Young People (13-25 yrs old)
with Severe and Complex Mental Health Issues
WHO ARE THEY?
Those who have not worked with or known young people with “severe and complex mental health issues” can often find it difficult to envisage what that categorisation could mean. Clinicians have described the group as:
“various combinations of developmental trauma, major psychiatric disorders and multiple comorbidities, high and fluctuating risk to self, major and pervasive functional disability, unstable accommodation options, learning disabilities, barriers to education and training, drug and alcohol misuse. In short, this was a cohort in the main characterised by high, complex and enduring clinical and support needs” (Kotze & Skippen, 2014)
“characterised by severity and persistence of illness, very limited or absent community supports and engagement, and significant risk to self and/or others” (ECRG Report, 08/05/2013; BACCOI Exhibit 216)
“Severe and complex” can be many things. It’s the uniqueness of each young person in this cohort’s situation that means a specialised and intensive approach to treatment (and education) can be the lifeline (or circuit breaker) that can change a pattern of social isolation at home -> hospitalisation for acute episodes -> social isolation at home and so on indefinitely. So although this isn’t a large group within the youth mental health demographic, it’s a significant group. And one for whom the right services can alter a path of ongoing trauma and dependence.
As examples, we’ve complied some profile snapshots to illustrate the types of experiences, challenges and behaviours that can exist. They are:
- Social interaction/ communication problems from infancy
- Changed primary schools 3 times
- Non-attendance at school since 13 years old
- Periods of aggressive/self-destructive behaviour followed by deep remorse
- Diagnosed psychosis (hears voices) – can’t clarify bi-polar or schizophrenia at this age
- Feelings of isolation/”darkness” from early childhood,
- Began alcohol consumption at 10 years old; self-harming from 11 (lied/hid from family for extended period)
- Suicide attempts from 15 years old
- Weekly psychiatrist appts (often missed) and regular acute admissions
- Illegal substance abuse from 13 years old
- Impulsive and risk taking behavior
- Hospitalised for internal injuries from self-harm
- Under diagnosis/in treatment since 9 years old – accessing CYMHS, family therapy, behavioural management
- Receptive language disorder
- Oppositional defiant disorder
- Poor impulse control
- Periods of extreme anxiety
- Single parent household, three younger siblings (at least one ASD)
- Minimal school attendance
- Disruptive domestic environment (mother not present)
- Ongoing abuse and violence
- Self-harming/overdosing from 14 years old
- Periods of hospitalisation from 15 years old (acute and adult facilities)
- Suicide attempts from 16years old
- Foster care placements changing frequently
- Diagnosed with depression and Post Traumatic Stress Disorder
- Learning difficulty diagnosed at 11 years
- Socially withdrawn, paranoid thoughts
- Eating disorder from 12 years
- Fear of abandonment; feelings of self-loathing
- School refusal from 14
- Terrified of leaving home/sometimes bedroom (periods of movement by crawling only)
- Feigns recovery during acute stays to accelerate release
None of these in a real person but the range and types of issues represent those who could be classified as having “severe and complex mental health issues” between the ages of 13 and 25.
WHAT IS SIGNIFICANT ABOUT THIS AGE BRACKET (especially in relation to mental health)?
There is no doubt that between 13 and 25 years old is a key stage for the emergence of severe and complex mental health issues as well as for the development of every human being.
For everyone, it is a time when a person is no longer a child but still not yet an adult. They are taking on responsibilities and aspects of independence but still reliant on others, often having to abide by parameters set by someone else e.g. a parent/guardian/carer. It is a time when the peer group has its strongest influence. It is a period of experimentation and exploration. Because it is inevitably a period of change.
AND when a young person experiences severe and complex mental health issues throughout this period (and often prior to it), this stage of life has even more challenges that create significant and frequently long-lasting consequences in a range of ways:
Both due to personal circumstances and biology/chemistry, a number of serious mental health issues begin to present during this time. With diagnoses for conditions like bipolar disorder, borderline personality disorder and schizophrenia withheld until there is genuine stability within an adult life, a marked state of uncertainty and flux heightens the typical de-stabilising changes of adolescence.
It’s very likely that severity and complexity will present during this stage of life. But as with all issues if timely and appropriate treatment is provided during period, then the kind of progress that can be achieved will provides the potential for the most stable and productive adult life possible. If intervention does not occur during the period of adolescence to young adulthood, the likelihood of progress later is seriously diminished, leaving people to be reliant on numerous healthcare and disability services for the rest of their lives.
The impacts of severity and complexity often mean general chronological milestones (cognitively, emotionally and socially) aren’t reached by this cohort, especially when there are often extended periods of social isolation i.e. withdrawing from engagement in schooling or any other kind of interaction in the community and remaining isolated or housebound. It can also mean a growing detachment from family and peers and the creation of an artificial and unhealthy environment and the continuation of or increase in destructive or harmful behaviour.
It’s also possible that the complexity exists because of dual diagnosis i.e. a young person could also be dealing with an intellectual disability as well as one or more mental health issues
The capacity of young people in this cohort to be successfully independent and manage responsibility for living and decision-making can’t be as reliable as in those without severe mental health issues especially when various supports are still essential to their existence. The developmental delays and reduced life experiences as well as the repercussions of the trauma that many suffer both in coping with aspects of their mental health and in trying to access effective support mean that many young people continue to need to be closed connected with carers well into their 20s.
DIVERSE AND COMPLEX NEED
Because of the multi-layered issues – which as well as mental health issues in and of themselves can also include a challenging domestic situation, a history of and/or ongoing situations inflicting trauma, substance use/abuse etc. – young people and their families require a range of services and supports. This can include specialised health and education, family services, legal and financial support, housing/accommodation, employment, etc. However those affected by severe and complex mental health issues are often the least equipped to coordinate the energy- and time-consuming management of a network of service providers due to the impact of the issues on their daily existence. Unless there is full integration of services and a true holistic approach which utilises high-level strategy and implementation, young people and those who care for them will face ever-increasing challenges and needs amidst an often hopeless struggle to remain able to function even on a basic level.
REDUCED CAPACITY TO ADVOCATE
Even young people and carers with great determination and compassion for others in similar circumstances frequently find themselves practically unable to pursue consistent, ongoing and effective advocacy in this area. For themselves or on behalf on others in similar complex situations. The extent of the impact of the mental health issues plus the knock-on effects, the possibility that traumatising life circumstances or triggers continue to exist and the lack of success in attempts to access understanding and effective treatment can be debilitating. So despite their own needs and their desire to prevent others from encountering similar obstacles to obtaining sustained and useful support, those with lived experience often cannot devote extended periods of time on advocacy or have the physical, emotional and social capacity to represent their needs to service providers. When such advocacy requires consistent and repeated efforts, this cohort will continue to be neglected when in fact their need is greater than many groups. i.e. the reason they need extensive service provision is also the reason they are rarely able to communicate that in ways that make positive change possible.
often ENCOUNTERing SIGNIFICANT PROBLEMS IF TRANSITIONED TO ADULT SERVICES AT AGE 18
Readiness for any change is service for this group must be managed extremely carefully, gradually, with extensive support and based solely on an assessment of the particular individual and their circumstances. If chronological age is the criteria rather than genuine readiness to transition to any new provider/environment/program, the negative effects can be considerable. Not only is it highly possible that the new service won’t meet the specific needs of the young person but such a lack of understanding can engender a loss of trust and faith in the capacity for supportive help to exist that a disengagement from any service provision can occur.