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Strengthening the Measurement of Adolescents' Mental Health at the Population Level

Open AccessPublished:November 08, 2022DOI:https://doi.org/10.1016/j.jadohealth.2022.10.007
      We have a notion that adolescence is a healthy time of life. Many parents wonder what is so stressful for young people who do not have the kinds of financial burdens and family worries that adults experience. Consequently, it is not uncommon for adults to dismiss the emotional concerns of their adolescent children. However, adolescence is a time of exceptionally rapid change both physically and neurodevelopmentally. As a time of numerous first experiences and exposures, the world around the adolescents changes in ways that they never experienced in childhood. Under normal circumstances, these changes result in stress that can lead young people to feeling overwhelmed, isolated, and depressed. In the ongoing COVID-19 pandemic period, the social isolation and socioeconomic impacts of the pandemic have taken a further toll on young people's mental health and wellbeing [
      • Fegert J.M.
      • Vitiello B.
      • Plener P.L.
      • Clemens V.
      Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.
      ].
      The inclusion of a goal specific to mental health in the United Nations Sustainable Development Goals is an important inflection point because it marks the first time that mental health is acknowledged by the global community as a cornerstone for national development. Valid, comparable, and reliable data on mental health conditions are essential for tracking progress in the achievement of the Sustainable Development Goals target on mental health. One problem that we face, however, is that we have poor measures to assess the emotional health and wellbeing of adolescents. Without being able to accurately identify those who have most significant mental health problems, we are handicapped in being able to meet their needs.
      The lack of data on adolescents' mental health has spurred several initiatives to address this gap. This supplemental issue of the Journal of Adolescent Health includes commentaries, protocols, and original studies that focus on the generation of population-level data that can inform programs and policies aimed at improving mental health outcomes among adolescents.
      A set of papers in this volume describes the reasons for the limited availability of data on adolescent mental health. Guthold et al. [
      • Guthold R.
      • Carvajal-Velez L.
      • Adebayo E.
      • et al.
      The importance of mental health measurement to improve global adolescent health.
      ] note that efforts to respond to the lack of data on adolescent mental health have been hampered by a lack of coordination. In addition, the challenge of developing measurement tools and approaches that account for rapid social, physical, cognitive, and emotional changes that characterize adolescence has hampered progress. So too, as Hayes et al. [
      • Hayes J.
      • Carvajal-Velez L.
      • Hijazi Z.
      • et al.
      You can’t manage what you do not measure - Why adolescent mental health monitoring matters.
      ] suggest, the lack of data stems from limited funding for research on mental health.
      As a first step to ensuring relevant data on adolescent mental health, Verhulst et al. [
      • Verhulst S.
      • Vidal Bustamante C.M.
      • Carvajal-Velez L.
      • et al.
      Toward a demand-driven, collaborative data agenda for adolescent mental health. J Adolesc Health.
      ] propose a list of research priorities based on a highly collaborative, multisectoral consultative approach. These priorities align with the conceptual framework of Azzopardi et al. [
      • Azzopardi P.
      • Hijazi Z.
      • Wulan N.
      • et al.
      Bringing a wider lens to adolescent mental health: Aligning measurement frameworks with multisectoral actions.
      ], which situates adolescent mental health in a broader socioecological environment.
      The supplement also presents research that aims to develop and test both new measures and approaches in low-income and middle-income countries (LMICs), which are all-too-often ignored in mental health research. Carvajal-Velez et al. [
      • Carvajal-Velez L.
      • Harris Requejo J.
      • Ahs J.W.
      • et al.
      Increasing data and understanding of adolescent mental health worldwide: UNICEF’s measurement of mental health among adolescents at the population level initiative.
      ] describe the Measurement of Mental Health among Adolescents at the Population Level (MMAP) initiative that seeks to develop a suite of tools that can be used both at population and clinical levels. Another article by Carvajal-Velez, Ahs et al. [
      • Carvajal-Velez L.
      • Ahs J.W.
      • Requejo J.H.
      • et al.
      Measurement of mental health among adolescents at the population level: A multicountry protocol for adaptation and validation of mental health measures. J Adolesc Health.
      ] presents a protocol for cultural adaptation and clinical validation of the MMAP tools in four LMICs. Several articles on the MMAP initiative, such as Carvajal-Velez, Ottman, et al. [
      • Carvajal-Velez L.
      • Ottman K.
      • Ahs J.W.
      • et al.
      Translation and adaptation of the Revised Children’s Anxiety and Depression Scale: A qualitative study in Belize. J Adolesc Health.
      ], Carvajal-Velez, Ahs et al. [
      • Carvajal-Velez L.
      • Ahs J.W.
      • Lundin A.
      • et al.
      Validation of the Kriol and Belizean English adaptation of the Revised Children’s Anxiety and Depression Scale for use with adolescents in Belize.
      ], Marlow et al., [

      Marlow M, Skeen S, Grieve C, et al. Detecting depression and anxiety among adolescents in South Africa: Validity of the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7. J Adolesc Health 2022. https://doi.org/10.1016/j.jadohealth.2022.09.013

      ], and Tele et al. [
      • Tele A.
      • Carvajal-Velez L.
      • Ahs J.W.
      • et al.
      Validation of the English and Swahili adaptation of the PHQ-9 for use among adolescents in Kenya.
      ] report on the transcultural translation and adaptation and validation of well-established measures such as the Revised Children's Anxiety and Depression Scale, the Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale.
      Evidence-informed decision-making on adolescent mental health is also limited by the dearth of cross-national and nationally representative data on mental health prevalence. The study reported by Erskine et al. [
      • Erskine H.E.
      • Blondell S.J.
      • Enright M.E.
      • et al.
      Measuring the prevalence of mental disorders in adolescents in Kenya, Indonesia, and Vietnam: Study protocol for the national adolescent mental health surveys. J Adolesc Health.
      ] is one attempt to better define prevalence of the most common adolescent mental health disorders in three LMICs—Indonesia, Kenya, and Vietnam. In another article based on data from Multiple Indicator Cluster Surveys conducted in 26 countries, de Castro et al. [

      De Castro F, Cappa C, Madans J. Anxiety and depression symptoms among adolescents in 26 low- and middle-income countries: Prevalence and association with functional difficulties. J Adolesc Health.

      ] report that adolescents aged 10–17 years with functional disabilities including difficulties with self-care and communication were significantly more likely to present with symptoms of depression and anxiety than their peers. This finding underscores the value of disaggregated data that identifies special adolescent subpopulations to better target services.
      Another focus of the supplement is on community-based approaches. Given the high prevalence of mental health issues and the severe shortage of mental health professionals, this area of work is especially critical. As van der Broek et al. [
      • van den Broek M.
      • Hegazi L.
      • Ghazal N.
      • et al.
      Accuracy of a proactive case detection tool for internalizing and externalizing problems among children and adolescents.
      ] note, there are many reasons for not using existing mental health services beyond availability including stigma, low mental health knowledge, and cultural/gender norms. Task-shifting mental health screening and psychological first-aid to nonspecialists or paraprofessionals working at the community level under supervision hold a promise in addressing the mental health treatment gap. Van den Broek et al. [
      • van den Broek M.
      • Hegazi L.
      • Ghazal N.
      • et al.
      Accuracy of a proactive case detection tool for internalizing and externalizing problems among children and adolescents.
      ] present results evaluating the accuracy of a modified Community Case Detection Tool implemented by community gatekeepers (teachers and community workers) to detect children and adolescents with significant mental health needs and to encourage their families to seek help. Their findings show that training community gatekeepers to use the Community Case Detection Tool is a promising strategy.
      Finally, and importantly, there are articles that underscore the importance of adolescents' participation in research and the design, implementation and monitoring of policies, services, and programs that affect their lives. Pavarini et al. [
      • Pavarini G.
      • Booysen C.
      • Jain T.
      • et al.
      Agents of change for mental health: A survey of young people’s aspirations for participation across five low- and middle-income countries.
      ] report on a quantitative survey assessing young people's aspirations for engagement and their perspectives on their sphere of influence in improving mental health, the support they would need to enable them to make a difference, and the barriers they face. The study provides useful insights into the value of peer-to-peer programs in schools and community settings and the need for mental health awareness programs that would ensure that young people have a good understanding of mental health to facilitate their engagement in mental health initiatives. El Omrani et al. [
      • El Omrani O.
      • Carmen V.A.
      • Bionat J.F.
      • et al.
      COVID-19, mental Health, and young people’s engagement.
      ] and van der Westhuizen et al. [
      • van der Westhuizen C.
      • Carvajal-Velez L.
      • de Carvalho Eriksson C.
      • et al.
      Implications for mental health Promotion and Prevention Interventions: Findings from adolescent focus Group discussions in Belize, Kazakhstan, and South Africa.
      ] underscore the value of ensuring that young people can be “equal stakeholders” in mental health responses and the need to ensure diversity in youth representation.
      Taken together, the articles in this important supplement highlight four areas of future action. First, significant financial and human resources are needed to enhance the availability of valid, reliable, and comparable data on adolescent mental health. For example, the transcultural translation and adaptation process described for the MMAP initiative is resource intensive. Sustained funding for research on adolescent mental health is therefore a critical ingredient in ensuring the availability of data that can inform efforts to improve adolescent mental health outcomes.
      Second, efforts are needed to strengthen local capacity to generate, analyze, and use rigorous, disaggregated data on adolescent mental health conditions. Strengthened local capacity for adolescent mental health research ensures that research responds to local needs.
      Third, there is a need to expand surveys that capture adolescents across the entire second decade of life and to include youth through age of 24 years. Attention needs to be paid to especially vulnerable young people: those who are out of school, homeless, incarcerated, engaged with very high-risk behaviors such as commercial sex, and those with disabilities.
      Finally, parents and other adult gatekeepers need to understand that many mental health problems are the result of the environments and contexts in which young people live including violence, abuse, gender inequality, interpersonal violence, and extreme poverty. Community-based tools need to explore the contextual drivers of adolescent mental health problems.

      References

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        • Vitiello B.
        • Plener P.L.
        • Clemens V.
        Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.
        Child Adolesc Psychiatry Ment Health. 2020; 14
        • Guthold R.
        • Carvajal-Velez L.
        • Adebayo E.
        • et al.
        The importance of mental health measurement to improve global adolescent health.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.03.030
        • Hayes J.
        • Carvajal-Velez L.
        • Hijazi Z.
        • et al.
        You can’t manage what you do not measure - Why adolescent mental health monitoring matters.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.04.024
        • Verhulst S.
        • Vidal Bustamante C.M.
        • Carvajal-Velez L.
        • et al.
        Toward a demand-driven, collaborative data agenda for adolescent mental health. J Adolesc Health.
        • Azzopardi P.
        • Hijazi Z.
        • Wulan N.
        • et al.
        Bringing a wider lens to adolescent mental health: Aligning measurement frameworks with multisectoral actions.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.03.021
        • Carvajal-Velez L.
        • Harris Requejo J.
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        Increasing data and understanding of adolescent mental health worldwide: UNICEF’s measurement of mental health among adolescents at the population level initiative.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.03.019
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        Measurement of mental health among adolescents at the population level: A multicountry protocol for adaptation and validation of mental health measures. J Adolesc Health.
        • Carvajal-Velez L.
        • Ottman K.
        • Ahs J.W.
        • et al.
        Translation and adaptation of the Revised Children’s Anxiety and Depression Scale: A qualitative study in Belize. J Adolesc Health.
        • Carvajal-Velez L.
        • Ahs J.W.
        • Lundin A.
        • et al.
        Validation of the Kriol and Belizean English adaptation of the Revised Children’s Anxiety and Depression Scale for use with adolescents in Belize.
        J Adolesc Health. 2022;
      1. Marlow M, Skeen S, Grieve C, et al. Detecting depression and anxiety among adolescents in South Africa: Validity of the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7. J Adolesc Health 2022. https://doi.org/10.1016/j.jadohealth.2022.09.013

        • Tele A.
        • Carvajal-Velez L.
        • Ahs J.W.
        • et al.
        Validation of the English and Swahili adaptation of the PHQ-9 for use among adolescents in Kenya.
        J Adolesc Health. 2022;
        • Erskine H.E.
        • Blondell S.J.
        • Enright M.E.
        • et al.
        Measuring the prevalence of mental disorders in adolescents in Kenya, Indonesia, and Vietnam: Study protocol for the national adolescent mental health surveys. J Adolesc Health.
      2. De Castro F, Cappa C, Madans J. Anxiety and depression symptoms among adolescents in 26 low- and middle-income countries: Prevalence and association with functional difficulties. J Adolesc Health.

        • van den Broek M.
        • Hegazi L.
        • Ghazal N.
        • et al.
        Accuracy of a proactive case detection tool for internalizing and externalizing problems among children and adolescents.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.03.011
        • Pavarini G.
        • Booysen C.
        • Jain T.
        • et al.
        Agents of change for mental health: A survey of young people’s aspirations for participation across five low- and middle-income countries.
        J Adolesc Health. 2022;
        • El Omrani O.
        • Carmen V.A.
        • Bionat J.F.
        • et al.
        COVID-19, mental Health, and young people’s engagement.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.03.020
        • van der Westhuizen C.
        • Carvajal-Velez L.
        • de Carvalho Eriksson C.
        • et al.
        Implications for mental health Promotion and Prevention Interventions: Findings from adolescent focus Group discussions in Belize, Kazakhstan, and South Africa.
        J Adolesc Health. 2022; https://doi.org/10.1016/j.jadohealth.2021.10.024