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There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

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The Brianna and Tanya case study reflects themes of:

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• Educational disparities.
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• Financial insecurity.
• Intergenerational issues.

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Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

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• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

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Adolescent mental health education InSciEd Out: a case study of an alternative middle school population

Affiliations.

• 1 Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA.
• 2 Postbaccalaureate Research Education Program, Mayo Clinic, Rochester, MN, USA.
• 3 Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.
• 4 Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA.
• 5 Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA. [email protected].
• 6 Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA. [email protected].
• PMID: 29615090
• PMCID: PMC5883586
• DOI: 10.1186/s12967-018-1459-x

Background: Mental illness contributes substantially to global disease burden, particularly when illness onset occurs during youth and help-seeking is delayed and/or limited. Yet, few mental health promotion interventions target youth, particularly those with or at high risk of developing mental illness ("at-risk" youth). Community-based translational research has the capacity to identify and intervene upon barriers to positive health outcomes. This is especially important for integrated care in at-risk youth populations.

Methods: Here the Integrated Science Education Outreach (InSciEd Out) program delivered a novel school-based anti-stigma intervention in mental health to a cohort of seventh and eighth grade at-risk students. These students were assessed for changes in mental health knowledge, stigmatization, and help-seeking intentions via a classroom activity, surveys, and teacher interviews. Descriptive statistics and Cohen's d effect sizes were employed to assess pre-post changes. Inferential statistical analyses were also conducted on pilot results to provide a benchmark to inform future studies.

Results: Elimination of mental health misconceptions (substance weakness p = 0.00; recovery p = 0.05; prevention p = 0.05; violent p = 0.05) was accompanied by slight gains in mental health literacy (d = 0.18) and small to medium improvements in help-seeking intentions (anxiety d = 0.24; depression d = 0.48; substance d = 0.43; psychosis d = 0.53). Within this particular cohort of students, stigma was exceptionally low at baseline and remained largely unchanged. Teacher narratives revealed positive teacher views of programming, increased student openness to talk about mental illness, and higher peer and self-acceptance of mental health diagnoses and help-seeking.

Conclusions: Curricular-based efforts focused on mental illness in an alternative school setting are feasible and integrated well into general curricula under the InSciEd Out framework. Preliminary data suggest the existence of unique help-seeking barriers in at-risk youth. Increased focus upon community-based programming has potential to bridge gaps in translation, bringing this critical population to clinical care in pursuit of improved mental health for all. Trial registration ClinicalTrials.gov, ID: NCT02680899 . Registered 12 February 2016, https://clinicaltrials.gov/ct2/show/NCT02680899.

Keywords: (alternative) Education; Adolescent; Mental health; School-based; Stigma.

Publication types

• Research Support, N.I.H., Extramural
• Research Support, Non-U.S. Gov't
• Research Support, U.S. Gov't, Non-P.H.S.
• Health Education*
• Health Knowledge, Attitudes, Practice
• Interviews as Topic
• Mental Health*
• Patient Acceptance of Health Care
• Social Stigma
• Surveys and Questionnaires

Associated data

• ClinicalTrials.gov/NCT02680899

Grants and funding

• R25 GM075148/GM/NIGMS NIH HHS/United States
• R01 grant 5R01HG006431/NH/NIH HHS/United States
• Graduate Research Fellowship Program Fellow ID: 2013170742/National Science Foundation/International
• UL1 TR000135/TR/NCATS NIH HHS/United States
• R25 GM 75148/NH/NIH HHS/United States
• R25 GM055252/GM/NIGMS NIH HHS/United States
• R01 HG006431/HG/NHGRI NIH HHS/United States
• Benefactor/Mayo Clinic Office of Development/International

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• Published: 07 August 2023

Youth mental health crisis management

Nature Mental Health volume  1 ,  pages 525–526 ( 2023 ) Cite this article

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Adolescence and young adulthood are decisive times for neurobiological, cognitive and emotional development, all of which converge on mental health. Research into the identification of risks for developing mental health disorders and early intervention in young people are crucial for curtailing the youth mental health crisis.

Adolescence and young adulthood make up a singular time in an individual’s life, in terms of both the amount of change that occurs and the personal evolution prompted by learning about oneself and our relationships with others and the world around us. It can also be amorphous. There is no definite age boundary on adolescence, although it is anchored to the onset of puberty. But by most definitions, including that of the World Health Organization, the boundaries are between ages 10 and 19. The period after, or ‘young adulthood’, generally covers ages 19–25.

Modern conceptualizations of adolescence and young adulthood go beyond age ranges and include well-developed theories that describe the numerous changes that individuals undergo during this period, including physical and neurobiological maturation, psychological and cognitive development, and heightened emotional lability. Perhaps not as simple as the picturesque “sturm und drang” (storm and stress) model put forth by G. Stanley Hall, the twentieth century American psychologist who is credited with establishing the study of the adolescent developmental period, but remnants of this description persist.

Across many fields that study mental health in adolescence and young adulthood, there is an acknowledgment that this time in an individual’s life is marked by the complex interplay between new experiences and environments and one’s emotional and cognitive responses. The experience and expression of emotions that arise for young people can be overwhelming, especially in light of newly developing regulatory mechanisms. And although heightened emotionality can be part of normative or typical development, adolescence, in particular, is often the time when mental health difficulties emerge. In addition to depression and anxiety, other psychiatric illnesses commonly present during adolescence, including obsessive-compulsive disorder, schizophrenia, eating disorders and substance-use disorders.

At the same time that an awareness has grown among healthcare providers, parents, educators and young people themselves, plus decades of adolescent and young adult psychopathology research, there is an alarming global trend of increasingly adverse youth mental health. Recent estimates 1 indicate that 25% of people under age 18 have experienced increased symptoms of depression, which is double the proportion from before the COVID-19 pandemic. Suicidality, including ideation and attempts, has risen in recent years, and suicide is the second leading cause of death among people aged 15–19 globally.

The rapid rise in negative mental health outcomes in young people has prompted health and government policymakers to refer to the present situation as a youth mental health “crisis”. In 2021, the US surgeon general added youth mental health to one of its current priorities and released the ‘ Protecting youth mental health ’ report 2 , detailing a multisectoral advisement on mitigating harms from the pandemic, social media and stigma. This year, the European Commission published its public health plan ‘ A comprehensive approach to mental health ’ 3 , which underscores more consideration of social determinants of health that affect young people, such as nutrition and access to alcohol and tobacco, as part of its focus on prevention of mental health disorders. Even with considerable focus on the potential role of the pandemic as a magnifier of mental health inequities and disruption and isolation for young people, there is concern that many negative changes have been in play for at least a decade, according to US Centers for Disease Control and Prevention data from 2011–2021 showing that young female, LGBT+ and people of color have experienced increased rates of violence, suicidality and substance use over time 4 . The pandemic has forced a reckoning on a global scale that youth mental health is in jeopardy, but recognizing the warning signs can be complex and challenging. Given the impact of youth mental health on influencing the trajectory of mental health and wellbeing across the lifespan, it is essential that we improve how mental health problems are identified for prevention, as well as how to implement interventions earlier.

In this month’s issue of Nature Mental Health , we include an assortment of original primary research and commentary that highlight important findings and provide advances in understanding the course of youth mental health disorders, from detection to intervention.

In the ‘front half’ of the journal, senior editor Ana Donnelly has a Q&A with Christian Kieling, an associate professor of child and adolescent psychiatry in Brazil, about his work on the Identifying Depression Early in Adolescence (IDEA) project, using a range of methods, including psychoneuroimmunology, imaging and qualitative research, to stratify risk for developing depression in adolescence. In a Perspective piece, Anne Duffy introduces us to children of parents with severe mental illness, who are themselves at increased risk of developing a mental illness, but who may benefit from developmentally sensitive interventions. Associate Editor Natalia Gass reports in a Research Highlight on new work from Yun-Jun Sun, Barbara Sahakian et al., finding that reading for pleasure in childhood was associated with greater academic achievement and cognitive performance and negatively correlated with psychopathology scores and mental health problems, concluding that reading for pleasure could be a useful mental health intervention owing to its scalability and relatively low cost.

Also in this issue, we publish original research on the patterns of violence and mental health outcomes in young adults both before and during the COVID-19 pandemic. In an Article , Wisteria Deng and coauthors sample more than 200,000 college students in the USA, and found greater levels of depressive and anxiety symptoms and increased numbers of sexual violence and assaults experienced by people from gender and sexual minorities during the pandemic. These data reinforce the disproportionate and heightened mental health and sexual violence risks for young people from gender and sexual minorities and the need to increase on-campus safety and crisis intervention. Two other papers out this month use different techniques to investigate psychiatric biomarkers. Margaret Westwater and colleagues report findings that show that the genetic risk for disordered eating was associated with distinct brain structure differences and symptom profiles in a sample of more than 4,900 adolescents. Using plasma-based proteomics, Katja Kanninen and coauthors present some of the first work in identifying protein alteration biomarkers associated with the risk of developing a mental health disorder.

Much of the work published now may not be immediately actionable in a real-world setting, yet it provides clear directive for where a more solid evidence base is needed — for example, with more representative participants or country settings. It also can be extremely valuable in determining where the thresholds for clinical utility of biomarkers should be placed, such as during routine screening programs or potentially at younger ages. In the face of the youth mental health crisis, concurrently pursuing several lines of inquiry is essential. From neurobiological markers, school-based interventions and social determinants of health to reducing stigma, changing the course of the youth mental health crisis will require all of the tools that we have available.

Racine, N. et al. JAMA Pediatr. 175 , 1142–1150 (2021).

Article   PubMed   Google Scholar  

The US Surgeon General’s Advisory. https://go.nature.com/3OrweUh (2021).

European Commission. https://go.nature.com/43HTMsv (2023).

CDC. https://go.nature.com/43D1Xq0 (2021).

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Youth mental health crisis management. Nat. Mental Health 1 , 525–526 (2023). https://doi.org/10.1038/s44220-023-00112-1

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NO 2 indicates nitrogen dioxide; PM 2.5 , particulate matter under 2.5 μm; and WHO, World Health Organization. Shading in panel A represents IQRs.

Results are from model 3, which is adjusted for ethnicity, family psychiatric history, maternal social class, maternal education, house tenure, population density, neighborhood deprivation, social fragmentation, and greenspace. Sample sizes of imputed data sets range from 2952 (adolescence noise pollution and psychotic experiences) to 6154 (pregnancy air pollution and anxiety). NO 2 indicates nitrogen dioxide; OR, odds ratio; and PM 2.5 , particulate matter less than 2.5 μm.

eMethods. Participants, pollution data, covariates, and multiple imputation

eResults. Findings from sensitivity analyses

eDiscussion. Interpretation of sensitivity analyses

eFigure 1. Correlations between NO2, PM2.5, and noise pollution across pregnancy, childhood, and adolescence

eFigure 2. Directed acyclic graph (DAG)

eTable 1. Association of early-life noise pollution exposure with youth mental health problems, treating noise pollution as a categorical variable

eTable 2. Comparison between e-value and covariate point estimates: pregnancy PM2.5 and psychotic experiences

eTable 3. Comparison between e-value and covariate point estimates: adolescent noise pollution and anxiety

eTable 4. Adjusting pollutants for one another: associations of early-life air and noise pollution exposure with youth mental health problems

eTable 5. Restricting to non-movers (~30% of participants): associations of early-life air and noise pollution exposure with youth mental health problems

eTable 6. Complete case analysis: associations of early-life air and noise pollution exposure with youth mental health problems

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Newbury JB , Heron J , Kirkbride JB, et al. Air and Noise Pollution Exposure in Early Life and Mental Health From Adolescence to Young Adulthood. JAMA Netw Open. 2024;7(5):e2412169. doi:10.1001/jamanetworkopen.2024.12169

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Air and Noise Pollution Exposure in Early Life and Mental Health From Adolescence to Young Adulthood

• 1 Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
• 2 Social, Genetic, and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
• 3 PsyLife Group, Division of Psychiatry, University College London, London, United Kingdom
• 4 ESRC Centre for Society and Mental Health, King’s College London, London, United Kingdom
• 5 Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
• 6 Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
• 7 UK Longitudinal Linkage Collaboration, University of Bristol, Bristol, United Kingdom
• 8 MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, United Kingdom

Question   Is exposure to air and noise pollution in pregnancy, childhood, and adolescence associated with the development of psychotic experiences, depression, and anxiety between 13 and 24 years of age?

Findings   In this longitudinal birth cohort study followed up into adulthood that included 9065 participants with mental health data, higher exposure to fine particulate matter (PM 2.5 ) in pregnancy and childhood was associated with increased psychotic experiences and in pregnancy was associated with higher rates of depression. Higher noise pollution exposure in childhood and adolescence was associated with increased anxiety.

Meaning   These findings build on evidence associating air and noise pollution with mental health, highlighting a role of early-life pollution exposure in youth mental health problems.

Importance   Growing evidence associates air pollution exposure with various psychiatric disorders. However, the importance of early-life (eg, prenatal) air pollution exposure to mental health during youth is poorly understood, and few longitudinal studies have investigated the association of noise pollution with youth mental health.

Objectives   To examine the longitudinal associations of air and noise pollution exposure in pregnancy, childhood, and adolescence with psychotic experiences, depression, and anxiety in youths from ages 13 to 24 years.

Design, Setting, and Participants   This cohort study used data from the Avon Longitudinal Study of Parents and Children, an ongoing longitudinal birth cohort founded in 1991 through 1993 in Southwest England, United Kingdom. The cohort includes over 14 000 infants with due dates between April 1, 1991, and December 31, 1992, who were subsequently followed up into adulthood. Data were analyzed October 29, 2021, to March 11, 2024.

Exposures   A novel linkage (completed in 2020) was performed to link high-resolution (100 m 2 ) estimates of nitrogen dioxide (NO 2 ), fine particulate matter under 2.5 μm (PM 2.5 ), and noise pollution to home addresses from pregnancy to 12 years of age.

Main outcomes and measures   Psychotic experiences, depression, and anxiety were measured at ages 13, 18, and 24 years. Logistic regression models controlled for key individual-, family-, and area-level confounders.

Results   This cohort study included 9065 participants who had any mental health data, of whom (with sample size varying by parameter) 51.4% (4657 of 9051) were female, 19.5% (1544 of 7910) reported psychotic experiences, 11.4% (947 of 8344) reported depression, and 9.7% (811 of 8398) reported anxiety. Mean (SD) age at follow-up was 24.5 (0.8) years. After covariate adjustment, IQR increases (0.72 μg/m 3 ) in PM 2.5 levels during pregnancy (adjusted odds ratio [AOR], 1.11 [95% CI, 1.04-1.19]; P  = .002) and during childhood (AOR, 1.09 [95% CI, 1.00-1.10]; P  = .04) were associated with elevated odds for psychotic experiences. Pregnancy PM 2.5 exposure was also associated with depression (AOR, 1.10 [95% CI, 1.02-1.18]; P  = .01). Higher noise pollution exposure in childhood (AOR, 1.19 [95% CI, 1.03-1.38]; P  = .02) and adolescence (AOR, 1.22 [95% CI, 1.02-1.45]; P  = .03) was associated with elevated odds for anxiety.

Conclusions and Relevance   In this longitudinal cohort study, early-life air and noise pollution exposure were prospectively associated with 3 common mental health problems from adolescence to young adulthood. There was a degree of specificity in terms of pollutant-timing-outcome associations. Interventions to reduce air and noise pollution exposure (eg, clean air zones) could potentially improve population mental health. Replication using quasi-experimental designs is now needed to shed further light on the underlying causes of these associations.

Childhood, adolescence, and early adulthood are critical periods for the development of psychiatric disorders: worldwide, nearly two-thirds of individuals affected become unwell by 25 years of age. 1 Identifying early-life risk factors is a crucial research challenge in developing preventative interventions and improving lifelong mental health trajectories.

Growing evidence suggests that air pollution exposure may be associated with the onset of psychiatric problems, including mood, affective, and psychotic disorders. 2 - 6 Air pollution comprises toxic gases and particulate matter (ie, organic and inorganic solid and liquid aerosols) of mostly anthropogenic origin. 7 Understanding the potential effect of air pollution on mental health is increasingly crucial, given the human and societal cost of poor mental health, 8 the global shift toward urban living, 9 , 10 and the backdrop of emissions-induced climate change. 11 Air pollution could negatively affect mental health via numerous pathways, including by compromising the blood-brain barrier, promoting neuroinflammation and oxidative stress, and directly entering the brain and damaging tissue therein. 12 , 13 However, key research gaps remain. First, the relative importance of early-life exposure, including prenatal exposure, is uncertain. Infants and children are thought to be especially vulnerable to air pollution, 14 , 15 but longitudinal, high-resolution pollution data spanning the early years of human life are scarce. Second, relatively few studies have examined the association of air pollution with youth mental health problems, 16 despite youth being a critical period for intervention. Third, few longitudinal studies have investigated the role of noise pollution in mental health, 17 despite the correlation between noise and air pollution. 18 Finally, studies have often used crude pollution data and lacked adequate controls for potential confounders.

We aimed to advance understanding on this topic by capitalizing on a novel linkage between high-resolution outdoor air and noise pollution data and a cohort of over 14 000 infants born in Southwest England in 1991 through 1993 and followed up into adulthood. We examined the association of air and noise pollution exposure from pregnancy to 12 years of age with mental health problems from ages 13 to 24 years. Based on previous evidence, we focused on psychotic experiences (eg, subclinical hallucinations and delusions), depression, and anxiety. These problems are common 1 , 19 - 21 and increasing 22 among youth and strongly predict future psychopathology, 23 , 24 making them useful and important targets. We hypothesized that participants exposed to higher air and noise pollution would subsequently experience worse mental health.

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a UK birth cohort, 25 - 28 described further in the eMethods in Supplement 1 . Briefly, pregnant women residing in and around the City of Bristol (population approximately 714 000 in 2024) in Southwest England with due dates between April 1, 1991, and December 31, 1992, were approached to take part in the study. The initial number of pregnancies enrolled was 14 551, resulting in 13 988 children alive at 1 year of age. At age 7 years, the initial sample was bolstered with additional eligible cases, resulting in 14 901 infants alive at 1 year of age. The catchment area has a mix of urban, suburban, and rural environments. 29 The study website contains details of all the data and a fully searchable data dictionary and variable search tool. 30 Ethical approval for the study was obtained from the ALSPAC Ethics and Law Committee and the Local Research Ethics Committees. Informed consent for the use of data collected via questionnaires and clinics was obtained from participants following the recommendations of the ALSPAC Ethics and Law Committee at the time. The present study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. 31

Psychotic experiences were measured at ages 13, 18, and 24 years using a semi-structured interview 32 that consisted of 12 core items about hallucinations, delusions, and thought interference, rated against the Schedule for Clinical Assessment in Neuropsychiatry version 2.0 (SCAN 2.0). 33 Consistent with previous ALSPAC studies, 34 , 35 psychotic experiences were defined such that 0 represented none, and 1 represented suspected or definite. The reporting period at each phase was since the participant’s 12th birthday. At 13 years of age, 13.6% (926 of 6788) of participants reported psychotic experiences, at 18 years of age 9.2% (432 of 4715) reported psychotic experiences, and at 24 years of age, 12.6% (491 of 3888) reported psychotic experiences. We summed psychotic experiences across time points and dichotomized the variable for analyses such that participants received a score of 1 for suspected or definite psychotic experiences if they reported psychotic experiences at any age.

Depression and anxiety were measured at age 13 years via parent-completed Development and Well-being Assessments. 36 Responses were classified into probabilistic bands according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for major depressive disorder and generalized anxiety disorder, and dichotomized for analysis (bands 0-2, 0; bands 3-5, 1). At ages 18 and 24 years, depression and anxiety were measured using the Clinical Interview Schedule Revised, 37 a self-administered computerized interview that gave International Statistical Classification of Diseases, Tenth Revision , diagnoses of moderate to severe depression and generalized anxiety disorder. The reporting period at each phase was the past month, although a 6-month reporting period was used for anxiety at 13 years of age. At 13 years of age, 5.6% (386 of 6944 of participants) reported depression and 3.6% (254 of 7044) reported anxiety. At 18 years of age, 7.9% (359 of 4560) reported depression and 5.7% (262 of 4560) reported anxiety. At 24 years of age, 7.7% (304 of 3965) reported depression and 9.8% (386 of 3956) reported anxiety. We summed depression and anxiety across time points and dichotomized the variables for analysis such that participants received a score of 1 if they had depression or anxiety at any age.

Air pollutants included nitrogen dioxide (NO 2 ) and fine particulate matter with a diameter smaller than 2.5 μm (PM 2.5 ). Both pollutants have well-established health impacts 10 and more recent associations with psychiatric disorders. 5 These air pollutants were estimated as part of the LifeCycle project 38 using the Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE) model, which is described elsewhere and further in the eMethods in Supplement 1 . 39 Briefly, the ELAPSE model is a hybrid land-use regression model for Europe that derived concentrations of NO 2 and PM 2.5 in 2010. The model produces annualized estimates at 100 m 2 resolution, explaining 59% and 71% of measured spatial variability for NO 2 and PM 2.5 , respectively. 39 Estimates were linked to residential geocodes from pregnancy to age 12 years for participants who had lived in the original ALSPAC catchment area 29 up to 12 years of age and provided permission for geospatial linkage. Linkage was completed in 2020.

Residential noise pollution exposure was also estimated as part of the LifeCycle project 38 based on the UK Government’s Department for Environment, Food and Rural Affairs 2006 road traffic noise map. Data represent an annualized mean of day and night noise pollution, categorized according to low to medium (<55 dB: the European Environment Agency’s threshold 40 ), high (55-60 dB), and very high (>60 dB) noise. eFigure 1 in Supplement 1 shows the correlation between noise pollution, NO 2 , and PM 2.5 across time points.

Potential confounders were informed by the literature and formally selected using a directed acyclic graph (eFigure 2 in Supplement 1 ). We considered individual- and family-level covariates that could be associated with mental health problems and with downward mobility into more polluted neighborhoods. These included ethnicity self-reported by mothers during pregnancy, family psychiatric history, maternal social class, maternal education, and housing tenure. Area-level covariates included population density, neighborhood deprivation, social fragmentation, and greenspace and were time varying, corresponding to the timing of pollution exposure. Covariates are described fully in the eMethods in Supplement 1 and briefly below.

Race and ethnic group was reported by mothers during pregnancy, with specific categories to select including Bangladeshi, Black/African, Black/Caribbean, Black/other, Chinese, Indian, Pakistani, White, and any other ethnic group. Family psychiatric problems were reported by mothers and fathers during pregnancy and defined as the presence of any psychiatric problem affecting the mother, father, or any biological grandparent. Maternal social class based on occupation was reported by mothers during pregnancy. Maternal education was reported by mothers when infants were around 8 months. Home ownership was reported by mothers during pregnancy.

Population density was derived from 1991 and 2001 census data. 35 Area-level deprivation was based on the Index of Multiple Deprivation 2000. 41 Social fragmentation was based on a z-scored sum of census data on residential mobility, marital status, single-person households, and home ownership. 35 Greenspace was assessed based on the Normalized Difference Vegetation Index. 42

Analyses were performed from October 29, 2021, to March 11, 2024, in Stata, version 18.0 (StataCorp LLC). The code can be found at GitHub. 43 The characteristics of the sample with vs without mental health data were described according to percentages, means, and standard deviations. Group differences were explored using χ 2 and t tests. To explore the importance of different exposure periods, we derived exposure estimates for 3 developmental stages, pregnancy, childhood (birth to age 9 years), and adolescence (ages 10-12 years), 44 which were calculated using mean exposure values for NO 2 , PM 2.5 , and noise pollution during these age windows. Given that NO 2 and PM 2.5 had very different absolute ranges, scores were standardized by dividing by the IQR. To aid comparison between air and noise pollution, we treated noise pollution as a continuous variable, assuming a normal distribution underlying the categorical variable. Results treating noise as categorical are reported in eTable 1 in Supplement 1 .

For main analyses, logistic regression was used to examine the associations of NO 2 , PM 2.5 , and noise pollution in pregnancy, childhood, and adolescence with the mental health outcomes. We conducted an unadjusted model (model 1), then adjusted for individual- and family-level covariates (model 2), and then additionally adjusted for area-level covariates (model 3). To better understand the independent associations from different exposure periods, we then adjusted childhood and adolescent exposure for previous exposure (model 4). However, given that the high correlation between pollutants over time (eFigure 1 in Supplement 1 ) could introduce multicollinearity, we interpreted model 4 with caution. To estimate residual confounding, we also calculated E values 45 for models 3 and 4, which indicate the strength of association that an unmeasured confounder would require to nullify associations. All models accounted for potential hierarchy in the data by clustering around the lower layer super output area (containing a mean of about 1500 residents) using the cluster command, which provides robust SEs adjusted for within cluster correlated data. 46 All analyses were conducted following multiple imputation by chained equations, 47 described in the eMethods in Supplement 1 . A 2-sided value of P  < .05 was considered statistically significant.

We conducted 3 sensitivity analyses. First, we analyzed NO 2 , PM 2.5 , and noise pollution simultaneously, to control each for the others and address potential copollutant confounding. Second, we restricted analyses to participants who did not move house from pregnancy to age 12 years (29.8%) to keep pollution levels as consistent as possible over time. Third, we repeated main analyses for individuals with complete data.

The study included 9065 participants (mean [SD] age at follow-up, 24.5 [0.8] years) who had any mental health data, of whom (with sample sizes varying by parameter) 51.4% (4657 of 9051) were female, 48.6% (4394 of 9051) were male, 95.8% (7616 of 7954) were ethnically White, and 4.2% (338 of 7954) were of other ethnicity (which included Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Pakistani, and others; these categories were collapsed into one because numbers in some categories were small enough to increase the risk of identification). In addition, 19.5% (1544 of 7910) reported psychotic experiences, 11.4% (947 of 8344) reported depression, and 9.7% (811 of 8398) reported anxiety ( Table 1 ). Over half of participants (60.8% [4793 of 7886]) had a family psychiatric history; 21.8% (1583 of 7248) had mothers who worked in manual occupations; 15.7% (1274 of 8093) had mothers with degrees; and 81.6% (6670 of 8176) lived in homes owned by their parent (or parents). Mean (SD) population density was 33 (21) persons per hectare, and 19.3% (933 of 4831) of participants lived in the most deprived neighborhoods. The sample with vs without mental health data differed for most variables: participants with mental health data were more likely to be female, be White, have a family psychiatric history, and have more advantaged characteristics across the other variables. These differences should be borne in mind when interpreting the results.

Figure 1 A shows estimated levels of NO 2 and PM 2.5 for the sample, alongside the World Health Organization’s (WHO) 2021 exposure thresholds. 48 Mean (SD) levels of NO 2 (eg, 26.9 [4.2] μg/m 3 in pregnancy vs 21.1 [3.5] μg/m 3 at 12 years of age) and PM 2.5 (eg, 13.3 [0.9] μg/m 3 in pregnancy vs 10.7 [0.8] μg/m 3 at 12 years of age) decreased slightly over time. However, the mean exposure at age 12 years remained above the WHO’s thresholds for both pollutants (NO 2 , 10.0 μg/m 3 ; PM 2.5 , 5.0 μg/m 3 ). Additionally, over two-thirds of participants were exposed to high or very high noise pollution, 40 which changed little over time (eg, 22.7% in pregnancy vs 22.2% at year 12 for high noise pollution) ( Figure 1 B).

Associations of levels of NO 2, PM 2.5 , and noise pollution with psychotic experiences, depression, and anxiety are given in Table 2 , which shows unadjusted and adjusted results alongside E values, and Figure 2 , which shows model 3 results. Before covariate adjustment, IQR (4.47 μg/m 3 ) increases in NO 2 levels during pregnancy were associated with elevated odds for psychotic experiences (odds ratio [OR], 1.08, [95% CI, 1.00-1.17]; P  = .04). However, there was no association after adjusting for area-level covariates. In contrast, following covariate adjustment, IQR (0.72 μg/m 3 ) increases in PM 2.5 during pregnancy (adjusted [A]OR, 1.11 [95% CI, 1.04-1.19]; P  = .002) and childhood (AOR, 1.09 [95% CI, 1.00-1.19]; P  = .04) were associated with elevated odds for psychotic experiences, although for childhood exposure (model 4), there was no association after adjusting for pregnancy exposure. There was no association between noise pollution and psychotic experiences (eg, AOR, 1.04 [95% CI, 0.92-1.18]; P  = .50 during pregnancy).

Following covariate adjustment, IQR increases in PM 2.5 during pregnancy were associated with elevated odds for depression (eg, AOR, 1.10 [95% CI, 1.02-1.18]; P  = .01 during pregnancy). There were no associations between NO 2 (eg, AOR, 1.10 [95% CI, 0.98-1.24]; P  = .10 during pregnancy) or noise pollution (eg, AOR, 1.02 [95% CI, 0.89-1.18]; P  = .74 during pregnancy) and depression.

Before covariate adjustment, IQR increases in NO 2 in pregnancy (OR, 1.14 [95% CI, 1.04-1.26]; P  = .006) and childhood (OR, 1.15 [95% CI, 1.03-1.27]; P  = .009) were associated with elevated odds for anxiety, but associations were attenuated to the null after adjusting for area-level covariates. There were no associations between PM 2.5 exposure during childhood and anxiety (AOR, 1.10 [95% CI, 0.97-1.25]; P = .58 for model 3). In contrast, participants exposed to higher noise pollution in childhood (AOR, 1.19 [95% CI, 1.03-1.38]; P  = .02) and in adolescence (AOR, 1.22 [95% CI, 1.02-1.45]; P  = .03) had elevated odds for anxiety; however, adolescent exposure was attenuated to the null after controlling for pregnancy and childhood exposure (model 4). eTable 1 in Supplement 1 gives results when noise pollution was treated as categorical. This analysis highlighted several dose-response associations, although no difference in model fit was observed compared with the main results.

In eTables 2 and 3 in Supplement 1 , we take as examples the associations of pregnancy PM 2.5 with psychotic experiences and adolescent noise pollution with anxiety from model 3 and compare the E values to the associations from included covariates. The E value ORs were 1.46 (lower confidence limit, 1.24) for pregnancy PM 2.5 with psychotic experiences and 1.74 (lower confidence limit, 1.16) for adolescent noise pollution with anxiety. These E value ORs were larger in magnitude than the ORs for associations of the covariates with the exposures and outcomes, indicating that an unmeasured confounder would require a relatively strong confounding influence to nullify associations.

Results from sensitivity analyses are described in the eResults in Supplement 1 , presented in eTables 4 to 6 in Supplement 1 , and addressed in the eDiscussion in Supplement 1 . Briefly, point estimates were generally similar after adjusting pollutants for each other, similar (and often higher) for participants who did not move house, and similar for complete cases, although CIs were often less precise.

In this longitudinal birth cohort study with a follow-up of approximately 25 years, participants exposed to higher PM 2.5 during pregnancy and childhood subsequently experienced more psychotic experiences and (for pregnancy exposure only) depression. In contrast, higher noise pollution in childhood and adolescence were associated subsequently with more anxiety. These associations were not explained by numerous potential individual-, family-, and area-level confounders.

Our findings suggest an important role of early-life (including prenatal) exposure to air pollution in the development of youth mental health problems. Early-life exposure could be detrimental to mental health given the extensive brain development and epigenetic processes that occur in utero and during infancy. 13 , 15 , 49 , 50 Air pollution exposure could also lead to restricted fetal growth 51 and preterm birth, 52 which are both risk factors for psychopathology. Notably, the point estimate for pregnancy PM 2.5 and depression (10% elevated odds for every 0.72 μg/m 3 increase) was considerably greater than a previous meta-analytic estimate based on exposure in adulthood (10% elevated odds for every 10 μg/m 3 increase). 2 These contrasting findings are in keeping with a particularly detrimental role of early-life air pollution exposure. However, our findings could also have arisen if early-life exposure data provide a proxy for cumulative exposure over a longer period, given that families often settle when children are young.

For noise pollution, evidence was strongest for childhood and adolescent exposure. Childhood and adolescent noise pollution exposure could increase anxiety by increasing stress and disrupting sleep, with high noise potentially leading to chronic physiological arousal and disruption to endocrinology. 53 Noise pollution could also impact cognition, 54 which could increase anxiety by impacting concentration during school years. It was interesting that noise pollution was associated with anxiety but not with psychotic experiences or depression. However, our measure of noise pollution estimated only decibels (ie, intensity) from road sources. Other qualities of noise, such as pitch, could be relevant to mental health.

We acknowledge several limitations. First, the causality of the findings is uncertain given that data were observational. Despite comprehensive covariate adjustment, residual confounding is inevitable given imperfect selection and measurement of covariates. The relatively large E values strengthened our confidence in the findings, but future studies should consider other methods to address confounding, such as quasi-experimental designs. Second, ALSPAC families are more affluent and less diverse than the UK population. 55 The extent to which our findings generalize to other populations and locations is uncertain. Our findings likely generalize to cities and surrounds in other high-income countries, but may be less generalizable to urban settings in lower-income countries, which can have more extreme pollution concentrations. 56 Third, modeled pollution data are subject to various sources of measurement error, 39 particularly Berkson-like error whereby estimates are smoother (less variable) than reality, leading to less precise, although unbiased, exposure-outcome estimates. 57 , 58 For instance, the 100 m 2 resolution, although an improvement over many previous studies, 59 - 61 would have masked hyperlocal variation (eg, differences between participants living on adjacent streets), to which NO 2 is especially prone due to its short decay function. 62 Additionally, the model estimated residential exposure, which would have masked variation due to behavior and time spent away from home. Finer-resolution data, including personal exposure estimates, would enable more precise exposure-outcome estimates, particularly for NO 2 . Fourth, we could not apply life-course models to investigate sensitive periods vs cumulative effects, as there was limited within-person variation in exposure over time. Larger data sets (eg, national registries) and quasi-experimental designs would be required to further tease out this question.

The results of this cohort study provide novel evidence that early-life exposure to particulate matter is prospectively associated with the development of psychotic experiences and depression in youth. This study, which is among only a handful of longitudinal studies to investigate the association between noise pollution and mental health, also finds an association with anxiety. The findings suggest a degree of specificity in terms of pollutant-timing-outcome pathways. The opportunity for intervention is potentially enormous. However, although our this study addressed various biases affecting observational research, the causality of the findings remains uncertain. There is now a pressing need for further longitudinal research using more precise measures of air and noise pollution and for replication using quasi-experimental designs.

Accepted for Publication: March 15, 2023.

Published: May 28, 2024. doi:10.1001/jamanetworkopen.2024.12169

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Newbury JB et al. JAMA Network Open .

Corresponding Author: Joanne B. Newbury, PhD, Population Health Sciences, Bristol Medical School, Oakfield House, Bristol, BS8 2BN, United Kingdom ( [email protected] ).

Author Contributions: Dr Newbury had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Newbury, Kirkbride, Fisher, Bakolis.

Acquisition, analysis, or interpretation of data: Newbury, Heron, Kirkbride, Boyd, Thomas, Zammit.

Drafting of the manuscript: Newbury.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Newbury, Heron, Bakolis.

Obtained funding: Newbury, Zammit.

Administrative, technical, or material support: Boyd, Thomas.

Supervision: Heron, Kirkbride, Fisher, Bakolis, Zammit.

Conflict of Interest Disclosures: Prof Fisher reported receiving grants from the Economic and Social Research Council (ESRC) during the conduct of the study. Dr Heron and Prof Zammit are supported by a grant from the National Institute for Health and Care Research (NIHR) Biomedical Research Centre. Prof Fisher is supported by the ESRC Centre for Society and Mental Health at King’s College London. Dr Bakolis is supported in part by the NIHR Biomedical Research Centre at South London and Maudsley National Health Service (NHS) Foundation Trust and King’s College London and by the NIHR Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. Messrs Boyd and Thomas are funded by the UK Medical Research Council (MRC) and ESRC to develop centralized record linkage services via the UK Longitudinal Linkage Collaboration and by Health Data Research UK to support the development of social and environmental epidemiology in longitudinal studies. No other disclosures were reported.

Funding/Support: The UK MRC and Wellcome Trust (grant 217065/Z/19/Z) and the University of Bristol provide core support for the Avon Longitudinal Study of Parents and Children (ALSPAC). This research was funded in whole, or in part, by grant 218632/Z/19/Z from the Wellcome Trust. This research was specifically funded by grants from the UK MRC to collect data on psychotic experiences, depression, and anxiety (MR/M006727/1 and G0701503/85179 to Prof Zammit); and a grant from the Natural Environment Research Council to facilitate linkage to geospatial and natural environment data (R8/H12/83/NE/P01830/1 to Mr Boyd). Dr Newbury is funded by Sir Henry Wellcome Postdoctoral Fellowship 218632/Z/19/Z from the Wellcome Trust and grant COV19/200057 from the British Academy.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This publication is the work of the authors, and they serve as guarantors for the contents of this paper. The views expressed are those of the authors and not necessarily those of the ESRC or King’s College London.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We are extremely grateful to all the families who took part in this study; the midwives for their help in recruiting them; and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists, and nurses. We are also extremely grateful to ISGlobal, Barcelona, for conducting the LifeCycle project and generating the air and noise pollution data.

Additional Information: A comprehensive list of grant funding is available on the ALSPAC website ( http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgments.pdf ).

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• Published: 15 May 2023

International youth mental health case study of peer researchers’ experiences

• Inga Spuerck 1 ,
• Milos Stankovic 1 ,
• Syeda Zeenat Fatima 2 ,
• Elmas Yilmas 3 ,
• Nicholas Morgan 1 ,
• Jenna Jacob 4 , 7 ,
• Julian Edbrooke-Childs 4 , 7 &
• Panos Vostanis 5 , 6  

Research Involvement and Engagement volume  9 , Article number:  33 ( 2023 ) Cite this article

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The involvement of young people as peer researchers, especially with lived experience, is increasingly considered important in youth mental health research. Yet, there is variation in the understanding of the role, and limited evidence on its implementation across different research systems. This case study focusses on the barriers and enablers of implementing peer researcher roles within and across majority world countries contexts.

Based on an international youth mental health project involving different levels of peer researchers and participants from eight countries, peer researchers and a co-ordinating career researcher reflect on lessons regarding enabling and challenging factors. These reflections are captured and integrated by a systematic insight analysis process.

Building on existing international networks, it was feasible to actively involve peer researchers with lived experience in a multi-country mental health study, who in turn recruited and engaged young participants. Identified challenges include the terminology and definition of the role, cultural differences in mental health concepts, and consistency across countries and sites.

Peer researchers’ role could be strengthened and mainstreamed in the future through ongoing international networks, training, sufficient planning, and active influence throughout the research process.

Trial registration : Not applicable.

Plain English summary

The involvement of young people with lived experience as collaborators (peer researchers) in mental health research has become more prominent in recent years. Yet, there is variation in the understanding of this role and how to involve young people. There is also limited evidence on how this role can be applied across different research systems, especially in majority world countries. We share our experience from a youth mental health project involving peer researchers in eight countries. Peer researchers and the co-ordinating career researcher reflected on lessons regarding enabling and challenging factors. Their reflections highlighted that, overall, it is feasible to successfully involve young people with lived experience in international mental health research. Several challenges were also identified, including terminology, definition of roles, cultural differences in understanding mental health, and consistency across participating countries and sites. According to peer researchers’ reflections, these challenges can be overcome through the establishment of ongoing international networks, training and support, sufficient planning and peer researchers getting involved at all the stages of the research. Lessons from this case study can be of interest to the international research community in strengthening the involvement of young people in mental health research.

Peer Review reports

In the last few decades, different approaches of participatory research have been developed and reported [ 1 ]. Common to variably defined approaches is that people who are the focus of the research are involved as collaborators in the research process, instead of them merely being participants [ 1 , 2 ]. While some of these approaches such as community based participatory research (CBPR) or participatory action research (PAR) aim to produce solutions arising from the research findings, co-production predominantly focuses on the generation of new knowledge [ 3 ]. A widely used term for co-production is ‘peer-research’ or ‘co-research’. However, the definitions of peer researchers and the levels of their involvement are inconsistent across the literature. Participation broadly consists of information, consultation, involvement, collaboration and empowerment [ 1 ].

The umbrella of co-production approaches includes concepts such as ‘patient and public involvement’ (PPI) in health research, ‘service user research’ across health and social care, and ‘peer research’. For example, patient and public involvement refers to consultation and collaboration with experts by experience (research carried out with or by members of the public rather than to, about or for them) [ 4 ], whilst peer researchers are experts by lived experience who conduct pre-defined components of the research. Peer researcher activities may include designing, delivering, analysing, interpreting, or disseminating aspects of the data they have generated; and identifying actions [ 5 ]. Nevertheless, these roles vary in the literature, and related terms are used inter-changeably. Lack of consensus possibly applies even more to the role of young people as peer researchers. This is both because of the relatively recent body of studies in this field, as well as because of developmental and ethical challenges [ 6 , 7 ].

Involving young people as peer researchers Footnote 1

The rights of young people to be involved in decisions affecting their lives is widely acknowledged, as highlighted by the United Nations Convention on the Rights of the Child [ 8 ]. To ensure that research findings are responsive to the needs of young people, there has been increasing interest in their meaningful involvement in research, i.e., their active input rather than tokenistic presence without their views being taken into consideration [ 9 ]. A growing body of evidence indicates several positive effects of involving young people as peer researchers on the youth-centredness and quality of the research process at all stages.

Because of their peer networks, young people can help with recruitment, especially of hard-to-engage groups, therefore, extend the pool of potential participants [ 7 , 10 , 11 ]. Involvement in data collection, e.g., by interviewing other young people, can reduce power imbalances between researcher and participant, and as a result, the bias of collected information. Peer researchers share similar experiences and language, which may lead to participants feeling more comfortable in sharing their views. Analysis and interpretation of data in collaboration with young people can add a new perspective, thus enhance our understanding of the subject; whilst dissemination of findings to their peers can enhance the uptake of solutions, hence the impact of the research [ 11 , 12 ]. Overall, the active involvement of young people as peer researchers can benefit both the young people by increasing their self-confidence and them feeling that their views matter, and the career researchers by enriching their insight into young people’s needs and perspectives [ 13 ].

Despite these benefits, the question of how to meaningfully involve young people in research remains a matter of debate, with various emerging peer researcher models [ 9 ]. Most authors agree that youth involvement in research needs careful consideration according to each research context [ 7 , 14 , 15 ]. This process requires flexibility and adaptation by the career researchers regarding the peer researcher role, required training and support, timescale, and budget [ 7 , 14 ]. To prevent any arising risks of harmful participation, a range of ethical issues should be considered and managed appropriately. These include the safeguarding of vulnerable young people, ensuring confidentiality, and incorporating professional payment rather than potentially coercive rewards [ 10 ].

Researchers need to have the necessary skills to build good rapport with young people and to respond to their needs in relation to, e.g., life changes, puberty, or school commitments [ 15 , 16 ]. McLaughin [ 11 ] recommends that the research process should allow for young people to leave and re-join the project if faced with personal challenges. It is thus essential that research teams sustain ongoing dialogue among everyone involved, whilst offering training and other support to peer researchers [ 14 ]. Brady and colleagues [ 17 ] argue that researchers should give young people an informed choice to decide whether and how they want to be involved, especially when conducting research on sensitive topics such as abuse, interpersonal violence, or exploitation, which may cause distress to both young interviewers and interviewees [ 15 ]. Mental health is another sensitive topic, because of the attached stigma, and the potential of triggering adverse experiences and emotions. Therefore, it is important to consider the additional requirements when involving young people as peer researchers in mental health related research.

Peer researchers in mental health studies

Evidence on the involvement of young people as peer researchers in mental health research mainly originates from high-income or minority world countries [ 9 , 14 , 18 , 19 ]. Important lessons also arise from the large body of literature on youth engagement in mental health research [ 20 ]. Overall, evidence indicates that the involvement of young people with lived experience of mental health difficulties in research is feasible, provides valuable insight [ 13 , 18 ], enhances empathy [ 21 ] and contributes to stigma reduction [ 22 ]; also, that young people, as well as career researchers, are motivated to engage with each other [ 18 , 23 ]. The Recovery Colleges approach of involving students with lived experience was found to lead to interpersonal changes and use of opportunities [ 24 ]. Delman [ 25 ] stated that meaningful youth involvement should be underpinned by the key principles of personal commitment to leadership, inclusion, respect, clear communication, project flexibility, additional resources, supportive infrastructure and training.

These promising findings also highlight the importance of providing adequate support to peer researchers in dealing with ongoing mental health and age-relevant issues [ 26 , 27 ]. If young people are feeling less confident because of mental health difficulties, it may take more time and encouragement from career researchers to involve them positively in a research project [ 23 ]. This means that career researchers themselves require training, irrespective of seniority and previous experience, as a youth participatory process would require new skills [ 26 ]. To this effect, Faithfull and colleagues [ 18 ] found that the degree of confidence and competence career researchers felt about engaging with young people influenced how they conceptualised youth participation.

Several challenges have thus been identified in relation to mental health research. At the planning stage, it is usually suggested to over-recruit peer researchers, as the risk of drop-out is higher due to the potential of deteriorating mental health difficulties, changes in life circumstances, and education or employment opportunities [ 14 ]. However, the recruitment of peer researchers with lived experience of mental health difficulties can be more challenging than in non-mental health related research, as young people might fear that their involvement could face stigmatising attitudes from the research team or stakeholders such as professionals; and lead to the deterioration of existing or the recurrence of previous mental health difficulties [ 23 ]. As similar fears were found to arise from young people previously experiencing discrimination and marginalisation, it is essential to allow for building trust with the other researchers over a longer period of time [ 28 ]. Consequently, a peer researcher with lived experience can feel being both ‘insider’ and ‘outsider’ in the research process [ 29 ].

Peer researchers in majority world mental health research

Although the limited evidence is based on minority world sociocultural contexts, participatory methods to involve young people in mental health research have been implemented in majority world countries (MWC). Approaches used in MWC were predominantly CBPR or PAR, rather than being based on the peer researcher model. These studies made a contribution to the involvement of peer researchers in international mental health research by understanding cultural norms, thus tapping into expert knowledge and maximising available resources, and empowering participants [ 30 ]. Most studies involved adults with mental health or disabilities [e.g., 31 , 32 .

In relation to youth mental health, Afifi et al. [ 33 ] followed the CBPR approach in a mental health study in Beirut, the multi-cultural capital of Lebanon, and established that lack of understanding of gender roles or patriarchal structures by the researchers hindered young people from openly sharing their opinions. Stacciarini et al. [ 34 ] also used the CBPR approach to explore the conceptualisation of mental health by minority populations. Consistent with other studies, concepts varied in different parts of the world, from ‘wellness’ to ‘mental illness’. Consequently, the authors suggested that the design of both culturally appropriate mental health research and interventions should be informed by feedback from community members, whilst also keeping the cross-cultural comparability of studies in mind. As underserved populations in MWC were often involved as just the ‘objects’ of academic research, usually with little benefit to their communities, there might be additional barriers in recruiting and truly involving young people as peer researchers in the growing body of international youth mental health research [ 33 ].

In summary, even though participatory methods are increasingly used in mental health research, to our knowledge there are no studies reporting on the participation of young people as peer researchers in international mental health research involving multiple MWC. Understanding and addressing the specific requirements of planning, conducting, and disseminating research with peer researchers in MWC is important in establishing generalisable evidence, thus improving youth mental health in resource-constrained settings across the world. This research gap informed the rationale for this case study, in the context of an international youth mental health participatory project.

Aim of the case study

In this case study, we reflect on the experiences of young people who were involved as peer researchers in an international mental health project, and further discuss best practices of youth involvement in sensitive research. We particularly focus on barriers and enablers of implementing peer researcher roles within and across MWC contexts. The wider objective is to clarify, strengthen and mainstream the role of peer researchers. To this effect, lessons from this case study would be of interest to peer and career researchers, governance bodies, policy makers and funders across the research community, especially in an international context.

Research context of the case study

We summarise the context of the wider research in which peer researchers were involved, before describing the methodology and procedure of this case study. Its objective was to establish the lived experience of young people on the active ingredients (or mechanisms) of common mental health difficulties, depression and anxiety. Details on the project can be found in [ 35 ]. We selected MWC that were broadly representative of the socioeconomic spectrum [ 36 ]. These consisted of India, Pakistan, Turkey, Kenya, South Africa and Brazil. We also opted to include youth experiences and perspectives from two minority world countries, Portugal and the UK, in order to explore both commonalities and context-specific issues across different systems. Within each country, a non-governmental organisation (NGO—in six MWC) or academic institution (Portugal) or peer-led lived experience charity (UK) acted as local project lead. Each host agency, through their local networks, invited young people aged 14–24 years who had experienced depression and/or anxiety, to participate in focus groups.

Two youth focus groups were facilitated in each country, with an average 6–8 and total 121 local youth participants. Research ethics approval was obtained by the University of Leicester Psychology Research Ethics Committee in the UK. Youth aged 16–24 provided written informed consent. Parents or carers of younger participants aged 14–15 years gave written informed consent, following which young people provided verbal assent. Each focus group was facilitated by a senior member of the host agency, with co-facilitation by a peer researcher from the same organisation. A member of the central research team observed remotely the focus group discussions.

Role of peer researchers in the overall international research project

Throughout the project, peer researchers were actively involved, to ensure that the research activities and outputs were in line with young people’s understanding and feedback. One peer researcher from each country/site was involved, although their local and central contributions varied. Each local peer research group was co-ordinated by two lead peer and one career researcher (also see below). In particular, local peer researchers:

Engaged young people in each partner country and interpreted their feedback, as a result of their cultural expertise.

Ensured that communications and materials were tailored to young people and reflected country-specific considerations.

Avoided losing sight of the young person’s perspective when interpreting the data.

Engagement practices were informed by PPI guidelines [ 4 ]. These objectives were achieved through participation in country-specific research team meetings, co-facilitation of local focus groups, and attendance at three multi-country advisory youth groups. The two lead (central) peer researchers were involved in parts of the research proposal and design. The local (country-specific) peer researchers were involved on confirmation of grant approval, because of the tight schedule between grant application, approval, onset and completion. They had though opportunities to influence both the local and wider context of the study.

Methodology of the case study

Although we did not follow a research methodology on peer researchers’ roles in parallel to the main project, we adopted a systematic insight analysis process of capturing and integrating young peer researcher and co-ordinating career researcher perspectives in relation to the aim of this case study. Insight analysis is an adopted methodology where evidence is reviewed and interpreted, with inferences derived [ 37 ]. This process included: a group directed discussion between three peer researchers from Turkey, Pakistan and Brazil; a directed discussion between the two lead peer researchers; and inclusion of the perspective of the co-ordinating career researcher. All participants considered their understanding of their role, experiences in different aspects of the project, cultural and other contextual issues, links with the central research team, and recommendations for future research. For the purpose of this paper, we asked the researchers who were involved in these discussions to summarise them. Their perspectives and experiences are synthesised as narrative reflections in three respective sections below and are subsequently integrated in an overarching discussion (see Additional file 1 : Appendix 1 for topic guide). We followed established guidelines in reporting the involvement of young people with lived experiences (see Table 1 ) [ 38 ].

Reflections of local (country-specific) peer researchers

We experienced several benefits and challenges whilst participating in this project. Our roles varied and involved organising and co-facilitating focus groups, helping with transcripts, sending materials, feedback, and opinions to the central research team, and writing a blog. Most importantly, we enabled young participants to express their opinions freely. Working with peers across the world and sharing learning among different countries throughout the research, was a unique experience. Our impression was that young participants felt more comfortable in working with a peer, rather than a career researcher, because of the generation gap: “It is important to have somebody of your age or little older, because they can empathise with you and understand you more than somebody who is of an older age. If the old researcher has been polishing his skills or is using different techniques, then it’s fine”. As focus groups should be both formal and comfortable, co-facilitation between a peer and career researcher appeared to achieve this balance.

Other benefits included the acquisition of research skills such as learning how to listen actively and develop critical thinking, dealing with ethics issues, co-facilitating focus groups, interpreting data, and giving feedback. Having access to the central research team and regular discussion forums were helpful in understanding and adapting our role during different stages of the project. Both the structure of research meetings and the ongoing communication with all researchers were important in this.

Taking part in such complex research also brought challenges, particularly for those of us who had not had any previous research experience, not least as peer researchers. The terms ‘peer advisor’ and ‘peer researcher’ are not easy to understand and translate in national languages, so they should be avoided. The best alternative is ‘young leader’. Other terms considered in our discussion were: young advisor, young researcher, young research advisor, youth facilitator, and research organiser.

Despite our similar age, engaging other young people was not always easy, as there were sociocultural barriers, even within the same society. Choosing research topics that are meaningful to young people and communicating their relevance, would increase recruitment and retention. Language constraints in multi-country meetings could improve with the use of visual tools. The facilitation of focus groups was difficult at times, trying to keep young people engaged whilst encouraging them to open up on sensitive mental health experiences, handling different opinions, and moderating between vocal and quiet participants. As allocated time was insufficient, a larger number of focus groups would have allowed the involvement of more diverse young participants. These multiple tasks require training, supervision and ongoing support; for example, in organising demo sessions of facilitating focus groups. These should start at the planning stage, be built in the project, and allow for time and resources.

Peer researchers have an advantageous role in disseminating findings by using creative, therefore engaging, approaches. By sharing findings with professionals and institutions, they can help break previous barriers in communication. Platforms could include online meetings, posters, radio interviews, study circles or multipliers, and other art-based formats. Cross-cultural presentations are particularly important in learning from each other, as well as highlighting similarities. Crucially, peer researchers can lead and/or take active part in implementing findings through psychoeducation and self-help groups.

Reflections of lead (central) peer researchers

Overall, the involvement as lead peer researchers in this research project was a positive and enriching experience. From our perspective, we believe that youth involvement, does not only have a benefit for the research results (being more related to young people's views), but also benefits young people’s personal development, e.g. feeling empowered.

We did not experience that the sensitive mental health topic was a barrier in this research project, but we did see that the concepts of mental health and mental health diagnosis are understood differently in different countries. Therefore, we needed the help of the local peer and career researchers to find appropriate wording that is understood in the specific country. In general, language was a challenge at some parts of the project. For example, some local focus groups were conducted in the predominant national language, so we were not able to follow along what was talked about and be supportive.

When we joined the central research team, most of the planning work had to be completed quickly, because of the strict time schedule of the project. Even though we were able to be part of the planning process, more time would have been helpful for us. Therefore, in the beginning it was challenging for us to understand our role as lead peer researchers and the roles of everyone else involved: central researcher, central co-ordination researcher, local career researchers, and local peer researchers. While having regular meetings with the co-ordinating career researcher, sometimes it would have been more helpful to have meetings with a career researcher being involved in the actual tasks we were involved in, such as data collection. But over time and through regular meetings with the whole central research team, our tasks and responsibilities became clearer. We both already had some previous research experiences, which also helped us in understanding the structure of the project.

Therefore, we suggest that, if peer researchers have never been involved in research projects, they should first attend basic training in research skills. Additionally, by involving peer researchers in the phase of research preparation and planning, the problem of not understanding their role could be prevented or at least confusion could be reduced. In general, we think that, for fulfilling the role as a peer researcher, it is helpful to have a space to speak about difficulties that come up during the project, discuss the content but also the way the project is managed, and formulate proposals on how to improve future research. To involve more young people as peer researchers in mental health research, it is important to inform young people about research, how research can impact on practice but also on their everyday life, and what difference their involvement can make.

Reflections of co-ordinating career researcher

The biggest issue that stuck out for me was related to both the varied differences and similarities among our peer researchers. Cultural experiences and how they impacted on their own and their peers’ insights across the research were incredibly useful. Also, working alongside our lead peer researchers ensured an element of consistency and youth perspective throughout our research narrative.

As someone who has worked in the field of youth participation in mental health, there was a range of understanding to the terminology and concepts of participation in research and ‘peer researchers’ at the start, which needed to be discussed and agreed upon. In future projects like this, thorough and effective training is needed to ensure that peer researchers are working from the same page, and that they feel empowered and comfortable sharing their insights and opinions.

Youth participation in general still needs a lot of awareness-raising and training for researchers and stakeholders. I do believe that the future of research rests in peer researchers, and the direct participation of young people in research design and initiation. Those who live certain experience know the topics and areas that need further research, as well as the methods and means of data collection, using current and up-to-date tools and resources.

The aim of this case study was to reflect on the experiences of young people who were involved as peer researchers in an international mental health project, and to further consider best practices of youth involvement in mental health research. It contributes to the field by demonstrating, through triangulation of sources, how young people with lived experience can co-produce solutions with mental health professionals and researchers. These principles can be applied in any local context, as well as internationally, especially in resource-constrained MWC contexts with limited research experience. The reflections of these key actors highlighted that, overall, it is feasible to successfully ‘connect’ young people with lived experience in international mental health research, whilst also identifying certain ‘disconnections’ that need further attention by researchers around the world.

Role definition

Participants reported that the definition of the peer researcher role in the project was not clear at the beginning, hence it led to confusion. While there is acknowledgement in the participatory research literature that terms and concepts vary [ 1 ], these reflections reveal two major points that appeared to contribute to lack of consistency in our project. Local peer researchers pointed out that the term ‘peer researcher’ was difficult to translate into national languages. As concepts can be understood differently in different languages, a good translation does not only include literal meaning but also requires contextual interpretation [ 39 , 40 ]. Collins and colleagues [ 41 ] acknowledged this disconnection, which goes beyond semantics, in that research and thematic terminology may often prove disengaging for some young people. Even though local peer researchers are experts of their own culture, therefore have the contextual background to interpret terms correctly, they may be new to research. It could thus become even more difficult for them to translate research-related terms into their language. Therefore, it is important to develop consensus on the term and underpinning role among all senior and peer researchers from the outset.

Role components

Lead peer researchers reflected that the use of several titles of career and peer researchers by the central and local research teams made it more difficult to understand differences in responsibilities and tasks. This may have been compounded by the fact (or resulted in) that the actual tasks varied between peer researchers. For example, some peer researchers were predominantly involved in organising and leading focus groups, while others helped mainly with preparing materials or interpreting data. However, giving peer researchers a choice in how they want to be involved—which can then lead to varying roles—has been preferred over having pre-defined roles by some researchers [ 17 ].

Another aspect that makes it more challenging to define and understand the role is the dilemma of them being caught between being viewed as ‘insider’ by peers and at the same time as ‘outsider’ by career researchers. The international context of this study added a further insider–outsider challenge, as local peer researchers can be seen as insiders of their cultural context but have an outsider’s perspective in relation to peer researchers from other countries. Kanuha [ 42 ] reconciles this contradiction as, in studying one’s own identity group (in our case young people), peer researchers need to maintain connection to their identity group, while at the same time distance themselves. This can be a difficult experience, at personal and professional level. Kara [ 43 ] evaluated the value of mental health service user involvement, and argued that such conflicting roles may produce resistance, but can also enrich individual and collective experience.

Several lessons from this project appeared universal to the peer researcher role, rather than context- or culture-specific. The overarching objective of involving peer researchers is to make findings more responsive to the needs of young people, thus impact on societal attitudes, practice, service development and policy. This requires their active influence throughout the research process. The involvement of lead and local peer researchers ensured that the youth perspective was represented consistently at all stages of the project. Several benefits were highlighted in relation to the organisation and delivery of the research. A unique contribution was the mediation between young participants and researchers, as well as the ‘translation’ and reframing of their perspectives. Recruitment, engagement and retention of young participants was particularly facilitated and enhanced by peer researcher input. Local peer researchers described that they could improve the quality of collected data, as young participants felt more comfortable sharing their mental health experiences with someone of their age. Empathy between the two young groups appeared to relate both to their mental health experience and life stage. For similar reasons, peer researchers indicated their advantageous role in the dissemination of results through youth-friendly and creative approaches that communicate positive implications for young people’s mental health.

Role application in mental health research

Lead peer researchers reflected that there was a culturally dependent understanding of the concept of mental health across participating countries. While different concepts of mental health are also existing within one country, these differences become more prevalent in cross-country research [ 44 ]. Mental health concepts could originate from variable levels of mental health awareness, stigma, and access to services [ 45 ]. Because of stigma and limited availability of mental health services in some countries, only few young people receive a diagnosis and appropriate support. These issues can make it more difficult for peer researchers to recruit and engage participants with lived experience. For those reasons, we included participants with ‘self-identified’ experience of anxiety and/or depression. This may have reflected a range of mental health needs and experiences of services, especially in MWC.

Peer researchers had limited information on which to engage young participants, without delving into sensitive personal issues or creating unnecessary distress through different understanding of, e.g., the meaning, causes or implications of a condition such as depression. In anticipation, we took into consideration previous evidence that terms like ‘wellness’ or ‘mental health promotion’ are culturally more acceptable, can help open up conversations and reduce stigma in minority and non-western populations [ 34 ].

The sensitive concept of mental health did not appear to be a barrier in this study. One reason, as suggested by local peer researchers, could be that a topic needs to be relevant to young people’s lives to motivate them to participate. Our information letters, communication and focus groups guides were designed to explore everyday implications of mental health difficulties and required support. Demonstrating such relevance to young people, who did not necessarily have many opportunities to share their own experiences and suggestions, can enhance their willingness to contribute, in order to help others, through the dissemination of the findings.

Developing the peer researcher role in an international context

As lead peer researchers reflected, several strategies need to be put in place to enable local peer and career researchers to approach, reassure and meaningfully involve young people in sharing their unique expertise across different cultures. Offering peer researchers different levels of involvement can strengthen their feeling of being heard, therefore raise engagement. Methods should be flexible and adapted to young people’s needs and preferences [ 46 ]. Although career researchers should drive, plan and organise such involvement, Faithfull et al. [ 18 ] found that their confidence to engage young people depended on their understanding of youth participation. Consequently, awareness-raising and training for career researchers is essential in this process, with significant contribution from peer researchers. When these strategies are put in place, there is evidence of positive impact on both peer and career researchers’ personal development [ 47 ].

In future research, it would be helpful to involve local peer researchers at an earlier stage of the project. Peer researchers would then have more time to find into their roles, before starting the main tasks like data collection. This would also enable them to be part of the process of defining and agreeing shared language regarding research terminology. Clear and regular communication between all research actors, especially when multiple countries and/or sites are involved, is paramount in ensuring role coherence and comparable outputs [ 14 ]. Training and ongoing supervision of peer researchers, in conjunction with cross-site forums, can help ensure youth recruitment, compliance with ethics standards, and fidelity of collected data, whilst allowing for cross-cultural variation of mental health concepts and support systems.

Even though we were able to engage a total of 12 peer researchers, the reflections of lead peer researchers, local peer researchers and co-ordinating career researchers highlight the importance of a more systematic approach on how to recruit and engage young people in this role, especially in settings where this is less understood and established. Involving peer researchers with lived experience would not have been possible without the collaboration of two international networks. The central (lead) peer researchers and co-ordinating career researcher were leading members of the Euro Youth Mental Health Group network, which generates expertise on different aspects of advocacy, mentorship, education and research. The World Awareness for Children in Trauma network provides access to both peer researchers and young participants in MWC through partnerships with host NGOs and local researchers, who have been involved in youth mental health capacity-building and research [ 48 ].

Although hosting organisations and researchers were not initially familiar with the peer researcher role, these networks had already established a working relationship with the central research team, were open to innovation and, crucially, shared a youth-centric philosophy. International (indeed national or local) research networks should involve peer researchers, and constantly monitor their evolving role, training and support needs, and available funding. For the same reason, peer researchers should be central to funding bodies and panels, with meaningful rather than tokenistic input to decision-making. They should have opportunities to disseminate their research in their own right, rather than through career researchers.

Limitations

These considerations should be interpreted within certain constraints of this case study. Although peer researchers had a central role in the wider project, the evaluation of their role was not included in the design and data collection. This would have been an interesting parallel process. The small and heterogenous sample is not necessarily generalisable to other populations. Similarly, the reported reflections were only made post-hoc. It would be interesting for future research to capture peer researchers’ views and experiences throughout a project by collecting reflective diaries. We only included reflections of some local peer researchers, hence not all cultural perspectives were captured. A self-selection bias may have occurred, as those who participated in the post-hoc insight analysis may have had a more positive experience. Allowing for time and budget early in the research process would have enabled the local peer researchers to influence the research design. If peer researchers are not actively and meaningful involved throughout all stages of a research project, this can create a power imbalance that will negate their influence on the findings and implications of the youth-focused research. Nevertheless, the reported perspectives provided a valuable first insight into the experiences of peer researchers participating in an international project. The complex organisation and completion of this study by involving peer researchers from eight countries highlighted a number of enabling and challenging factors, especially in majority world countries contexts, which can inform the further development of the role.

Conclusions

To our knowledge, this is the first paper reporting on the experiences of peer researchers in an international youth mental health study. Reflections present an overall promising picture and indicate that it is feasible to successfully involve young people with lived experience in cross-cultural or cross-country research, particularly if connections through networks and partnerships are already in place. Lessons from this project also highlight existing or potential disconnections, and how these can be anticipated and addressed. Strategies could involve a clear structure and orientation, while remaining flexible in enabling young people to influence the peer researcher role. International studies could use standardised concepts of mental health, but also remain aware and sensitively reconcile cultural differences. This is especially important if peer researchers and young participants have lived experience. Peer researchers’ motivation could be enhanced and sustained through a systematic approach to the research, training, supervision and financial support. Allowing for time at the planning stage could help delineate different aspects of the role such as local recruitment of young participants and data collection, as well as co-ordination across countries and sites. Peer researcher input would be more meaningful through co-production with other research stakeholders. While high quality research should strive for methodological fidelity, the involvement of peer researchers from minority and majority world countries with variable research systems and youth participation, requires flexibility and adjustment to cultural, systemic and professional contexts. The parallel development of international young peer researcher networks, ongoing training and infrastructure can contribute to high quality outputs with, crucially, lasting impact for young people in need.

Availability of data and materials

Not applicable.

In this paper we are using the term ‘peer researcher’, as this closely reflects the focus of the role addressed in the paper, whilst acknowledging the variation of terms used in the literature; and the term ‘career researcher’ to refer to researchers across career stages, who are employed by an academic or other research institution.

Abbreviations

• Majority world countries

Patient and public involvement

Community based participatory research

Participatory action research

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Acknowledgements

We are grateful to all participants and peer researchers for their involvement in this project. We thank our partners in the eight participating countries for their contribution.

This research was supported by a Wellcome Trust Grant.

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Contributions

IS: Led writing up, and literature review, lived experience. MS: Insight analysis, lived experience. SZF, EY: Writing up input on peer searcher role in MWC context, lived experience. NM: Conceptualisation of paper, writing up. JJ, JEC: Conceptualisation, writing up. PV: Conceptualisation, insight analysis, writing up. All authors read and approved the final manuscript.

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Correspondence to Panos Vostanis .

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Research ethics approval was obtained by the University of Leicester Psychology Research Ethics Committee in the UK. Youth aged 16–24 provided written informed consent. Parents or carers of younger participants aged 14–15 years gave written informed consent, following which young people provided verbal assent.

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Additional file 1.

. Topic guide of issues explored with peer researchers.

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Spuerck, I., Stankovic, M., Fatima, S.Z. et al. International youth mental health case study of peer researchers’ experiences. Res Involv Engagem 9 , 33 (2023). https://doi.org/10.1186/s40900-023-00443-4

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America is in the midst of a Youth Mental Health Crisis, but Black youth have been in crisis for over 20 years. Black youth suicide rates are rising faster than any other racial/ethnic group, Black children are the most likely to be physically restrained in emergency departments, and Black youth are more likely to be diagnosed with disruptive mood disorders than white children with comparable symptomatology. A mounting number of studies document the adverse mental health effects of anti-Black racism on Black children, even before birth. The stress of anti-Black racism experienced by Black mothers, including experiencing inferior care by healthcare providers, has been linked to low birthweight babies, putting Black infants at greater risk for developing depression and other mental health disorders. There is a clear lack of awareness, education, and accountability for the devastating lapses in care that Black children and families can receive in the healthcare system, which undoubtedly affect their mental and physical wellbeing. There is an urgent need for dynamic, expert-led conversations to generate ideas and transform mental healthcare for Black youth and families.

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Are School-going Adolescents Mentally Healthy? Case Study from Sabarkantha, Gujarat, India

Tapasvi puwar.

Department of Epidemiology, Indian Institute of Public Health, Gandhinagar, Gujarat, India

Sandul Yasobant

1 Center For Development Research (ZEF), University of Bonn, NRW, Germany

Deepak Saxena

Background:.

Mental health issues becoming the global public health challenge, especially among the youth (12–24 years of age), although they are often detected later in life. In India, the adolescent population constitutes a quarter of the country's population and burden of disease varies from 9.5 to 102/1000 population. Most of the mental health disorders remain unidentified due to negligence and ignorance of multiple factors. Keeping this in mind and lack of population-based studies with good quality for guiding the mental health policies, this study aims to document the prevalence of emotional and behavioral difficulties among adolescents in Sabarkantha district of Gujarat, India.

This is a school-based cross-sectional study conducted among 11–19 years of school-going adolescents during August–September 2016. About 477 adolescents who gave consent to participate were selected from 20 randomly primary and secondary schools. A prevalidated questionnaire for sociodemographic information including global validated standard questionnaire for mental health scoring known as Strengths and Difficulties Questionnaire (SDQ) were administered and self-reported responses were documented. Statistical analysis was conducted through SPSS version 20.

Mean age of the study population was 14.2 ± 1.4 years. About 14.6% boys and 12.6% of girls had abnormal total SDQ score, while 15.3% boys and 21.9% of girls had borderline SDQ score. Thus, 70.1% of boys compared to 65.6% girls had normal SDQ score. The difference between mean (higher mean score among girls) of total SDQ score of boys and girls was statically significant at the level of P < 0.05. Major risk factors for self-reported mental health issues were illiterate mother, occupation of parents, which make them away from family during daytime, nuclear family, severe addiction to alcohol in the family, financial problem in the family, and adolescent getting daily physical punishment. One-seventh adolescents are vulnerable for mental health problems found in this study. About one-fifth adolescents have internalizing (emotional) and about one-sixth have externalizing (conduct) manifestations.

Conclusion:

There is an urgent need to address the emotional and conduct manifestation among school-going adolescents. Rashtriya Kishor Swasthya Karyakram framework needs to address these issues on priority.

I NTRODUCTION

About 14% of global burden of diseases is attributed for mental health problems in all age groups.[ 1 ] Mental health is complex and is much more than simply the absence of illness. It describes the capacity of individuals to interact with each other and their environment in a way that promotes optimal development and the use of cognitive, affective, and relational abilities, as well as overall well-being.[ 2 ] Rates of mental disorders among young people (12–24 years), ranged from 8% (in the Netherlands) to 57% (for young people receiving services in five sectors of care in San Diego, California, USA).[ 3 ] The Australian National Survey of Mental Health and Well-Being reported that at least 14% of adolescents younger than 18 years were diagnosable with a mental or substance use disorder in 12 months. The National Mental Health Survey of India 2015–2016 shows 7.3% prevalence of all psychiatric morbidity among 13–17 years age group.[ 4 ] The suffering, functional impairment, exposure to stigma and discrimination, and enhanced risk of premature death that is associated with mental disorders in adolescents has obvious public health, social, and economic significance for any society.[ 5 ]

Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Hence, mentally healthy adolescence are needed for our feature nation as well as for their own needful family life.[ 6 ] The poor mental health is strongly related to other health and development concern in adolescence people, for example, low self-confident, less socially responsible activities, committing illegal activities, and so on.[ 6 ] It is estimated that around 20% of the world's adolescents have mental health or behavioral problem.[ 7 ] About half of lifetime mental disorders begin before age 14, the prevalence of mental disorders among adolescents has increased in the past 20–30 years; the increase is attributed to disrupted family structures, growing youth unemployment, and families' unrealistic educational and vocational aspirations for their children.

In India, the adolescent population constitutes a quarter of the country's population, which is approximately 243 million, which in turn constituted 20% of the world's 1.2 billion adolescents. As per the National Mental Health Survey 2015–2016 of India, the prevalence of overall psychiatry disorder among 13–17 years age group was 7.3%, however, a systematic review indicates that prevalence of psychiatric disorders among adolescents ranged from 0.48% to 29.40%.[ 8 ] Not much importance is given in India to this branch of medical science; due to multiple factors very starting from medical cause to social causes, resulting into lack of statistical measures of prevalence and details of treatment. Most of the mental health disorders remain unidentified due to negligence and ignorance on the part of parents.[ 9 ] Proper counseling and guidance by parents play an important role in child's life. One more aspect to explore is mental status of caretaker or parents, which play an important role in their overall development.[ 10 ] Keeping this in mind, and lack of population-based studies with good quality for guiding the mental health policies, this study aims to document the prevalence of emotional and behavioral difficulties among adolescents in Sabarkantha district of Gujarat, India.

This is a cross-sectional, school-based study conducted during August–September 2016.

Study setting

The present study was conducted Sabarkantha in one of the 33 districts of Gujarat selected purposefully because of administrative feasibility. It is a diverse district in terms of composition of population with an aggregate population comprising of both tribal and nontribal population, the population of the district is 2,428,589.[ 11 ] This study has been conducted during August–September 2016.

Study sample and sampling

This study was conducted among government schools of Sabarkantha district, Gujarat. Considering the dropout rate of 20%–30%, it was also important to cover out of school adolescents. As this study used a self reported tool, most of out-of-school adolescents were unable to report the same; therefore excluded from the sample.

A representative samples of adolescents were sampled based on facts such as the reported prevalence of mental health problems among adolescents in India is 15%–20%,[ 12 ] with response rate of 80%.

The sample size for this study was calculated as 470 at 95% confidence interval level, the expected prevalence of 15%, design effect of 2 and non-response rate of 20%. Further as per, Rashtriya Kishor Swasthya Karyakram (RKSK) framework age categorization, this study recruited 235 adolescents in 11-14 years of age and another 235 adolescents in 15-19 years of age group. Considering an average class size of 30, ten schools each from primary section and secondary/higher secondary section were randomly selected from the list of schools obtained from the district education office. All the primary schools were selected from rural area as secondary/higher secondary schools were situated in the urban area. The selected class were administered with the Strengths and Difficulties Questionnaire (SDQ) for assessment of mental health.[ 12 ]

Study instrument

The self-assessment format of SDQ[ 13 ] was used to assess the mental health of the adolescents. The SDQ is a user-friendly screening questionnaire, which can be used to assess behavioral problems and mental health disorders. Goodman, Ford, Simmons, Gatward, and Meltzer reported the scale's internal reliability to be acceptable, with a Cronbach alpha coefficient of 0.73.[ 6 , 13 ] The questionnaire consists of 25 questions subdivided into five categories: Conduct; hyperactivity; peer problems; emotional; and prosocial, with five questions in each scale. Each of the categories is given a score and then summed to get a total difficulties score, except the prosocial score, which is assigned a separate score. The scores can then be used to make separate predictions for conduct–oppositional disorders, hyperactivity–inattention disorders, and anxiety–depressive disorders. The prevalidated SDQ questionnaire available in Gujarati language was used in the present study.[ 14 ] As per the suggested guidelines for SDQ, cutoff points were derived by classifying approximately 10% of the normative sample with the most extreme scores in the “abnormal” banding, the next 10% in the “borderline” banding, and the remaining 80% in the “normal” banding categories.[ 13 ]

In addition to the SDQ, relevant sociodemographic details were recorded. Perceptions of difficulties in the family domain; for example, physical punishment, parental marital discord, death of a parent, excessive alcohol/drug use by a family member, and financial difficulties in the family were documented through a prevalidated questionnaire in vernacular language.

Study analysis

Descriptive statistics analysis was carried out using SPSS version 20 (Armonk, NY, IBM Corp). For categorical variables, proportion was used to describe, whereas for continuous variables were described as mean ± standard deviation was used. Further, one sample t -test and Chi-square test were used to understand the statistical difference among the groups at level of P < 0.05.

Study ethics

Permission to conduct the study was obtained from the Institutional Ethical Committee of Indian Institute of Public Health, Gandhinagar. Verbal consent was obtained from each adolescent before administration of the study questionnaire. List of adolescents with abnormal SDQ scores will be submitted to the school management for further referral.

About 60% of adolescents were in the age group of 11–14 years and 62% of participants were boys. Mean age of the study population was 14.2 ± 1.4 years. Mean age of boys was 14.3 years while that of girls was 14.1 years. The details descriptive are shown in Table 1 .

Sociodemographic characteristics of adolescents a in Sabarkantha, Gujarat

About 9% of fathers of the study participants were unemployed, while majority of them work as labor. Over 40% of mothers of participants were homemakers. Out of the total samples included in the present study, three participants also reported about demise of their parent, six reported demise of mother while, and 16 reported loss of father. Eleven (2.3%) participants reported that their parents were not staying together (separated and divorced). Around than 7% boys and 8.2% girls reported a history of excessive alcohol consumption by father or grandfather. On inquiring about the issues pertaining to finance, around 11% boys and 13% girls reported financial problems; faced by respective families. Out of all 72% of participants believed that physical punishment is necessary if children are not studying properly on the contrary, only 5.6% participants reported receipt of physical punishment daily.

The present study utilized SDQ, to assess various aspects of mental health of adolescents. About 14.6% of boys and 12.6% of girls had an abnormal total SDQ score and 15.3% of boys and 21.9% of girls had borderline SDQ score. Overall 70.1% of boys and 65.6% of girls had normal SDQ score. The difference between mean (higher mean score among girls) of total SDQ score of boys and girls was statically significant at the level of P < 0.05.

In general, SDQ is divided into five subcategories as shown in Table 2 . According to that, almost 40% girls had abnormal or borderline Emotional Problem Score (EPS), compared to <30% of boys. The difference in mean EPS among boys and girls is statistically significant. Almost 38% of boys and 33% of girls had abnormal or borderline Peer Problem Score (PPS). However, this observed difference is not statistically significant. Most importantly, girls have higher mean SDQ score compared to boys in EPS, Hypersensitivity Score (HS), Total SDQ score, and Prosocial Score and all these differences are statistically significant. Boys had higher mean score in conduct problem score and PPS; however, these differences were not statistically significant. On application of hierarchical regression model, a statistically significant difference in mean total SDQ score was observed for gender, mother's education, occupation of mother, occupation of father, type of family, living in the hostel (away from family), severe addiction to alcohol in the family, receiving physical punishment daily, and having some financial problem in the family.

Strengths and Difficulties Questionnaire score and its differential components in relation to gender of adolescents of Sabarkantha, Gujarat

D ISCUSSION

The World Health Organization defines mental health as a “state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities.” Applying such adult-based definitions to adolescents and identifying mental health problems in young people can be difficult, given the substantial changes in behavior, thinking capacities, and identity that occurs during the teenage years. The impact of changing youth subcultures on behavior and priorities can also make it difficult to define mental health and mental health problems in adolescents. Although mental disorders reflect psychiatric disturbance, adolescents may be affected more broadly by mental health problems. These include various difficulties and burdens that interfere with adolescent development and adversely affect the quality of life emotionally, socially, and vocationally. There are limitations of available community-based status of mental health among adolescent, published studies largely focus on measures of individual disorder and dysfunction, without consideration of contextual factors that shape mental health and well-being. There are available evidence that have identified contextual factors that place adolescents at greater risk of mental health problems.[ 15 ] The present case study was undertaken to document mental health vulnerability of school-going adolescent in rural Gujarat. The study reveals that 14% of the study population is vulnerable for mental health problems. More than 18% of adolescents have internalizing (emotional) and more than 16% have externalizing (conduct) manifestations. However, only 3% had hyperactivity manifestations as per the study. Bhola et al . reported in a study using SDQ tool among preuniversity college students at Bengaluru, reported 10.1% of adolescents had total difficulty levels in the abnormal range, with 9% at risk for emotional symptoms, 13% for conduct problems, 12.6% for hyperactivity/inattention, and 9.4% for peer problems.[ 16 ] The observed difference between two studies may be due to difference in the age of the study participants where the mean age of study population was 16.4 years compared to 14.2 years in the present study. The same study identified gender differences in patterns of psychopathology among adolescents. Along with other studies using the SDQ,[ 17 , 18 , 19 , 20 ] emotional symptoms were predominant among girls and peer problems among boys. This study found out same, but the observed difference for emotional symptoms was statistically significant while observed difference in peer problems was not statistically significant. We also observed that girls were more social compared to boys. Kharod et al . reported in a study in rural Gujarat, 33% adolescents with abnormal SDQ scores.[ 21 ] The highest abnormal score was reported for peer problem scores in the study and lowest among the Prosocial Score category.

Interestingly, in contrast to other research, the findings from Bhola et al . study and the present study showed that there was no gender difference for conduct problems and hyperactivity problems. This may be due to narrowing gender gap for these problems. This suggests gender-sensitive modification should be made in school- or college-level adolescent mental health programs. The present study also showed a significant higher total difficulty scores where mother is illiterate, occupation of parents which make them away from family during daytime, nuclear family, severe addiction to alcohol in the family, financial problem in the family, and adolescent getting daily physical punishment. However, they were not the predictor of low SDQ score as suggested by very low R 2 value of regression models tried in the study which indicates the need of larger scale study to predict such vulnerabilities. Although these factors suggest vulnerability for mental health problems in adolescents, this is worth to explore with further research studies to prevent the risks in this age group. The existing guidelines of RKSK do talk about the mental issues; however, it does not suggest methods on how to assess the status of mental health among the adolescent. Limitation of the present study is that it has used self-reported SDQ screening and not matched it with parents or teacher version as suggested by studies using SDQ beyond Europe.[ 22 ] Furthermore, the study could not examine adolescents with abnormal scores with other diagnostic tools used in psychiatry.

C ONCLUSION

The present study documents about one-seventh of the adolescents were vulnerable for mental health issues. About one-fifth adolescents have internalizing (emotional) and about one-sixth have externalizing (conduct) manifestations; however, very few (3%) had hyperactivity manifestations. Most common risk factors for self-reported mental health issues were illiterate mother, occupation of parents, away from family during daytime, nuclear family, severe addiction to alcohol in the family, financial problem in the family, and adolescent getting daily physical punishment. It is recommended based on the study to use the SDQ screening tool in Gujarati for screening adolescents in Gujarat and adolescents with abnormal scores should be referred to psychiatrist and counselors at Adolescent Friendly Health Clinics for further diagnosis and treatment if required. SDQ tool can be used in screening for adolescents under Rashtriya Bal Swasthya Karyakram to strengthen the focus on the mental health aspect of the program and linking referral of adolescents with low SDQ scores to adolescent-friendly health clinics for further steps.

Financial support and sponsorship

This study was funded by John D. and Catherine T. MacArthur Foundation. Funders have no role in study designing and findings from this research.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The authors are thankful to the Government of Gujarat, Department of Health and Family Welfare and also to the school staff for providing constant support for this study and to students for participating in this valuable research.

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Many blame social media for poor mental health among teenagers, but the science is murky

If Jordy had a switch to instantly shut down social media, she would flip it.

"I'd switch it off, 100 per cent, even if it was for a week, just so people could have that taste of what it would be like," she said.

Now in her first year out of school, the 18-year-old studies nursing at university and works at a local cafe in Charleville, a small town 745 kilometres west of Brisbane, where she has lived most of her life.

Like Australian teenagers everywhere, she has another life online.

"It's like a second world, really," she said.

"You have reality and then you have social media — two extremely different things."

At the moment, she spends an average of five-and-a-half hours a day on her phone, but it's lower than her peak during high school.

"When I first got a phone I was on it constantly, probably like seven hours, eight hours a day," she said.

She has cut back since then because that second world was not always kind, especially when it came to body image — and despite the fact her parents were always strict about phone usage.

"Growing up, I've always been a big girl … and a sporty person — I'm pretty healthy," she said.

"But when we see images, it tends to be just very thin, skinny people.

"It can just take you down, with the click of your fingers."

Jordy was also being bullied at school, but social media meant it could happen around the clock, no matter where she was.

"A group of boys at my school had tagged me on TikTok telling me to go kill myself," she said.

"It was just so heartbreaking. I was just like, 'I go to school with you every day, we've never had an issue in the past.' That's probably the worst thing that's happened."

Jordy's mental health was tanking, and she began to withdraw from activities she used to love, like footy training or seeing friends.

"I just felt so scared to talk to my mum … I was just like, 'I don't want my mum to think I'm using social media the wrong way'," she said.

No matter how bad things got, logging off still felt impossible.

"It was like that fear of missing out, I guess. I think that's the addiction thing, right?" she said.

"You sort of just have to be on your phone to socialise."

Does more screen time cause worse mental health in teenagers?

Teen mental health has deteriorated at an accelerating rate in the last two decades — more or less exactly since social media and smartphones started to become widespread in 2007.

For obvious reasons, many people, especially concerned parents, have leapt to the conclusion that tech is the culprit.

But the science is surprisingly murky, even though there is a link — research shows more screen time is associated with higher rates of depression in adolescents.

"What we know about the link is there's a link, and that's pretty much what we know," said Aliza Werner-Seidler, a senior researcher at the Black Dog Institute.

"We have really good correlational data, there is a strong linear relationship, particularly in young girls.

"What we don't know is about causation — so is young people's mental health leading them to spend more time on social media and screens, or is it actually the other way around?

"We don't know the direction of the effect."

Dr Werner-Seidler is one of thousands of researchers around the world trying to solve that mystery.

Even if many people are convinced they already know the answer because of their own experience online.

"Personally I would say that it's both," Jordy said.

After a session doomscrolling perfect bodies on TikTok, she "would feel horrible" about herself.

"But then I'd continue to use it and then it made me feel even worse."

After 17 years, why don't we have the answers yet?

Despite 17 years of widespread smartphones and social media, researchers still don't have enough data to definitively say whether they're to blame for deteriorating teen mental health.

Getting those long-term studies done is particularly difficult because trends, algorithms and habits change so quickly.

"When I started this work, TikTok wasn't even a thing … Snapchat, really has only taken off in the last decade or so," Dr Werner-Seidler said.

"It's a very fast-moving field. And so it's very, very difficult to get a handle on it before the next thing comes out."

Part of the problem is that studies have focused on overall screen time, instead of looking at what people were doing online.

"Are they FaceTiming with Grandma? Are they viewing distressing content? Are they being groomed online?" Dr Werner-Seidler said.

"This idea of nuance and it matters what people do and how they do it and how long for and with whom.

"We can't tell any of this information just by looking at how long young people spend on screens."

What social media companies know but don't say

The National Mental Health Commission has been investigating the relationship between digital tech and teen mental health.

On Friday it released its findings after months of consultation, noting the lack of longitudinal evidence and calling for further research to be made a "top priority".

Frustratingly for Dr Werner-Seidler, and other researchers in this area, the data that might solve the mystery does exist — but they can't access it.

"Big tech companies have all of this information," she said.

"If they were to share it with academics and scientists, we would be able to learn so much more, so much more quickly."

The data that has so far emerged in other ways, courtesy of lawsuits and whistleblowers such as Frances Haugen in 2021, has been disturbing.

Ms Haugen, a former Facebook employee, revealed detailed internal research showing Instagram was harmful for teenage girls.

One slide from an in-house presentation reportedly said: "We make body image issues worse for one in three teen girls."

The peak body for Australia's technology industry — whose members include social media companies Meta, Snapchat and TikTok — has defended the sector's contribution to public research.

"DIGI's relevant members have long-standing research and community partnerships in mental health and online safety, and specific policies … informed by that work," a spokesperson said.

Depending on the platform, those policies might include parental controls, avenues to report inappropriate content and seek help, customisable settings, and age limits.

Adherence to those age limits has been mostly voluntary, and the federal government is spending $6.5 million on an age verification trial in the hopes of introducing a higher standard of proof.

Some social media companies are trying to get ahead of any future legislation.

Facebook's parent company Meta announced this week it would no longer allow Facebook users to edit their birthdate to say they're over 18 without verification — a feature that's been in place on Instagram in Australia since last year.

A window for change

The public and political mood when it comes to big tech has rarely been darker.

"I've never seen the appetite [for change] as strong as it is right now," said Alice Dawkins, executive director of Reset Tech Australia.

She says there's a window for change with the federal government currently reviewing its key legislation, the Online Safety Act.

"Our online safety laws are geared at protecting people from [one] another online … [but] there's virtually nothing that can be done about protecting people from the tech itself."

As it stands, companies are rarely obliged to share information on how their products, and not just the people using them, may cause harm.

"It's highly exceptional — think about other sectors, like food, like medicine, like toys — it's incredibly routine in those sectors to have risk assessment and risk mitigation of products," Ms Dawkins said.

"There's compounding public awareness of the problem … it's never been a more appropriate time for the government to legislate."

Dr Werner-Seidler said that for now, internal data was being used by big tech to keep users scrolling for as long as possible.

"These are commercial big companies [and] they use a whole bunch of engagement strategies to keep people coming back, and that is their goal," she said.

The conversation you need to have with your kids

Jordy eventually found the courage to tell her mum what was happening to her online.

"When it got really bad I was just like, 'Mum, I need to show you … this is what's happening.'"

After that, her parents insisted she cut back her screen time but, despite everything that had already happened, she still fought it.

"I was so mean to her … I would get so angry, I'd be like, 'Mum, it's not your life,'" she said.

But that was before Jordy noticed a big improvement in her mood and her grades.

"I'm thankful every day that my mum did what she did.

"You can't ever change the fact that your kids are going to use social media," said Jordy, although boundaries were useful in her case.

"Saying to your kids, 'What are you using social media for? Why do you have to be on social media?'

"For parents out there that are struggling, I think it's that conversation you need to have with your kids.

"As a kid, you're going to get frustrated, but it's really just parents trying to protect their kids from what's out there."

Mental health disorders among young people have soared by nearly 50 per cent in 15 years. The ABC is talking to youth, parents, and researchers about what's driving this pattern, and what can be done to turn things around.

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• Federal Government
• Mental Health
• Mental Wellbeing
• Social Media

New Study Deepens Scientific Evidence of Social Media Addiction’s Impact on Teens

Posted: June 7, 2024

The science keeps rolling in. More and more, it becomes impossible to ignore the negative impact that addictive social media platforms have on our youth.

Studies released in May and June of 2024 underscore the significant impact of internet and social media addiction on the mental health and cognitive development of adolescents, highlighting the necessity of proactive strategies to address this growing concern.

June 2024 Study Reveals Harm to Teens’ Brains

A study published on June 4, 2024, in the journal PLOS Mental Health highlights the detrimental effects of excessive social media use on teenagers, shedding light on how it hampers their ability to focus on essential tasks like homework and quality time with loved ones.

This investigation offers objective insights into these claims, revealing that teens diagnosed with internet addiction exhibit significant disruptions in brain signaling, particularly in regions crucial for controlling attention and working memory.

The study reviews neuroimaging data from 12 studies conducted between 2013 and 2022, involving a few hundred adolescents aged 10 to 19. “The behavioral addiction brought on by excessive internet use has become a rising source of concern since the last decade,” the authors note.

Trumps Relationships

The clinical diagnosis criteria for internet addiction in the study included persistent preoccupation with the internet, experiencing withdrawal symptoms when offline, and prioritizing internet use over relationships for at least 12 months. Max Chang, the study’s first author and outreach case manager at Peninsula Family Service in San Francisco, explained to CNN that this behavior pattern leads to significant impairment or distress in the individual’s life.

Disrupts Executive Function Network

Given the dynamic nature of adolescent brain development, the researchers emphasized the importance of understanding how internet addiction affects teenage brains. Their findings revealed that teens with internet addiction showed considerable disruptions in the brain’s executive function network, which governs attention, planning, decision-making, and impulse control.

These disruptions suggest that such behaviors become more challenging to perform, potentially impacting the teens’ development and overall well-being.

2023 Gallup Study Underscores Effects on Mental Health

Social media poses a particularly strong concern. A Gallup poll of 1,567 U.S. adolescents revealed some of the effects of social media on teens—as reported by teens and their parents.

May 2024 Study Reveals Anxiety From Smartphone/Social Media Use

In another related study, researchers Silja Kosola, Sara Mörö, and Elina Holopainen conducted a population-based study to explore the impact of smartphone and social media use on the well-being of adolescent girls . Published in May 2024 in Archives of Disease in Childhood , this study aimed to objectively measure smartphone and social media usage and evaluate its association with mental health and well-being indicators.

The cohort consisted of 1164 first-year female students from 21 socioeconomically diverse high schools, with an average age of 16.3 years. Participants completed an online survey using validated questionnaires based on the Bergen Social Media Addiction Scale (BSMAS), Generalised Anxiety Disorder-7, and Body Appreciation Scale 2. They also provided screenshots of their smartphone usage.

Addiction and Anxiety

The results revealed that 16% of the participants had possible social media addiction, while 37% exceeded the threshold for possible anxiety disorders. Higher BSMAS scores correlated with increased anxiety, poorer body image, lower overall health and mood, greater tiredness, and increased loneliness. Notably, participants who provided smartphone usage screenshots averaged 5.8 hours of daily smartphone use, with 3.9 hours dedicated to social media.

Need to Mitigate Adverse Outcomes

The findings of this study align with previous research, indicating that social media addiction is prevalent among adolescent girls and is associated with poorer mental health and well-being. These results underscore the necessity of implementing measures to mitigate the potential harmful effects of social media use on young people.

 Social Media Addiction Lawsuits

Amid growing concerns over the impact of social media on adolescents, social media addiction lawsuits have been initiated against major social media companies. The Multidistrict Litigation (MDL), In re: Social Media Adolescent Addiction/Personal Injury Products Liability Litigation (MDL No. 3047) , involves defendants such as Meta Platforms, Inc., Instagram LLC, Snap, Inc., TikTok, Inc., ByteDance, Inc., YouTube LLC, Google LLC, and Alphabet Inc.

Social Media Companies Design to Addict

Plaintiffs in this MDL allege that the defendants’ social media platforms are designed to maximize screen time, encouraging addictive behavior in adolescents. They argue that these platforms are defective and their design leads to various emotional and physical harms, including severe cases that result in death.

A Call for Regulation, Safety Measures, and Accountability

This litigation highlights the potential accountability of social media companies in contributing to the addiction crisis among teens, emphasizing the urgent need for regulatory measures and safer platform designs to protect young users.

“As these and other studies show, social media companies have created a youth mental health crisis the effects of which will reverberate for throughout society,” said Emmie Paulos, an attorney with Levin Papantonio Rafferty. Paulos has been appointed as a member of the Plaintiffs Steering Committee for the Social Media Addiction MDL.

“Companies like Meta, Instagram, Snap, and TikTok create their products specifically to be addictive to children. These companies must pay for the damage they’ve done and continue doing, and they must stop targeting our youth in the name of profit,” Paulos added.

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• Open access
• Published: 03 April 2018

Adolescent mental health education InSciEd Out: a case study of an alternative middle school population

• Joanna Yang 1 ,
• Roberto Lopez Cervera 2 ,
• Susannah J. Tye 3 ,
• Stephen C. Ekker 1 , 4 &
• Chris Pierret   ORCID: orcid.org/0000-0003-0000-4813 1 , 4  

Journal of Translational Medicine volume  16 , Article number:  84 ( 2018 ) Cite this article

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Mental illness contributes substantially to global disease burden, particularly when illness onset occurs during youth and help-seeking is delayed and/or limited. Yet, few mental health promotion interventions target youth, particularly those with or at high risk of developing mental illness (“at-risk” youth). Community-based translational research has the capacity to identify and intervene upon barriers to positive health outcomes. This is especially important for integrated care in at-risk youth populations.

Here the Integrated Science Education Outreach (InSciEd Out) program delivered a novel school-based anti-stigma intervention in mental health to a cohort of seventh and eighth grade at-risk students. These students were assessed for changes in mental health knowledge, stigmatization, and help-seeking intentions via a classroom activity, surveys, and teacher interviews. Descriptive statistics and Cohen’s d effect sizes were employed to assess pre–post changes. Inferential statistical analyses were also conducted on pilot results to provide a benchmark to inform future studies.

Elimination of mental health misconceptions (substance weakness p = 0.00; recovery p = 0.05; prevention p = 0.05; violent p = 0.05) was accompanied by slight gains in mental health literacy (d = 0.18) and small to medium improvements in help-seeking intentions (anxiety d = 0.24; depression d = 0.48; substance d = 0.43; psychosis d = 0.53). Within this particular cohort of students, stigma was exceptionally low at baseline and remained largely unchanged. Teacher narratives revealed positive teacher views of programming, increased student openness to talk about mental illness, and higher peer and self-acceptance of mental health diagnoses and help-seeking.

Conclusions

Curricular-based efforts focused on mental illness in an alternative school setting are feasible and integrated well into general curricula under the InSciEd Out framework. Preliminary data suggest the existence of unique help-seeking barriers in at-risk youth. Increased focus upon community-based programming has potential to bridge gaps in translation, bringing this critical population to clinical care in pursuit of improved mental health for all.

Trial registration ClinicalTrials.gov, ID:NCT02680899. Registered 12 February 2016, https://clinicaltrials.gov/ct2/show/NCT02680899

The priority of mental health

Prevention and treatment of mental illness remain significantly underserved health needs, despite poor mental health being of worldwide concern [ 1 ]. Youth are uniquely vulnerable, as most mental illnesses have early onset [ 2 ]. Effective help-seeking remains low, and attitudinal barriers—particularly stigma and inadequate mental health literacy—are commonplace [ 3 ]. Regardless of established need, few stigma-reduction programs target adolescents [ 4 ], and broader promotion–prevention interventions are lacking [ 2 ]. Youth-centric programming is therefore a critical need given the formative and persistent role of adolescence in development.

Theoretical frameworks to break down the barriers

While structural barriers to mental healthcare exist for broader policy intervention, knowledge and attitudes are readily addressable at the individual level. Improvements have been made in recent years to both study and bolster the public’s mental health literacy, but dissemination of accurate information remains a necessary focus for betterment of mental health [ 5 , 6 ]. This is particularly true for youth, where mental health literacy efforts have traditionally been flagging [ 7 ]. One theoretical framework often applied to health interventions is the knowledge–attitude–behavior (KAB) model. In this model, increased knowledge can change attitudes and result in behavioral modification [ 8 , 9 ]. The knowledge–attitude–behavior continuum plays a key role in modern definitions of mental health literacy with evidence to suggest that improved knowledge and reduced stigma can result in increased help-seeking and improved outcomes in mental health [ 10 ]. Meta-analysis additionally shows that educational programming can alter stigma toward mental illness, particularly for youth audiences [ 11 ].

Traditional health education at the bedside only works, however, if patients enter healthcare systems in the first place. Underserved populations who tend to not seek care may therefore be better reached though community-based methods [ 12 , 13 ]. For youth, K-12 classrooms represent a unique community platform in health intervention due to the significant amount of time youth spend in school [ 14 ]. Yet, there is insufficient evidence for efficacy of school-based anti-stigma programming pertaining to mental illness [ 15 ]. Interventions targeting youth with mental illness or at high risk for developing mental illness are rare and comparatively unstudied. Lack of research evidence in this space is a priority, as it contributes to care fragmentation. Translational research is necessary to bridge the gap from bedside to curbside for the most vulnerable children and adolescents [ 16 ]. The study herein presents preliminary results from a school-based anti-stigma intervention in mental health piloted by one such translational program called Integrated Science Education Outreach (InSciEd Out).

The InSciEd Out framework

InSciEd Out [ 17 ] is an intracurricular partnership that connects K-12 teachers with scientists and other health professionals to design school-based units targeting salient health topics. These units give real world context to selected state standards taught in the classroom and replace previous curricula targeting these standards. Under this novel framework, a foundation of science excellence for all students [ 18 , 19 ] is extended to address student learning related to health, disseminating health education into the community. Because of this, InSciEd Out is a truly translational program that capitalizes upon longitudinal community engagement to help test, interpret, implement, and assess the impact of knowledge. These data transfer elements address a spectrum of translational science aimed toward behavioral changes and improved public health [ 20 ].

The InSciEd Out program is a community-based participatory research model where health topics of focus are chosen in collaboration with partnering schools and their community leaders. Selected teacher partners undergo a 12-day scientific and pedagogical internship before collaborating to design, implement, and assess their health-focused units. One key aspect of the produced lessons is that students are encouraged to be active creators rather than passive consumers of knowledge. This student-driven inquiry is at the heart of the health literacy that InSciEd Out fosters. Clinically-focused interventions using InSciEd Out’s health-related curricula are called prescription education [ 21 ] and are driven in part by the KAB health model. InSciEd Out’s mental health arm consequently seeks to improve attitudes and downstream behaviors toward mental illness through addressing mental health literacy.

Longitudinal study of InSciEd Out reveals sustained gains in science literacy, demonstrating capability of InSciEd Out-facilitated knowledge transfer [ 19 ]. An initial assessment of prescription education in influenza-focused curriculum found improvements in unprompted knowledge of preventative behaviors [ 21 ].

Study design

This pilot study presents findings from the inaugural run of InSciEd Out prescription education curriculum in mental health. Its quasi-experimental design follows a single cohort of seventh and eighth grade students at an InSciEd Out partner public alternative school in the Midwestern U.S. While alternative education is a broad term encompassing all nontraditional educational programming [ 22 ], the study school here voluntarily admits its ~ 350 students (grades 7–12) based on entrance criteria that include potential chemical dependence or mental health issues. These students are “at-risk” youth, defined as youth with diagnosed/diagnosable mental illness or who have a high likelihood of developing mental illness.

The intervention was a 20-day anti-stigma classroom experience in the 2015–2016 school year. Intervention lessons replaced non-mental health focused lessons addressing selected state standards in science, math, and language arts. The intervention unit culminated with mentored science research projects based on student-driven questions in mental health. One highlight of this curriculum was its integration of biogenetic explanations of mental illness with broader social and cultural context through a combination of education and contact programming (Table  1 ).

Assessing student outcomes

This case study was hypothesis-generating by design due to its novel population. Nevertheless, it aimed to test the premise that students undergoing InSciEd Out mental health curriculum exhibit pre–post increases in mental health literacy, decreases in mental illness stigmatization, and increases in hypothetical mental health help-seeking behavioral intentions. Study metrics were chosen to align with the KAB theoretical framework. Classroom activities and student surveys were administered pre–post intervention. Pilot status, novelty, and lack of a comparable partner school drove the decision to not recruit an external control.

Misconceptions activity

A curriculum-embedded activity on mental health misconceptions used anonymous student polling to assess preliminary, cohort-level mental health literacy. Anonymous cohort polling precluded matched analyses. The activity incorporated ten misconceptions assembled from websites of repute [ 23 , 24 , 25 , 26 ] grouped into three categories, covering mental illness: (1) being fictitious, irrelevant, and caused by personal weakness (generally and specifically for substance use and depression); (2) having no recovery and no prevention; and (3) causing patients to be violent/unpredictable, be unintelligent, and need separation in healthcare.

Mental health surveys

Three previously published and validated adolescent surveys totaling 28 questions were selected to assess mental health knowledge, stigmatization, and help-seeking behavioral intentions. Reliability and validity testing were not completed in the study population due to restricted sample size and lack of a comparable population for validation.

There is no gold standard mental health knowledge inventory, particularly for youth. Here the study used the Westbrook Mental Health Knowledge Test (WMHKT) , a 13-question, true/false/not sure survey on knowledge of generalized mental health [ 27 ]. Analysis primarily concerned correctness of response without distinguishing between incorrect and “not sure” responses.

To assess whether knowledge changes were accompanied by attitudinal change, the Adolescent Attribution Questionnaire (AQ - 8 - C) measured stigmatizing attitudes [ 27 , 28 ]. The AQ-8-C is the short-form, eight-question attribution questionnaire for assessment of public stigma. It measures stereotypes of blame, anger, pity, help, dangerousness, fear, avoidance, and segregation. Each question is rated on a 9-point Likert scale with question 7 (help) reverse coded. Higher scores indicate higher stigma, so pre–post change shows stigma reduction when negative. Primary analysis concerned overall stigma score with secondary analysis of each stereotype.

Lastly, the General Help - Seeking Questionnaire Vignette Version (GHSQ - V) was administered to assess whether knowledge and attitude changes extended to changes in intended behavioral modification. The GHSQ-V measures help-seeking intentions, health literacy, and perceived need for help [ 29 ]. Seven vignettes for different health conditions are posed, and respondents indicate their intention to seek help via 7-point Likert scales. Various help sources are queried for each scenario, and additional fields are provided for respondents to give a diagnosis (literacy) and to indicate whether they think the individual in the vignette needs help (perceived need). Preliminary analysis to generate a summative score for the GHSQ-V revealed highest scale reliability with exclusion of item I “would not see help” (Table  2 ). Missing responses were therefore filled in with the average value of responses in A–H (all other help sources) to facilitate total scoring. Help sources were not split into formal and informal sources due to small sample size and scale reliability. Analysis of fill-in responses for diagnoses accepted schizophrenia for psychosis, any reference to alcohol or drugs for substance misuse, and heart attack or stroke for heart disease.

Teacher exit interviews

Semi-structured interviews were conducted post-curricular implementation with the two partner teachers to capture a larger narrative of student change. Questions were designed to explore teachers’ perceptions of (1) the curriculum, (2) metrics for assessing curricular effect, and (3) changes in student knowledge, attitudes, and behaviors. Interviews were recorded and transcribed before primary coding by two independent coders. Resultant coding was compared and condensed into a final coding manual for secondary coding into emerging themes.

Statistical analyses

Of 19 eligible students, 14 assented to formal pre- and post-survey assessments. All participating teachers consented to interviews. Due to small sample size, primary results largely refer to changes in response distribution (average ± standard deviation, unless otherwise indicated). Effect sizes were calculated as Cohen’s d values from \(d = \frac{{M_{post} - M_{pre} }}{{SD_{pooled} }}\) , where \(SD_{pooled} = \sqrt {\frac{{SD_{pre}^{2} + SD_{post}^{2} }}{2}}\) . They are included for subscales for thoroughness but are subject to potentially low reliability and should be interpreted with caution. To supplement these descriptive statistics, inferential statistics were also conducted to provide a benchmark for future studies. Statistical tests were performed in JMP Pro 12 (2015). To be conservative, two-tailed p-values are reported. Misconceptions data was analyzed via Fisher’s exact test due to incompletely matched samples; average change in response on each survey inventory was assessed by Wilcoxon signed rank tests due to variable normality and small sample size.

Mental health knowledge

The classroom activity, surveys, and teacher interviews painted a narrative of curricular effects. First, the misconceptions activity showed significant elimination of student misconceptions of mental illness (Table  3 ). At baseline, at least one student present indicated agreement with every misconception posed besides separation. By post-evaluation, none of the students present still agreed with any of the misconceptions, demonstrating with statistical significance (χ 2 , p = 0.00–0.05) for four of the statements posed that the InSciEd Out curriculum lowered students’ mental health misconceptions. After Bonferroni correction, misconception elimination for statement 5 was still statistically significant.

Analysis of the Westbrook Mental Health Knowledge Test partially corroborated this trend toward gains in mental health literacy. There was a shift toward higher post-scores in the negative skewness of the data (Fig.  1 a). Individual item analysis of the number of students answering each question correctly (Fig.  1 b) revealed that the largest gains were in questions 2 (“mental illness is like other diseases because a person who has it has symptoms that a doctor can diagnose”) and 4 (“the brain of a healthy person works the same as that of a mentally ill person”). Conversely, students scored poorest on question 11, which asked if “depression is a disease.” Matched change showed a 0.43 ± 2.59 increase in overall mental health knowledge from pre- (8.14 ± 2.07, median 8) to post- (8.57 ± 2.71, median 9.5) that was not statistically significant with an effect size of d = 0.18. GHSQ-V vignette identification was variable at baseline (stressed = 7%; psychosis = 21%; heart disease = 21%; anxiety = 29%; suicidal = 36%; depression = 43%; substance = 64%) and comparable at post-evaluation, excepting improvement in depression recognition (+ 36%).

Westbrook Mental Health Knowledge Test. Students trend toward gains in mental health knowledge on the Westbrook Mental Health Knowledge Test post-intervention. Pre-scores are white; post-scores are grey; dotted lines indicate maximum possible score; “+” is the mean. a Cumulative score distribution. b Number of correct student responses, out of 14 eligible students, for each question

Mental illness stigmatization

The AQ-8-C extended results in knowledge to attitudinal shifts. Analysis revealed low baseline stigma that remained largely unchanged (Fig.  2 a). This low baseline left nearly no room for stigma decrease post-intervention. Stigma was particularly low for the items of blame, segregation, and anger. The largest changes were seen in constructs of pity (− 0.86 ± 3.18) and help (1.21 ± 2.19) (Fig.  2 b). Students scored 17.14 ± 4.80 pre- and 16.79 ± 4.79 post- for a matched stigma reduction of 0.36 ± 4.68 and an effect size of d = − 0.07 (Table  4 ). Effect sizes for individual stereotypes are provided in Table  4 for completeness but were heavily influenced by floor effects.

Adolescent Attribution Questionnaire. Student stigma is low at baseline and remains largely unchanged post-intervention. Pre-scores are white; post-scores are grey; dotted lines indicate minimum and maximum possible score; “+” is the mean. a Cumulative score distribution. b Score distribution for each of the different domains measured

Mental health help-seeking intentions

Ultimately, behavioral change is the outcome with highest clinical relevance. GHSQ-V data showed student responses trending toward increased hypothetical help-seeking intentions (Fig.  3 ). Responses became more centralized post-intervention with particular shortening of the interquartile range in the suicidal, substance, and psychosis vignettes. This regression to the mean is likely more representative of actual behavior and important for students who previously indicated a strong reluctance to seek help. Although none of the post-intervention changes were statistically significant under conservative two-tailed analyses, results in depression (Wilcoxon signed rank p = 0.12; d = 0.48) and psychosis (Wilcoxon signed rank p = 0.11; d = 0.53) approached statistical significance with additional small to medium effects in anxiety d = 0.24 and substance misuse d = 0.43 (Table  5 ). There appeared to be a general shift toward health help-seeking overall with a medium pre–post effect size for heart disease (d = 0.56). Perceived treatment need was high at baseline (79–100%) and remained largely unchanged post-intervention (86–100%).

General Help-Seeking Questionnaire: Vignette Version. Students trend toward more centralized or increased help-seeking post-intervention. Pre-scores are white; post-scores are grey; dotted lines indicate minimum and maximum possible score; “+” is the mean

Overall, the teachers reported positive perceptions of the unit and of their students’ outcomes. The mental health content was relevant, and lessons with active inquiry were especially well received. In retrospect, surveys were not perceived to be the ideal source of data collection, particularly for a population of “reluctant learners” with “years and years of school failure.” One suggestion for future data collection was to conduct interviews with individual students to assemble a student-driven narrative. The teachers felt this might be a more sensitive metric of student growth.

Teachers reported numerous changes in student behaviors post-curricular implementation. Generally, the curriculum elicited high student participation. There were noted improvements to student willingness to risk their voice, both when talking about mental health and when presenting classwork to community members, teachers, and peers. Students were perceived to now have a common language to converse about mental health and consequently shared first/second-hand experiences more openly. Teacher 1 stated: “We would never hear [the students…] in the other years, or even at the beginning of the year […], own what they had,” but “because now they understand that these things all [fall] under mental illness, […] they [are] more willing to accept that that’s what they [have]. There [isn’t] that negative stigma attached to it.” Teacher 2 reported that students post-unit are “more tolerant of their classmates who have issues” while simultaneously encouraging peers to “do something” by seeking help. The teachers reported beliefs that their students now have a better idea of when to seek help for their mental health.

These preliminary findings show three trends meriting future study. First, at-risk adolescents may fundamentally differ from their peers. Baseline mental health literacy was significantly higher in this sample (8.14 ± 2.07) when compared to that of a previously published [ 27 ], general middle school population (6.87 ± 2.30) (GraphPad unpaired t-test p = 0.04; Table  6 ). Stigmatization was also lower in this at-risk cohort. One explanation could be prior exposure to the mental health system. Another rationale could be that there is a dimension of stigma unmeasured by the AQ-8-C. Establishing baseline literacy and stigma in this unique adolescent population is important, both to shed light on how to decrease care fragmentation and to tailor future health interventions to the needs of this vulnerable group.

Second, despite low inventory-reported stigma, teacher interviews suggest stigma remains a barrier for at-risk youth. More sensitive metrics, perhaps through individual interviews, are needed to better capture these students’ stories. This adolescent cohort may share more openly in venues prioritizing verbal communication, especially given positive reception to lessons involving open dialogue, project-based learning, and oral presentations. Clever data capture designed to be minimally invasive has the potential to draw out rich stories that cannot be easily gleaned from more traditional methods.

Lastly, this case study demonstrates potential feasibility and acceptability of curricular-based, anti-stigma mental health interventions for at-risk youth. This is an area of research that is sorely lacking in the current evidence base. Preliminary trends toward efficacy in mental health promotion make school-based partnerships a potentially efficient platform for health education dissemination. Mental well-being during childhood and adolescence is often inextricably tied to academic success. As such, schools have a vested interest in fostering open discourse about mental health amongst their students.

This pilot study is limited by its single cohort design and small sample size of a vulnerable population. To minimize risk, teacher exit interviews were conducted in lieu of student interviews, and actual student help-seeking behavior was not measured. An external control was not employed due to the preliminary nature of this study, the school-specific implementation of mental health curriculum, and lack of a comparable peer cohort. Random assignment was likewise not possible given the classroom environment, as InSciEd Out lessons are embedded into existent curricula. Future directions will work toward sample size enlargement facilitating recruitment of an external control, which will aid psychometric testing of existent tools and development of new assessment tools. In addition to this, upcoming studies will work with clinical partners to capture measures of actual student help-seeking behavior. Study metrics will also be monitored longitudinally with follow-up for retention.

The pilot case study herein underscores the utility and potential of school-based mental health promotion efforts, particularly through InSciEd Out’s community-based framework. Targeted improvements in mental health literacy and moderate improvements in help-seeking intentions were accompanied by large decreases in mental health misconceptions. Inventory-reported stigma was low and largely unchanged. Nevertheless, teacher observations suggested anecdotal evidence of increased student self-identification with mental health diagnoses, openness to share, and peer acceptance.

Early and effective intervention is an undervalued tool for preventing or mitigating the negative, long-term consequences of poor health. Improved mental health for all can only be realized if affected individuals and their social support structures have sufficient literacy to recognize and understand mental illness, at least at a basic level. A necessary byproduct of this understanding is that stigma toward mental illness needs to decrease, or become eliminated, such that help-seeking is the norm rather than the exception. As such, anti-stigma interventions deserve heavy focus, particularly in high-risk populations. The students in this study represent a segment of general adolescents with demonstrated need for mental health promotion efforts. Although this study’s sample size is small, it is enriched for youth with increased risk of developing mental health issues. These students are difficult to reach in general K-12 populations and represent an underserved segment of adolescents.

Although care must always be exercised when working with vulnerable populations, community programming can no longer ignore at-risk youth simply because such studies are difficult to design and execute. Translational research pushing bedside to curbside has potential to give voice to the experiences and needs of this unique cohort in pursuit of improved mental health for all.

Abbreviations

Integrated Science Education Outreach

Westbrook Mental Health Knowledge Test

Adolescent Attribution Questionnaire

General Help-Seeking Questionnaire Vignette Version

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Authors’ contributions

JY headed study design, data collection, data analysis, and drafting of this work. RLC coded transcripts for interview data analysis and aided with critical manuscript revision. SJT, SCE and CP contributed to conception and design of the study and critical revision of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Thanks go to Madeleine E.M. Hammerlund for her help in administration of the mental health surveys, Dr. Ashok Kumbamu for his review of the semi-structured interview questions and insight into qualitative coding methodology, and Thomas J. LaBounty for his statistical guidance. Additional thanks go out to InSciEd Out team members and especially to the alternative school teacher partners for their support of this project.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to privacy agreements made during school board approval but are available from the corresponding author on reasonable request. Copies of all study metrics are available by inquiry.

Consent for publication

Consent was obtained from the teachers to utilize quotes from their interviews anonymously.

Ethics approval and consent to participate

The survey and interview portions of this study were approved by the Mayo Clinic Institutional Review Board (IRB) with a waiver of informed parental consent under 45CFR46.116. Classroom data in the misconceptions activity was also collected under normal program evaluation in a study declared exempt by the Mayo Clinic IRB.

This publication was made possible in part by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NIH. Additional funding for this work was provided through philanthropic support of InSciEd Out through the Mayo Clinic Office of Development. JY’s graduate studies were supported in part by the National Science Foundation’s Graduate Research Fellowship Program. RLC’s position in the Postbaccalaureate Research Education Program (PREP) is supported in part by NIH grant R25 GM 75148 and SCE’s NIH R01 grant 5R01HG006431. RLC is now at the University of Minnesota, Minneapolis, MN, and JY is with Mayo Clinic, Jacksonville, FL.

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Yang, J., Lopez Cervera, R., Tye, S.J. et al. Adolescent mental health education InSciEd Out: a case study of an alternative middle school population. J Transl Med 16 , 84 (2018). https://doi.org/10.1186/s12967-018-1459-x

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DOI : https://doi.org/10.1186/s12967-018-1459-x

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Teen and Young Adult Perspectives on Generative AI: Patterns of Use, Excitements, and Concerns

June 3, 2024

Generative artificial intelligence (AI) has quickly become an integral part of the digital landscape, surfacing new ways for people to learn, create, and innovate. At the same time, it brings both proven and unknown risks to everything from privacy to equity and accuracy.

Young people are extremely important in considering the future of generative AI—they're not only early adopters and influencers, but will also be among the first to grapple with its consequences. Understanding the perspectives of young people when it comes to generative AI is paramount, especially considering the impact of digital technologies on youth well-being.

This study, conducted in partnership with  Hopelab and the  Center for Digital Thriving at Harvard Graduate School of Education, examines how young people perceive and interact with generative AI technologies, with special attention to race and ethnicity, age, gender, and LGBTQ+ identity.

These nuanced views of teens and young adults from diverse demographic groups offer valuable insights into the potential benefits of generative AI, such as broader access to information, streamlining of tasks, and enhanced creativity. However, young people also expressed concerns about potential negative impacts, including job loss, privacy issues, intellectual property theft, misinformation and disinformation, and even AI taking over the world.

It's essential to understand young people's perspectives about generative AI, especially when considering programs, policies, and design features that impact the mental health of marginalized and minority populations like LGBTQ+, Black, and Latinx youth. The data in this report can ensure that the well-being of the earliest adopters is prioritized.

More resources:

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Case Studies & Best Practices: Strategies to Reduce Youth Overdoses

February 14, 2023

• Focus Areas Capacity Building & Leadership , Women, Youth & Children
• Expertise Leadership Development
• Programs Center for Health Leadership and Impact
• Strategic Initiatives Opioids

In 2022, communities across California developed innovative strategies in harm reduction and youth engagement. These case studies from PHI’s California Overdose Prevention Network (COPN) contain concrete examples of data-driven strategies that address rising rates of overdose among youth.

Case studies were drawn from overdose prevention coalitions participating in the California Overdose Prevention Network Accelerator 3.0 Program. These can serve as models for other coalitions and organizations across the country.

• Case Studies: Four Data Driven Strategies to Engage Youth in Overdose Prevention
• Case Studies: Four Data Driven Harm Reduction Strategies in Overdose Prevention
• Factsheet: Supporting Coalitions in Harm Reduction Services & Approaches for Youth

See the case studies and key highlights:

Four data driven strategies to engage youth in overdose prevention.

This summary of case studies includes:

• Empower Watsonville created a point-in-time survey to anonymously survey and assess local youth’s experiences with substance use. Youth administered the survey to their peers and therefore received a high response rate. They are using the findings to help establish a restorative policy for students who possess drugs or are intoxicated on a school campus.
• The Central Coast Regional Team adopted a parent toolkit to better facilitate conversations about youth substance use within their communities. They operated a massive mailing campaign to send a printed version of the booklet, in both English and Spanish, to every parent of an incoming 9th grader in their region.
• SafeRx Lake County used a combination of data sources and strategies including overdose hotspotting and survey data to drive their work. Their data helped them better understand and describe the scope of the problem and build a strong case for more appropriate policies in a predominantly conservative political environment.
• Safe Rx Mendocino Opioid Safety Coalition implemented a harm reduction curriculum for youth. This resource will be taught and distributed throughout schools, drop-in centers and family resource centers.

download the case studies

We prioritized fostering youth-to-youth relationships, where youth could express their concerns, voice their needs, and share their experiences. Additionally, the data from our survey has been foundational to gathering data in our community and has given us leverage to introduce substance use concerns in our community. Esme Vargas Empower Watsonville

Using data-driven strategies increased partnerships and trust among the education sector, validified our work, and made it possible for us to respond to community-youth focused needs. Rita Hewitt Empower Watsonville

The shock and awe from the data and the pressing need to work hard and quickly to stay ahead of the tragic overdoses has been key in our work. Kim Tangermann SafeRx Lake County

Four Data Driven Harm Reduction Strategies in Overdose Prevention

• The Butte Glenn Opioid Safety Coalition successfully launched a naloxone upon release program and has strengthened partnerships with their local jails.
• The Northern Sierra Opioid Safety Coalition developed an anti-stigma campaign called Addiction has a Face. The coalition also increased access to harm reduction supplies using vending machines and has shared their operations manual for other communities looking to implement a similar model.
• The Santa Clara County Opioid Overdose Prevention Project implemented naloxone vending machines at Santa Clara University and the local jail to allow individuals to access Narcan and information without fear of judgement, stigma, or recognition. These vending machines provide low-barrier access to health products to Santa Clara County residents.
• The SLO Opioid Safety Coalition collaborated with the Cal Poly Digital Transformation Hub (DxHub) and a team of university students to develop Naloxone Now! so members can find the nearest location to get naloxone or have it delivered at no cost. The coalition also created a billboard and outreach campaign to promote community awareness of increasing overdoses and the availability of naloxone through the app.

Sharing our data with other networks and stakeholders has been key to true policy shifts and changes throughout our communities. We realized the rates of certain populations were less than we thought, and that we would have created more stereotypes and stigma had we put our focus there. Monica Soderstrum Butte-Glenn Opioid Safety Coalition

Our coalition used key informant interviews and public opinion polls during the data collection and analysis phase of the COPN Accelerator 3.0 Program. By doing so, we discovered that there is a disconnect between key decision makers and the public. Kate Manganaro Northern Sierra Opioid Saftey Coalition

Our data shows who is affected by the overdose epidemic in our county, reveals trends and associated responses that need to be changed, and allows for a review of what is working and what changes need to be made. Mike Torres Northern Sierra Opioid Saftey Coalition

Supporting Coalitions in Harm Reduction Services & Approaches for Youth

The National Harm Reduction Coalition (NHRC) worked with PHI’s California Overdose Prevention Network (COPN) funded multi-sector coalitions throughout the state in 2022 and focused on supporting coalitions in harm reduction services and approaches for youth. This handout contains key highlights from the COPN Accelerator 3.0 Program of coalitions working NHRC and implementing harm reduction services for youth.

Lessons Learned

In multiple communities, overdose deaths of young people ages 12-20 were motivating factors to seek out harm reduction education.

• In multiple communities, coalition members did not have a true understanding or grasp on youth drug use, so involving youth or youth-led organizations could provide key stakeholders and experts to enhance and expand this work.
• Drug education for young people has historically been punitive and relied on strict, unexplained prohibition of drugs which only stigmatizes students and denies them access to honest lifesaving information.
• Harm reduction for youth inherently involves working with parents, teachers, and other adults that engage with young people.
• Coalitions that built relationships with schools were able to embed more into sustainable structures of education. Coalitions were successful in implementing naloxone training for teachers and bringing in consultants to create curricula.

Best Practices

There are some best practices that are very similar to how we support adults around substance use, but our own fears can trip us up in implementing them with young people.

• If someone is using drugs on a regular basis, especially a young person, understand why they want to alter their reality and try to understand what needs the drugs may be filling; stay curious and avoid using shame because that often pushes young people further from accurate information, connection, and safety.
• If someone is curious about drugs, especially a young person, give them accurate information about the effects (both positive and negative), potential risks, and ways to stay safe and reduce harm if they do decide to use drugs.
• Be careful not to perpetuate fear-based messaging or misinformation about fentanyl or any other drug. We want young people to feel safe and empowered when talking about drug use with parents and other adults.
• It is essential to give naloxone directly to people who are at risk for overdose, including young people.

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where every youth belongs, choose the support they need and thrives

What we believe

Guided by our vision where every youth belongs, chooses the support they need and thrives, allcove centers are designed to create meaningful, positive experiences for every person who comes through our doors.

The first of its kind in the U.S., allcove is developing an innovative network of integrated youth mental health centers designed with, by and for youth that reduce stigma, embrace mental wellness, increase community connection and provide access to culturally-responsive services.

allcove centers serve young people ages 12-25, providing a unique space for them to access our services, with resources and support for friends, family and the larger community. Our centers are embedded within the communities they serve and reflect the unique needs of local youth.

How we co-create

Everything about allcove is designed with, by and for young people.

From the look and feel of an allcove center, to the options young people have to engage in center activities, young people are our co-creators and our champions. We intentionally use a participatory process to co-create every aspect of the allcove experience with young people, and we’re excited to elevate and promote youth voices along the way.

What we offer

­Anchored in a model of care that considers the holistic needs of young people, allcove centers are places for them to take a moment of pause and access a range of services. These include:

Mental health

Physical health, substance use, peer support, supported education and employment, family support, why allcove.

Nearly 50% of all mental health conditions have their onset by the age of 14 and 75% by the age of 24. Half of adolescents meet the criteria for a mental disorder at some point and 79% of youth and young adults with mental health issues do not access care. Unfortunately, the United States lacks a comprehensive, reliable system of early socio-emotional care and support for adolescents to easily access early health and mental health services in an environment that speaks to their unique developmental and cultural needs. This lack of early mental health services is creating tragic and expensive consequences in communities across the country.

The current U.S. mental health system is not resourced to detect and prevent emerging and mild to moderate mental health issues, despite their astonishing prevalence. Young people with emerging mental health issues have difficulty finding timely treatment and a service system that can respond quickly and confidentially to their needs. Because of this lack of early intervention and the prevailing stigma surrounding mental health treatment, young people often do not reach our health, social service or justice systems until their mental health needs have become more severe and often more difficult and costly to treat.

Service approach

A focus on mild to moderate.

The focus on mild to moderate mental health needs is the essence of the model and fills a significant gap in adolescent public mental health service provision. In addition, if the young person needs a higher-level behavioral health service, linkages are made to the community behavioral health system for more intensive intervention.

Integrated care services

Mental health, physical health, substance use, peer support, family support and supported education and employment.

The provision of integrated care services allows for holistic care for young people while also acknowledging the stigma issues related to being seen for a mental health related service. Furthermore, given the high frequency of comorbid health and mental health related conditions for young people, linking these services makes sense.

Centers are stand-alone sites with their own entrance and exits. Part of their success internationally is that young people see the program as their own independent place for integrated care. Also, by standing alone but still linking to the larger allcove brand, each center is able to reflect the unique culture of young people within the geographic community being served.

Marketing directly to young people

Critical to breaking down stigma and other barriers to access is strategic marketing and advertising campaigns that include linkages to local events, the involvement and voice of youth leaders, and ties to activities of interest to young people. In addition, marketing research and investments are made to ensure that messaging specifically targets a demographically diverse audience.

Meet our Youth Advisory Group

What does allcove mean to you.

The Youth Advisory Group is comprised of young people between the ages of 16-25, who represent diversity in race, ethnicity, gender, sexual orientation, lived experience, ability and socioeconomic status. Youth Advisory Group members provide a better understanding of young peoples’ needs and opinions ensuring we:

• Have a meaningful youth space aimed at providing services geared towards youth.
• Reduce stigma in mental health.

They are passionate about affecting change and connecting with other youth to increase access to mental health care.

News Spotlight

Youth help to design a new model for health and wellness care

This Rocky Mountain PBS special covers how two communities found solutions when faced with teen suicide clusters. The work of Drs. Shashank Joshi and Steven Adelsheim, and Vicki Harrison, program director of the Stanford Center for Youth Mental Health and Wellbeing, and allcove youth advisors is featured throughout.

Rocky Mountain PBS Video

allcove development

Current and upcoming allcove centers.

At each allcove center young people can expect a warm welcome, the comfort of being themselves and staff they can trust.

In partnership with the California Mental Health Services Oversight and Accountability Commission, we work together to support the ongoing development of  allcove centers . 

Explore the resources below to learn more about the development of the allcove model, previously referred to as headspace. 

What is the role of the Stanford Center for Youth Mental Health & Wellbeing?

Stanford Center for Youth Mental Health and Wellbeing is leading the effort to bring the allcove model to the U.S. by building a community-academic partnership that has the potential to develop a nationally replicable model for supporting youth mental health with an early intervention infrastructure that does not currently exist.

The allcove model has been developed by the Center with input from its international collaborators, youth advisors, Santa Clara County Behavioral Health Services, the State of California and its communities.

The Center has created the infrastructure and partnerships to pilot the first U.S. implementation of the model by opening centers in geographically and socioeconomically diverse locations within California.

The licensing of the program and the allcove TM  trademark in California is overseen by the Mental Health Oversight and Accountability Commission with technical support and model integrity monitoring provided directly to centers by the Central allcove Team housed within the Center.

For more information on the allcove program, please visit:

https://www.allcove.org/

LGBTQI+ People and Substance Use

• Research has found that sexual and gender minorities, including lesbian, gay, bisexual, transgender, queer, and intersex people (LGBTQI+), have higher rates of substance misuse and substance use disorders than people who identify as heterosexual. People from these groups are also more likely to enter treatment with more severe disorders.
• People in LGBTQI+ communities can face stressful situations and environments like stigma and discrimination , harassment, and traumatic experiences . Coping with these issues may raise the likelihood of a person having substance use problems.
• NIDA supports research to help identify the particular challenges that sexual and gender minority people face, to prevent or reduce substance use disorders among these groups, and to promote treatment access and better health outcomes.

Latest from NIDA

A Plan to Address Racism in Addiction Science

Find more resources on lgbtqi+ health.

• Hear the latest approaches in treatment and care from experts in the fields of HIV and SUD in this NIDA video series, “ At the Intersection .”
• See the Stigma and Discrimination Research Toolkit from the National Institute of Mental Health.