffic infringements.
Less common but even more astounding are the young lives lost when swimming in crocodile-infested waters in northern Australia, despite conspicuous warning signs, and widespread knowledge of high risk.
This is more than risk-taking behaviour. It would seem that with some young people there is no concept of risk.
The question then arises as to whether there can be some developmental- biological explanation for this.
In the 1990’s, researchers in the neurosciences began to explore a possible association between the neurophysiology of the developing brain and adolescent affect and behaviour.
Adolescents over time have commonly reported episodes of feeling stressed, of being susceptible to exhaustion, to changes of mood, to strong emotions, and to harsh self-criticism.
Whilst young people in today’s society are showered with a multiplicity of stressful stimuli such as school demands, parental demands, career and employment uncertainty, and sometimes sexual doubts, not all experience turmoil and disruption going on to significant depression.
Advanced technology in Magnetic Resonance Imaging of regions of the human brain has identified that adolescent brains respond differently to certain stimuli when compared to adult brains presented with the very same stimuli. This phenomenon was demonstrated when a visual stimulus of photographs of people expressing fear was presented to each group (adults and adolescents) whilst magnetic resonance imaging was being undertaken.13
Dr Deborah Yurgelen-Todd (Director of Neuropsychology and Cognitive Neuroimaging at McLean Hospital, Belmont, Massachusetts) regards the amygdala area within the temporal lobe of the brain as having a significant contributory role in adolescent anxiety; and that while adults (as demonstrated in the MRI studies) predominantly used the frontal lobe area of the brain, in adolescents the amygdala area was used far more.
It is acknowledged that the frontal cortex, of the frontal lobe area of the brain, is the region which is involved in modifying emotion, judgement and insight. However, this frontal area is not fully developed in adolescents, and the use of the amygdala is believed to influence a more reactionary response to stimuli.
With the maturation of frontal cortex tissue, acuteness of response is lessened and modified cautious behaviour develops with the associated lessening of anxiety.
Professor Frances Jensen and Dr David Urion (neurologists of Boston Children’s Hospital and Harvard Medical School) have been researching adolescent brain function using MRI for over a decade. They believe that “young brains have fast growing synapses and sections that remain unconnected and consequently they are easily influenced by their environment and more prone to impulsive behaviour even without the impact of souped-up hormones and any genetic or family predispositions.”14
Such insights arising from neuroscientific research might inevitably lead to consideration again of those youth who act out in impulsively violent ways and the impact of environmental influences on such individuals.
An extreme example of violent behaviour occurred in Europe, earlier this year and was reported in the international media (The Independent, 15 March 2009), when a 17-year old youth killed 15 people (including nine former classmates, three teachers and three bystanders) before shooting himself.
The unfolding of this tragic event may have been foreshadowed in his message on an internet chat room the previous evening — “I’m sick of this life…,….everyone laughs at me.” His background was one of abysmally low self-esteem, loneliness, difficulty in gaining friends, humiliation by peers, denigration by teachers, and episodes of depression requiring therapy. And at home, his father kept 15 guns, with which this young man used to practise target shooting for hours at a time in the family home basement.
It should be noted, that research has not provided evidence which implicates a neurological basis for violence. Rather, numerous studies over time point consistently to social-environmental factors.
However, research has established that brain growth, in which connections are ultimately completed to the frontal lobe, is not finalised until around 25 - 30 years of age. The frontal lobe, which is responsible for cognitive processes (as noted earlier), such as reasoning, planning and judgement, is the last section to complete connections.
Jensen and Urion note that “learning takes place at the synapses between neurons, as cells excite or inhibit repeated stimulation.” This cellular excitement, which they refer to as “long term potentiation”, is one reason why children and teenagers can learn languages and musical instruments faster than adults.
These young brains however, as new knowledge is now emphasising, are more sensitive than adult brains to the toxicity of induced substances such as alcohol and marijuana. It is now also established that marijuana use blocks signalling in the brain. These researchers give practical warning that marijuana use on the weekend will still be affecting a young brain four days later when tests or examinations are due.
The researchers have more than a distant academic commitment to their young subjects. Professor Frances Jensen (the mother of two young men), and her colleague Associate Professor Urion, are visiting secondary schools in their region, imparting to audiences of students and parents, educators and fellow scientists these psychological insights to approaches in teaching, punishing, and in the medical and psychological treatment of young people.
By raising awareness of this paradoxical period in brain development, the neurologists hope in such workshops to help young people with their challenges as well as to recognise their considerable strengths.
In April 2008, Professor Jensen said “”This is the first generation of teenagers that has access to this information, and they need to understand some of their vulnerabilities.”15
A very different assessment of the relationship between the brain and the behaviour of young people, however, is vigorously expounded by Robert Epstein, psychologist and researcher at the University of California, San Diego. Epstein is a former Editor-in-Chief of Psychology Today.
Epstein regards the ‘still developing’ interpretation of the adolescent brain, and I quote, as a ‘myth’ and ‘fraudulent’. Indeed, he believes that the episodes of so-called turbulence or turmoil have been created by the effects of modern western culture.
He considers that research on the adolescent brain has been limited. He draws attention to anthropological research findings across more than 180 cultures over the past 50 years which have claimed that in over 100 such cultures around the world, adolescent turmoil is absent.16
Further, Epstein considers from his research studies in a range of the social sciences — in anthropology, psychology, sociology and history — that the turmoil observed in his own country (the USA) results from the “artificial extension of childhood”, — infantilisation past puberty.
Another eminent social scientist and academic who has further developed this theme is Richard Eckersley of the Australian National University in Canberra. Eckersley poses the provocative question, “Is modern western culture a health hazard?”17
Eckersley draws upon a range of disciplines to argue that materialism and individualism are detrimental to health and wellbeing, through their impact upon psychosocial factors such as personal control and social support.
He points out that for some time, interest in the social environment of health has focussed on socio-economic inequality, especially on financial income, which is now challenged. He calls for an examination of the role of culture, the psychosocial factor which he considers to be the pathway by which inequality and other social determinants affect health. They do so, he states, through the perceptions and emotions generated, regarding the individual or group’s perceived position in the social hierarchy, and their perceptions of social disadvantage, and a lack of control over one’s life.
He refers to other writers (Marmot and Wilkinson)18, who describe ‘a culture of inequality’, a culture that is more aggressive, less connected, more violent and less trusting. Socialisation, they claim, provides the mechanism of transferring attitudes, beliefs and behaviours between and within generations, thereby influencing behaviour and affecting health.
Indeed Eckersley also believes that “modern western culture undermines, even reverses universal values and time-tested wisdom”, resulting in “a loss of moral clarity: a heightened moral ambivalence and ambiguity…… and a deepening cynicism about social institutions”19.
The global economic crisis of the 21st Century has highlighted significant deficits other than financial, drawing attention again to research findings which have suggested that materialism, (with its priority for money and possessions), status, competition and individualism, and does not breed happiness, but rather dissatisfaction, depression, even alienation.
The Equality Trust is a London-based organisation committed to researching these disturbing trends, in the hope of driving improvements in the quality of life of populations in developed countries.
The Trust has pointed to valuable data which supports Eckersley’s view that inequality makes social relations more stressful by differences of status and associated competition.
Less equal societies with significant disparity in living standards and lifestyles fare worse in regard to the level of societal trust. Societal trust in turn is linked to health and wellbeing and to a relative reduction in violence.
High levels of trust have been demonstrated to be linked to low levels of inequality. The Scandinavian countries and the Netherlands ranked highest in this regard.
The Trust has provided comparative aspects of contemporary life between different countries. This has been made possible by the collection by WHO of comparable survey data20.
First, it was demonstrated that different countries had different levels of mental illness and that the rate of mental illness was higher in the more socio-economically unequal countries; that is, those countries with substantial differences between the rich and the poor.
Thus, in some countries, in the year 2008, 5% - 10% of the adult population had suffered from mental illness, but in the USA the rate was 25%. That nation scored highest on income inequality and for the incidence of mental illness also in the previous year.
A strong tendency for the presence of drug abuse has also been identified by the United Nations Office on Drugs & Crime in its analysis of inequality; and further, the more unequal areas had the higher drug death rates
Are these two streams of “explanation” for the so-called ”turmoil” or sense of “invulnerability” of the years of adolescence and young adulthood irreconcilable? — the neurophysiological, for which scientific research is providing evidence on the one hand, the sociological, seeking evidence on the other.
Whatever the underlying causes of the period when some young people become accident-prone, risk-takers and vulnerable to mental illness, behavioural problems and the ravages of substance abuse, it is our responsibility to understand and to meet the challenge.
In charting the way forward, a realistic policy is essential. Such a policy should be based on evidence (of what works), on the most recent and reliable research data on youth, and formulated following input from all key stakeholders. These include young people themselves, relevant government departments responsible for youth services, including education, health, law and welfare – and non-government organisations which also serve youth.
A new Youth Policy in New South Wales is currently being formulated by the New South Wales Centre for the Advancement of Adolescent Health, in partnership with the state’s Health Department21.
The draft policy document will be presented on June 12, 2009 at a one-day long face-to-face comprehensive community consultation whose participants will include young people. A further consultation network will be available to young people on-line. The modified draft document will then be available for final comment in October 2009, and listed on the Centre’s website, www.caah.chw.edu.au
Underpinning this new policy, is the reference group’s acknowledgement of WHO’S definition of health — “a state of complete physical, mental and social wellbeing, and not merely the absence of disease”.
Therefore, initiatives to enhance resiliency in young people at risk will have a high priority, together with programs for prevention and early intervention. Such programs would be integrated within school and youth-oriented community programs.
Resilience has been described as “a pattern of positive adaptation in the context of past or present adversity”22.
Current available evidence of the health of young people should accelerate implementation of these programs. Research has identified that 75% of major mental disorders have their onset before the age of 25 years23, and that 60% of disability24 across the years of adolescence to young adulthood (15 – 34 years), is attributed to mental health and substance abuse disorders.
A team from the University of Sydney Brain and Mind Research Institute (in which Professor Ian Hickie, Chairman of this Session plays a leading role) has also been examining issues and developing treatment models providing greater accessibility to quality mental health care for young people25.
They emphasise the need for a well-integrated collaborative multidisciplinary model, affordable and easily accessible. The Australian Federal government, as noted earlier, has established 30 such clinics across the nation.
As well as responding to unmet need, including scholastic and vocational advice, access to general practitioners linked to the mental health team will provide valuable primary health care. Of critical importance is the recognition that so often in this age group, mental health problems and substance abuse co-exist, and an experienced drug and alcohol worker should be included in the team. The areas of social, educational, employment and vocational needs should also be examined.
Participation in such programs with a skilled group leader may assist in strengthening a sense of identity, and provide friends with similar interests and vulnerabilities, with peer support in addressing parental relationships and anger management.
Ideally, schools should provide continuing education for teaching staff, in identifying, with sensitivity, the vulnerable child from the earliest school years, quietly noting the child with special needs, such as those with autism spectrum disorder or attentional difficulties, where early intervention can make a vital impact.
Community-based youth development programs involving the environment, or caring for others, such as visiting the elderly in nursing home care, can contribute to the development of a sense of self-worth and of the needs of others.
Certainly, for those young people in whom signs of mental health disorder are emerging, high quality youth-specific specialist services are required.
We are fortunate in Australia that effective treatment models have been developed, well-documented and researched, for the early intervention of first episode psychosis with careful follow-up.
These treatment programs, empathic to the developmental tasks of young people and linked to rehabilitation, can be effective in reducing the risk of downward progression to chronicity and isolation, and the disabling artefacts of poor treatment regimes.
Similarly, considerable community awareness and medical education of general practitioners and other primary health care workers in the effective management of depressive disorders is required, also emphasising the need for vigilant observation of any warning signs of suicidal intent.
Although much has been achieved in the past decade to advance and better understand the health and vulnerabilities of our young people, much more is required.
Most Australians are aware of the challenging demographic of an ageing population on the one hand and the vulnerability of our youth – the nation’s richest resource - on the other.
To conclude with Disraeli’s words of wisdom,
“The Youth of a Nation are The Trustees of Posterity”
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16. Epstein Report. The Myth of the Teen Brain, in ‘Scientific American Mind’, April/May 2007 issue
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21. ROBARDS F. (2009) Increasing the resilience of young people at risk: A literature review. NSW Centre for the Advancement of Adolescent Health, The Children’s Hospital at Westmead, Westmead and The Centre for Clinical Governance Research, University of New South Wales
22. O’DOUGHERTY WRIGHT AND MASTEN 2005 (see Policy Paper)
23. KESSLER RC, BERGLUND P, DEMLER O, JIN R, MERIKANGAS KR, WALTERS EE. Lifetime prevalence and ageing-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 2005; 62:593-602
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25. SCOTT E, NAISMITH S, WHITWELL B, HAMILTON B, CHUDLEIGH C and HICKIE I. Delivering youth-specific mental health services: the advantages of a collaborative, multidisciplinary system. Australasian Psychiatry 2009 Vol. 17 No. 3.
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