Mental health services have traditionally been oriented towards crisis events and emergency situations among adults. Youth health care, on the other hand, is vastly underresourced, although around three-quarters of all mental health disorders emerge before the age of 25.
Sadly, this approach means treatment is only accessed after years of harm to a young person’s life, and when mental health disorders have typically become more complicated and harder to treat.
Instead of following a reactive, crisis-driven model, mental health services should focus on prevention and early support for young people. When it’s accessible, early intervention has been shown to improve long-term outcomes for young people, at a clinical, social and occupational level.
This article explores the importance of early intervention in teen mental health, touching on existing barriers, transdiagnostic interventions and early diagnoses of serious mental health disorders.
The Importance of Early Intervention in Teen Mental Health
Adolescence is a period of rapid emotional, social, biological and cognitive development. These changes not only make young people especially vulnerable to developing mental health disorders, but also increase the harm that mental health symptoms can cause.
Most mental health disorders have their peak incidence of onset during the transition from childhood to adulthood. Among 10–24-year-olds, mental health problems account for 45% of the global burden of disease, and one in five has experienced a clinically relevant mental health concern.
At the same time, mental health is a key element of a person’s ability to cope and function in everyday life, and to develop skills to manage difficult or stressful events. Such emotional and social skill development is particularly pertinent in adolescence, as young people become more autonomous, explore their identity and become more reliant on friendships.
Mental health disorders can disrupt these developmental pathways, leaving adolescents with fewer socio-emotional coping strategies or maladaptive ones. This can profoundly impact their future well-being, affecting their social, emotional, behavioural and occupational life as adults.
Existing Barriers to Early Intervention
Despite the importance of early intervention in teen mental health, internal and external barriers mean that very few young people have access to treatment when mental health disorders first develop.
Internal barriers to help-seeking, particularly stigma, prevent many teenagers from reaching out for support when they need it. Entrenched prejudices around mental health can cause young people to feel ashamed about their thoughts, emotions and experiences rather than speaking with friends, family or professionals.
Young people from ethnic minorities and socio-economically disadvantaged backgrounds are among the least likely to make contact with mental health services.
At the same time, long waiting lists, delays in receiving care and a lack of specialist, evidence-based treatment prevent many young people from receiving effective treatment, even when they have made the step to seek support. Chronic underfunding of specialist, youth-friendly services makes effective early intervention inaccessible to the majority of teenagers around the world.
“At-Risk” States and Transdiagnostic Interventions
An at-risk state is a term used to describe the period of low-intensity mental health symptoms that may later develop into mental health disorders. At-risk states were first studied in the context of mental health disorders such as schizophrenia, where certain sets of symptoms are predictive of the future development of psychosis.
However, research has increasingly recognised that while these at-risk states sometimes develop into experiences of psychosis, at other times they evolve into other disorders, such as depression, anxiety, personality or substance use disorders. Many mental health disorders share common risk factors, meaning that young people who are more vulnerable to developing one disorder are also at a higher risk of developing others.
Using the idea of a transdiagnostic high-risk mental state may, then, help prevent the development of a wide range of mental health disorders, facilitating early intervention before definitive symptoms of any specific disorder are visible. High-risk states may be identified by socio-emotional challenges, including depression, anxiety, anger and interpersonal difficulties. They may also take into account past experiences, such as childhood trauma, that increase vulnerability for mental health disorders.
Among younger children, early intervention programs may focus on skill development encompassing physiological reactivity, cognitive control, and self-regulation through parenting- and classroom-based interventions. During adolescence, interventions might include cognitive-behavioural therapy, relaxation, social skills training, social support, mindfulness, meditation, psychoeducation and interpersonal therapy.
Research suggests that indicated prevention programs among young people with various presenting difficulties not only improve the targeted mental health difficulty, but also other non-targeted aspects of well-being.
Early Diagnosis of Borderline Personality Disorder
While transdiagnostic early intervention may play a profound role in preventing mental health disorders from developing before the onset of a particular disorder, clinicians also need to provide a timely diagnosis when disorder-specific traits and symptoms do emerge. Diagnosing mental health disorders at their onset paves the way to more effective and specialist care, improving treatment and recovery outcomes.
Unfortunately, stigma and misunderstanding around certain mental health disorders mean that their diagnosis during the teenage years is still uncommon, despite clear evidence that many adolescents have a stable presentation of these disorders. For young people with borderline personality disorder, delayed diagnosis and misdiagnoses are common, although studies suggest that BPD is just as common among teenagers as adults.
Clinicians’ reluctance to diagnose BPD in under-18s may be based on misconceptions that BPD-like symptoms are part of the normal course of adolescent development, although evidence shows that BPD traits are well outside of it. They may also falsely believe that BDP symptoms in adolescence are transient and likely to change without support.
Stigma around BPD also plays a big role in delayed diagnosis. Misconceptions that BPD is an untreatable disorder, or concerns about how a BPD diagnosis may impact a young person’s future, may also discourage clinicians from making an accurate diagnosis.
Sadly, delayed diagnoses lead to delays in accessing specialised treatment, exposing young people to long-term social and psychological harm. Young people with BPD or subthreshold BPD have a lower health-related quality of life and experience increased psychopathological distress. Both diagnoses are also linked to co-occurring mental health disorders and worse overall functioning.
Studies also show that experiencing personality disorder symptoms in childhood or adolescence is the strongest predictor of having a personality disorder in adulthood. A community study found that young people with a BPD diagnosis were at a much higher risk than others of having the same diagnosis two years later. Early diagnosis and subsequent intervention can help prevent these disorders from progressing and protect young people from future harm.
Early Intervention in Eating Disorders
Like teenagers with BPD, young people with eating disorders also face barriers to timely and effective treatment. These barriers often exist as a cut-off point for access to professional care, where teenagers have to prove that they are ‘ill enough’ to receive support. In many cases, these limits are based on a young person’s BMI, rather than a holistic assessment of their psychological well-being.
This overlooks the complexity of eating disorders as mental health disorders underpinned by experiences and socio-emotional traits such as interpersonal difficulties, emotional dysregulation and perfectionism.
Using cut-off points for entering treatment can make young people feel like they are ‘not well enough’, encouraging disordered eating behaviours to intensify. As eating disorders endure and progress, they typically become more difficult to treat, as co-occurring disorders develop and thoughts and behaviours become increasingly entrenched. This means that recovery becomes more difficult and long-term outcomes worsen the longer treatment is delayed.
On the other hand, neurobiological, clinical and socioeconomic evidence shows that early intervention may improve outcomes and facilitate full sustained recovery from an eating disorder.
Establishing Early Intervention Practices in Teen Mental Health
Establishing widespread early intervention practices in teen mental health requires commitment from different levels and institutions of society.
At the core is the need for more specialist child and adolescent mental health services and services that offer specialist care. Social-emotional interventions can also take place in school and classroom settings for wider preventative strategies.
Clinical practices also need to change, moving away from models where only the most ‘serious’ presentations are said to require treatment. We need to overcome internalised stigmas, viewing timely diagnoses of BPD, schizophrenia and other mental health disorders as a step towards effective treatment and recovery.
More broadly, challenging stigma in different parts of society helps young people reach out for support when they need it and begin treatment as soon as possible. We can challenge stigma through having open conversations about mental health, taking care of our language and correcting misconceptions. Together, we can move towards a society where effective, exceptional mental health care is accessible to all.