Essi Viding, Pasco Fearon, Tom Wu, Alexander Lloyd, Laura Lucas, Roslyn Law, and Jaime Smith discuss new approaches to preventing adolescent mental health problems from emerging
Adolescence is a period of heightened vulnerability to developing mental health problems. Rates of mental health disorder among adolescents have increased in the last decade(1). In light of the vast associated interpersonal and economic costs(2,3) , it is striking how few resources have been invested in advancing our understanding of how to effectively prevent mental health problems developing before they become entrenched, particularly in adolescents who are at high risk.
Understanding why adolescent mental health problems develop
In order to prevent mental health problems, we must understand and address the processes that underlie their development. Extant research has typically had a narrow focus, examining one or two key processes and outcomes within a single disorder, for example the role of emotion regulation difficulties as precursors to depression(4). But multiple factors incrementally increase risk of mental health problems and it is unlikely that we will find a single cause for any of them. Furthermore, compelling evidence indicates that traditional diagnostic categories include individuals with very different causes for their difficulties. Many people have symptoms that span different diagnostic categories, and individuals may move across diagnostic categories over time(5,6).
In that context, the prevention of adolescent mental health problems is a particularly complex challenge. It is often not possible to predict in advance which disorder(s) should be targeted and adolescents may be at risk for more than one. In recognition of these challenges, attention is shifting to the development of transdiagnostic approaches to treatment and prevention(5). The aim is to target common cross-disorder mechanisms, rather than specific diagnoses, consistent with the recent evidence that the structure of mental health difficulties is underpinned by a general liability factor (known as the ‘p-factor’)(6).
Emotion processing and social relationships
Emotion processing and social relationships are two fundamental— and closely interlinked —transdiagnostic mechanisms that can either promote resilience or confer vulnerability to mental health problems(5,6). Emotion processing, including emotion recognition and regulation, undergoes continued development during adolescence(7), which suggests that early intervention could be effective in building emotional resilience at this age. Adolescence also involves a major developmental shift in the social environments, which must be negotiated with increasing independence from family. Peers become more, and parents become less significant(8). The success at navigating new social challenges is crucial for ongoing mental health and wellbeing(8).
Surprisingly, although prior work has established an association between emotion processing and mental health/wellbeing, and between social relationships and mental health/wellbeing, little work has systematically investigated how adolescents’ emotion processing might actively shape their social relationships, or how social relationships shape adolescent emotion processing in ways that either predispose to or protect against mental health problems. Investigating these processes in a school environment is potentially helpful, as adolescents spend much of their time at school and school is a key setting for peer interaction. Schools also enable interventions to be framed in a way that focuses on skill-building and is non-stigmatising.
With support from the UKRI Adolescence Mental Health and the Developing Mind programme, we have recently started a programme of research that develops and tests a new school based indicated prevention programme. Our ReSET (Building Resilience through Socio-Emotional Training) study works with 12-14-year-olds who are already experiencing some signs of vulnerability to mental health difficulties (symptoms in the top quartile of their age group). We are harnessing well-established approaches from cognitive-emotion training and Interpersonal Psychotherapy.
This hybrid approach targets emotion processing and regulation mechanisms using computerised training techniques, delivered in sessions at school, where the adolescents also do therapist-guided exercises to address social relationship mechanisms. In other words, we are building adolescents’ intra-personal emotional skills and their interpersonal social skills (which we refer to as ‘me-skills’ and ‘we-skills’ in the programme). The adolescents are also supported to explore and learn about how one’s emotional responses are linked – bidirectionally – to one’s experiences in social relationships and how to promote wellbeing by managing emotions and relationships more effectively.
A hybrid approach like this has a number of potential advantages over interventions that focus on either cognitive-emotion training or social skills-building alone. By combining different approaches we directly address the close connection between emotional processing and social relationships and their impact on mental health problems. Our approach promotes explicit awareness of the learnt emotional skills, ensures generalisation of these skills, and hopefully provides lasting impact and ‘inoculation’ against future setbacks and challenges. We can think of it as building a ‘mental health and wellbeing toolkit’, not targeting specific disorders, but instead developing skills that promote resilience.
How to ensure preventative interventions are effective
From the very beginning we have worked closely with adolescents to develop the ReSET intervention – adopting an approach known as ‘co-production’. We have held several workshops to co-produce the content of the intervention, facilitated by a London-based youth theatre group called Company3 – experts in creating a creative and inclusive space for adolescents to express their ideas. We have collaboratively generated scenarios for the intervention to help us explain the links between emotion processing, social relationships and wellbeing, in ways that resonated with adolescents. We also included a pilot stage and used feedback from adolescents, teachers and group facilitators in participating schools to reduce barriers to participation, optimise delivery and gain insights into what was experienced as particularly helpful.
Our view is that preventative interventions need several key features to be effective. Interventions need to tackle the underlying mechanisms that create vulnerability to mental health difficulties and should recognise that a number of such mechanisms are often interlinked. This means that focusing on a single mechanism may not be enough. Effective prevention programmes should provide adolescents with transferrable skills that can be applied to the genuine challenges in their lives. Delivering interventions like these within schools has numerous advantages, such as increasing access and providing a familiar environment, and our project has benefited from strong support from teachers, school mental health champions and school leadership teams.
A final critical ingredient of good prevention programmes, we believe, is that they are non-stigmatising and strengths-based, giving adolescents confidence in themselves and a sense of connection to others. Our ReSET programme strives to do this. We are now testing the benefits of ReSET in a clinical trial so that we can see, using rigorous scientific evidence, whether it is as good as we think it is.
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