OPEN

Assessing mental health

in vulnerable adolescents
Downloaded from http://journals.lww.com/nursing by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 04/20/2022

BY HOLLY R. FARLEY EdD, RN

Abstract: A dramatic shift in adolescent risks and behaviors in recent years threatens adolescents’
mental well-being more than ever. This article explores vulnerable adolescent populations, describes
the importance of nurses in all categories of assessment for adolescent mental health, and identifies
assessment strategies and immediate interventions for successful outcomes.

Keywords: adolescence, behavioral health, mental health, suicide, vulnerable populations

MENTAL ILLNESS in adolescents is Adolescence is a time of great psy-

a serious public health concern that
is on the rise in the US. A dramatic
shift in adolescent risks and behav-
iors during the 21st century threatens
adolescents’ mental well-being more
than ever.1 Adolescents make up 12%
of the US population, with 30% re-
porting symptoms of depression each
year. One in five adolescents has had a
serious mental health disorder at some
point in life, and most children and
adolescents who attempt suicide have
at least one mental illness.2,3 ED visits
for suicidal ideations or attempts rose
92% from 2007 to 2015, and suicide-
related ideations, attempts, and death
increased from 2008 to 2017.4,5
Suicide is the second leading cause
of death in children and young adults
between ages 10 and 24.6 Adolescent
mental well-being is multidimensional
and includes many risks that make this
group vulnerable.1
Vulnerable populations can be
defined by various characteristics or
circumstances that create barriers to
healthcare and constitute a potential
threat to health.7 Adolescents are a vul-
nerable population and are susceptible
to mental health issues by nature.
chological and physical change.8 Many
social and physical conditions and
behaviors can impact adolescent health
and heighten the risk of mental illness
and suicide. Nurses have a crucial role
in assessing vulnerable populations in
all healthcare settings. Engaging in for-
mal and informal assessments that can
identify adolescents at risk for mental
illness saves lives. However, to improve
these alarming statistics, nurses must
first understand the complexity of the
many risk factors contributing to men-
tal illness, the impact of early recogni-
tion, and the use of valid assessment
and screening tools.
This article explores vulnerable
adolescent populations, describes the
importance of nurses in all categories
of assessment for adolescent mental
health, and identifies assessment strat-
egies and immediate interventions for
successful outcomes.
Background
Populations that are commonly consid-
ered vulnerable include ethnic minori-
ties, people with a low socioeconomic
status, members of the LGBTQ+ com-
munity, people with a disability, and

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those with a family history of mental
illness. Individuals in these groups
are typically not well integrated into
the healthcare system and at risk for
decreased access to care.
Adolescents as a group are vulner-
able to health issues because of their
stage of development, which affects
their ability to make safe decisions,
and the need to rely on others for
support. They may feel that expecta-
tions from family and peers are too
high, leading to feelings of stress and
hopelessness.
In addition, adolescents can be
particularly vulnerable due to risk
factors that can contribute to stress
during adolescence, such as a desire
for greater autonomy, pressure to
conform with peers, exploration of
sexual identity, and increased access
to and use of technology.9 The higher
the number of risk factors, the great-
er the potential for mental illness.9
Adolescent mental well-being is
multidimensional and is influenced
by a shift in adolescent risks and be-
haviors during the 21st century. Tra-
ditional threats to mental health such
as low socioeconomic status, poor
living conditions, substance abuse,
early sexual activity, and bullying are
further compounded by contempo-
rary risks such as little social support
from parents, peers, or teachers;
social media use; and cyberbully-
ing.1 Without sufficient emotional
and economic support, adolescents
may be overwhelmed with feelings of
helplessness, insecurity, and stress.8
Successful treatments exist for
adolescents with mental illness;
however, screening among this age
group is low. A 2018 study of pri-
vately insured adolescents showed
that those receiving routine wellness
checks were not being screened for
depressive disorder, which is a com-
mon issue in this age group.10 Timely
interventions are imperative. If not
diagnosed early, the clinical onset of
mental illness during adolescence can
lead to difficult-to-treat chronic men-
tal illness throughout adulthood.11
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All nurses should have
the knowledge to
assess and intervene,
even if they are not
trained mental health
professionals.
Nurses interact with adolescents
in many settings, such as schools,
community or public health settings,
outpatient clinics, and EDs. Nurses
must be educated on the needs of
vulnerable populations as well as
mental illness and suicidal behav-
iors, and utilize every opportunity to
identify mental health issues. When
assessing patients, nurses must be
aware of specific findings that iden-
tify adolescents with symptoms of
mental health issues or increased
risk.
Healthcare professionals often see
vulnerable patients only in a school,
public health agency, or urgent care
setting due to high costs and lim-
ited access to routine healthcare.
These settings are far from the walls
of behavioral health units, leaving
the responsibility of assessment
to nurses on those front lines. All
nurses should have the knowledge
to assess and intervene, even if they
are not trained mental health pro-
fessionals. Nurses are perfectly po-
sitioned to get to know patients and
their families, learn their history
and family dynamics, and provide
education and resources.11
Common mental health
disorders in adolescents
The World Health Organization
reports that half of mental health
disorders start by age 14.9 Some
common mental health disorders that
emerge in adolescence may be risk
factors for suicide. Recognizing the
signs and symptoms is imperative.
Anxiety and depression are the
most common mental illnesses af-
fecting adolescents, with girls and
boys displaying different manifesta-
tions of suicidal ideations.12 Teach-
ers and parents noted in one study
that young boys displayed behavior
problems of dependency and anxiety,
while girls displayed hyperactivity
and aggressiveness. These are signifi-
cant predictors of suicidal ideation.13
Along with anxiety and depres-
sion, emotional disorders can emerge
in adolescents. Common early signs
and symptoms include irritabil-
ity, frustration, anger, unexpected
outbursts, mood changes, and sleep
disturbances. Young adolescents
may develop additional physical
symptoms such as constant abdomi-
nal pain, headaches, or nausea.9,14
Overall, girls have a higher percent-
age of anxiety and depression, and
although girls have a higher rate
of suicidal thoughts and ideations,
more adolescent boys die of sui-
cide.1,10,11
Behavioral disorders such as
attention-deficit/hyperactivity dis-
order more commonly begin in
children and younger adolescents.
Characteristics are excessive activity
and trouble paying attention, with
disregard for consequences. These
children may also have conduct
disorder, which is characterized by
a repetitive and persistent pattern
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of behavior that violates basic rights
of others or major societal norms or
rules.15
Eating disorders can also be a
precursor to chronic or debilitating
mental illness in adulthood. Eat-
ing disorders are more common in
females than males and encompass
binge-eating, anorexia, and bulimia.9
Less common disorders are psycho-
sis, somatization disorders, and bor-
derline personality disorder.
Any family history of mental ill-
ness can be a risk factor.16 Nurses
should be aware of any unusual
behaviors such as hallucinations or
delusions, obsessive preoccupation
with body image or food intake, sub-
stance abuse, and sudden extreme
behaviors. Alert the patient’s health-
care provider if the patient demon-
strates any of these behaviors.
Assessing vulnerable
populations
Many in the adolescent age group
do not have access to mental health
services or may be unwilling to ad-
mit they have a problem, such as
depression, due to the stigma associ-
ated with mental illness.17 Assess-
ment practices need to be changed
to identify at-risk youth and ensure
early prevention and intervention
because they are likely too scared to
seek help.
Although any adolescent can
be at risk, nurses need to consider
some lesser-known vulnerabilities.
For example, early menarche in
girls has been found to be an ante-
cedent of mental health disorders
such as depression, anxiety, eating
disorders, and substance abuse.
Extensive changes in physical and
psychological well-being present
challenges to all adolescents, and
particularly girls who mature ahead
of other girls their age.18 In a recent
study, Mendle and colleagues sup-
ported findings from past research
showing that, even after accounting
for other vulnerabilities associated
with mental health, girls who expe-
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rience early-onset puberty are at a
higher risk for antisocial behaviors
and psychological issues.16 Past
studies have also found that girls
with early-onset puberty are more
likely to engage in early sexual re-
lationships, use drugs and alcohol,
and experience more psychological
stress overall than boys and girls
who do not experience early-onset
puberty.19 Further, Owens describes
how the onset of menses in adoles-
cence associated with fluctuating
hormones can be a risk factor for
suicidal thoughts and behaviors, no
matter the age of onset.12
Exposure to school violence can
also have an ongoing impact on
mental health. Violence in schools
is a broad concept that encompasses
physical and verbal harm, bullying
and threats, and sexual and ethnic
harassment.20 Victims of violence
and bullying have an increased
risk of poor psychological health
in adulthood.21 Bullying cannot be
stopped entirely, but early interven-
tion for the victim can prove benefi-
cial for future mental health.
How well the family unit func-
tions is also important to consider.
Dysfunctional families in which
a young person’s environment is
consistently adverse and abusive is
a significant risk factor for suicidal
behaviors.13
Family violence can take many
forms within the family unit. Sibling
violence is one common example,
as well as physical and sexual abuse
from another person related to the
adolescent. These instances are rarely
isolated, and victims can experience
more than one type of violence.22
Family violence can be compli-
cated, creating relational trauma
for the entire family. This violence
may not be easy to assess; family
violence is often generational and
the caregivers in the household may
have also experienced violence.
Sexual orientation, gender
identity, and gender expression
are identified in populations that
are considered vulnerable regard-
ing mental illness and suicide at-
tempts.23 Recent studies confirm
that LGBTQ+ adolescents experience
high levels of peer victimization,
violence, rejection, harassment, and
sexual abuse contributing to mental
illness and suicidal behaviors.24
Social factors
Adolescence is a time of developing
self-identity and self-confidence.
Adolescents place great importance
on peer groups and relationships.
Peer rejection, conflicts, and school
stress can contribute to anxiety and
depression.8,13
Romantic relationships are another
factor. Adolescents are changing both
physically and emotionally. Teens be-
gin to feel intense emotions toward
others and experience intimacy. Rela-
tionship stressors and breakups can
undermine mental well-being.8,15
The internet and social media
also can play a role in mental ill-
ness and suicide in young people.
Cyberbullying and problematic
social media use can jeopardize
mental well-being.1
Another potential risk and precur-
sor to suicide is experiencing losses,
such as another teen or close rela-
tive committing suicide or another
tragic life event. Poor social support,
either parental or otherwise, can also
compound risks to mental health in
young people.8
Assessment strategies
Mental health assessment is an in-
tegral part of every evaluation, even
when the patient has no remarkable
health history, presenting signs and
symptoms, or complaints. Adoles-
cents who present with physical
complaints may not be willing to
share their mental health issues.
Knowing the characteristics and
experiences of vulnerable patients
and the questions to ask can identify
youth at risk.10
Although adolescents are typi-
cally healthy, a thorough health
October l Nursing2020 l 51
history that addresses past and
present acute illnesses, chronic
health disorders, hospitalizations,
and social history must be ob-
tained to identify potential risks.7
The focused interview should be
structured to include fewer questions
that obtain the most information.
Adolescents may be uncomfortable
asking questions. Consider the fol-
lowing assessment strategies:
• Adolescents may communicate bet-
ter with peers or adults other than
parents or guardians, such as nurses,
so engage in informal conversations
with the patient to gain information.
Ask questions that show interest and
build rapport such as, “What hobbies
and interests do you have?”
• Try to get them alone. Assessing
adolescents one-on-one without a
parent or caregiver allows them to
speak freely.
• Use open-ended questions such
as, “Tell me about your friends,” and
employ silence to give the adolescent
time to answer questions thoroughly.
• Interview family members sepa-
rately when possible to gain a clearer
picture of the situation.
Adolescence is a time of height-
ened self-consciousness and associ-
ated uncertainty. Fear of others’ opin-
ions and a need for privacy is typical.
A teenager’s willingness to openly
share with a nurse depends on his or
her perceptions of the relationship
and comfort level. The nurse should
be aware that first attempts at inter-
action may be met with rejection. It
is vital to communicate in a genuine,
respectful, and honest way.14
When to seek further
evaluation
Older children and adolescents may
benefit from an evaluation for men-
tal health disorders if they meet any
one of the following criteria:
• loss of interest in things that they
used to enjoy
• low energy
• too much or too little sleep, or
sleepiness throughout the day
52 l Nursing2020 l Volume 50, Number 10
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
• spending more and more time
alone, and avoiding social activities
with friends or family
• fear of gaining weight, or dieting or
exercising excessively
• engaging in self-harm behaviors,
such as cutting or burning their skin
• smoking, drinking alcohol, or us-
ing drugs
• engaging in risky or destructive
behavior alone or with friends
• thoughts of suicide
• having periods of highly elevated
energy and activity and requiring
much less sleep than usual
• saying they think someone is try-
ing to control their mind or that
they hear things that other people
cannot hear.7,14,16
Intervention
Early intervention improves out-
comes.5,11 Nurses must be able to
recognize normal variations in ado-
lescent development and behaviors.
If a nurse suspects an adolescent
is at risk for mental illness or the
adolescent shares feelings of depres-
sion, the nurse should first interview
the patient alone and further assess
for suicide risk. Initiate conversa-
tions with statements such as, “I
know it may not be easy to talk to
someone you don’t know,” and fol-
low with open-ended questions such
as, “Have you ever thought about
killing yourself or wished you were
dead?”16 Also, communicate that
patient safety takes precedence over
confidentiality and sharing informa-
tion with family and the primary
care provider may be needed.
Patients who have potential men-
tal illness without suicidal concerns
can be educated on resources avail-
able and referred to the primary care
provider for further assessment. The
nurse must contact the child’s pri-
mary care provider to ensure close
follow-up and further assessment
and referral if needed.16
If suicidal thoughts or ideation are
identified through assessment, or the
nurse has significant concerns, the
nurse must determine if the adoles-
cent has a plan. Share with the par-
ent that the adolescent is suicidal and
plan to keep him or her safe. A plan
should include an immediate evalu-
ation by a mental health professional
and potentially inpatient hospitaliza-
tion. In all cases, safety is a priority. It
is important to note that adolescents
who do not have a high number of
risk factors can still be vulnerable.16
The risk of suicide is exception-
ally high in the time directly after a
nonfatal self-harm event. This risk
is significantly higher in instances of
young people who used more violent
self-harm methods such as hanging
or a firearm.25
Esposito suggests that the inter-
net is a risk factor for suicide due
to social media and the potential
for bullying.16 It allows the teen to
identify different means to attempt
suicide. Therefore, identification of
precipitating factors and ongoing
assessment to assure safety should
be a priority. All potential weapons,
prescription and over-the-counter
medications, and any toxins or illicit
substances must be removed imme-
diately, and the child placed in a safe
space with supervision.16
Intervention for mental health ill-
ness in adolescents usually requires
an interdisciplinary approach that
includes a thorough mental health
assessment, education for the par-
ent and teen, the involvement of
teachers and school counselors,
and treatment specific to the mental
illness. Treatment often includes
pharmacotherapy and cognitive
therapy.14
Suicide prevention
The association between suicidal be-
haviors and mental health disorders
is strong in the adolescent popula-
tion. Nurses should be knowledge-
able about the warning signs of
mental illness and impending sui-
cide. Teach the patient’s family and
friends the potential warning signs
of an impending suicide attempt.
www.Nursing2020.com
 11. Shan Y. Perspectives for nurses on mental
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Care. 2017;27(1):35-41.
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• TeenMentalHealth.org is a resource for assessment and diagnosis tools. health assessment in the emergency department.
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