Introduction
Adolescent psychiatry is still being neglected in many parts of the world, including South Africa. Adolescents are treated with either children or adult clients, resulting in ineffective treatment. Not enough emphasis is placed on adolescent psychiatry within the occupational therapy curriculum in most countries.
The developmental changes that take place during this life phase play a large role in adolescents’ specific needs, behaviours and problems and should form the foundation of their treatment. These developmental changes make adolescent clients unique. The occupational therapist should integrate medical and occupational science knowledge with clinical reasoning to fulfil the needs of an adolescent client diagnosed with a mental illness.
Adolescence can be described as the time between childhood and adulthood, and the term adolescence, from the Latin word ‘adolescere’, means ‘to grow up’ or ‘to grow to adulthood’. Generally, the adolescent phase is from 12 to 18 years for girls and 13 to 20 years for boys (Cherry 2013).
Some believe adolescence to be a tumultuous time, while others are of the opinion that it is not as turbulent as it was previously thought to be. The majority of adolescents negotiate their way through this life phase successfully (Szabo 1996). The ease with which the adolescent makes the transition is dependent on different factors, for example, speed and length of transition, attendance of school or college, outlook on life, environmental factors and adult expectations within the culture. Whichever way, it still remains a time of transition in which individuals develop from a child into an adult after which they will be recognised by society as being a mature adult with all the accompanying responsibilities.
Although strictly speaking adolescence can be divided up further into three stages, that is, early phase (11–14 years), middle phase (14–17 years) and late phase (17–20 years), these divisions are arbitrary, as growth and development occur along a continuum that varies from person to person (Sadock & Sadock 2007).
The chapter will make use of the Occupational Therapy Practice Framework (American Occupational Therapy Association (AOTA) 2008) as a guideline to indicate the differences between adolescents and clients in other life phases.
Adolescent developmental life stage within the Occupational Therapy Practice Framework
Context and environmental factors
The core of the domain of occupational therapy is ‘supporting health and participation in life through engagement in occupation’ (AOTA 2008, p. 626). Occupational therapists are primarily concerned with occupational performance, which occurs as a result of a transaction between the person(s), the context and environment and the occupation (Law et al. 1996; Christiansen & Baum 1997). This perspective is based on an ecological approach, which views adolescent development as taking place within complex systems, and the interaction between these systems influences how individuals proceed through life. Changes or conflicts in one layer have a ripple effect on the other layers and thus on development. Adolescents, with their own unique characteristics, interact with people and structures such as families, peers, schools and sports groups. These structures nest within community settings, which in turn nest within broader cultural, social, political and economic settings (Bronfenbrenner 1979). It is important for occupational therapists to consider context and environment when assessing and planning interventions for adolescents.
Context and environment comprise the following constructs: cultural, personal, physical, social, temporal and virtual (AOTA 2008). In South Africa, many adolescents live in contexts which do not promote health and well-being and contribute to placing them at risk of developing mental illness. Adolescents face a wide range of challenges including poverty, unemployment, violence, gangsterism, substance use, HIV infection and teenage pregnancy. Many adolescents grow up in unsupportive families where parents lack basic parenting skills or with one or both parents absent or deceased. In these cases, adolescents may be forced to adopt the parenting role and take on additional responsibilities. Risk factors such as using drugs, aggression, attention and learning problems, antisocial beliefs and difficulty resisting peer pressure increase the likelihood of adolescents joining gangs and/or engaging in violent and delinquent behaviour (Cooper & Ward 2012).
These factors contribute to the fact that in South Africa almost two thirds of adolescents drop out of school before reaching grade 12 (Department of Education, South Africa 2003). Schools should be safe contexts for adolescents, but unfortunately, this is not always the case as can be seen by the high prevalence of bullying, gang activity, educator-on-learner abuse and sexual violence (Gevers & Flisher 2012). Recently, cyberbullying has emerged as one of the main types of psychological bullying through the use of the Internet, interactive or digital technologies and mobile phones (RAPCAN 2009). This situation is not confined to South Africa alone and is common in many countries in the world.
Areas of occupation
When working with adolescents, occupational therapists need to consider which areas of occupation are relevant, namely, activities of daily living (ADL), instrumental ADL, rest and sleep, education, work, play, leisure and social participation (AOTA 2008). Engagement in these areas provides opportunities for adolescents to develop knowledge, skills and attitudes in diverse ways. For example, leisure activities enable adolescents to explore different interests, make decisions, socialise and develop confidence and self-esteem. However, leisure may also place adolescents at risk of negative and unhealthy behaviours such as boredom, substance use and violence (Wegner 2011). The occupational performance area of education is also important, as adolescents develop, among others, pre-vocational and vocational skills. Truancy and dropping out of school are indicators of problems in this area.
Values, beliefs and spiritual needs
During this developmental phase, adolescents start to internalise their own values and beliefs. They often question the values, beliefs and spirituality prescribed by those around them, for example, parents and educators. This may lead to conflict as they start to question others’ beliefs and values, which could cause parents and educators to be offended. It is important to be aware that adolescents, whose behaviour is incongruent to their internalised values, are at risk of developing depression.
Physical factors
Occupational therapists are advised to read about the body structural and functional changes that occur during puberty if they are working with adolescents. These changes are precipitated by hormonal changes. The body functional changes will be briefly described, and the implication for occupational therapy explained.
Due to hormonal changes, adolescents’ bodies start to change. Their growth rate increases and they start to develop secondary sexual characteristics. These physiological changes require energy, and adolescents therefore often present with an apathy or lethargic nature, which could easily be labelled as laziness. Their bodies do not change or grow proportionally, and they often appear gangly. These body changes affect their body image, which needs to adjust continually as their bodies change. Adolescents become self-conscious about their bodies, and physical appearances become more important.
Performance skills
Only the performance skills unique to adolescence will be discussed in the following text. Therefore, sensory perceptual skills and motor and praxis skills are not affected as normal development is complete by adolescence. On the contrary, it is recommended that if these problems present in adolescents, therapy does not focus on remediation (improve skills) or habilitation (preparing for a position) but rather on compensation (use abilities to overcome challenges).
Emotional regulation skills
Due to the influence of hormonal changes on emotions, the adolescent phase is fraught with frequent emotional instability and lability. Adolescents find it difficult to regulate their emotions. They will be aggressive the one moment and then in tears the next, to the astonishment of the people around them. Due to their egocentrism, they are more focused on their own emotional experiences. The changes in their bodies and expectations and responsibilities around them leave them feeling out of control and confused. However, occupational therapists should remember that this is part of normal development and does not necessarily indicate the presence of pathology.
Cognitive skills
According to Piaget’s (McLeod 2009; WebMD 2013) theory, adolescents’ cognitive development is described as formal operational thought. As adolescents develop abstract thought processes, they develop the ability to formulate a logical argument and are able to speculate. Their ability to plan improves as well as their metacognitive ability, which enables them to evaluate their own thinking. Their ability to think creatively improves, which in turn improves their problem-solving abilities. They enjoy formulating, testing and evaluating hypotheses. For example, an adolescent may debate the political situation with his/her parents or choose to change his/her religion. Obviously, this may result in conflict arising as the adolescent practises his/her newfound skills and abilities.
Adolescents’ cognitive development includes self-centred thought, and their egocentrism often causes conflict with others around them. They may have an imaginary audience to whom they ‘play’ and are under the impression that everyone is focused on them and how they look and act. They find it difficult to take thoughts of others into account and like to think that no one thinks and feels the way they do.
During adolescence, peer groups become important because it allows adolescents to practise social skills and they learn to build relationships with others, which form the foundation of intimate relationships in adult life. The peer group acts as a mini-society in which the adolescent can experiment with social behaviour and relationships because it is viewed as a safe environment. In the early phases, adolescents tend to surround themselves with a same-sex peer group, which then affords them safety to interact with the opposite sex. Once they are more confident, they form heterosexual pairs.
Due to the emotional and cognitive developments that occur, adolescents are often in conflict with their parents, educators and those in authority. Other reasons for conflict include their need for independence, their need to explore relationships and their challenging behaviour surrounding the development of their value system. If the peer group does not meet with the approval of their parents, conflict may arise. The conflict will then be exacerbated by the adolescents’ need for independence and their need to form their own value system. Their feelings of being invincible make them vulnerable to risk-taking behaviour. This is another cause for conflict.
Their friendships change in that they view friendships as more intimate, loyal and faithful. As these become more crucial, they compete less with each other and share more equally. They wear the same clothes as their peer group and use the same language, which creates a sense of belonging and unity. Their peer group helps them to develop their identity of who they are and what is important to them. The majority of adolescents receive sex education from their peer group.
Performance patterns
In addition to the basic roles of childhood such as son/daughter, sibling, scholar and friend, adolescents develop more diverse roles, for example, member of a sports team, boyfriend/girlfriend, and volunteer and casual worker. These new roles contribute to the adolescent’s identity and skills development and provide a framework for habits, routines and rituals, which in turn structure the use of time. However, performance patterns can also be destructive and hinder occupational performance as in the case of an adolescent who is depressed, drops out of school and sleeps all day.
Settings where occupational therapists work with adolescents
There are numerous settings in which occupational therapists can work with adolescents such as health, social welfare and educational systems. In the health setting, occupational therapists can work within public and private psychiatric hospitals and clinics where remediation and rehabilitation programmes are implemented. There are also specialised units for eating disorders or substance abuse where occupational therapists are an asset. Although employment within the community in South Africa is currently limited, occupational therapists working within the community are mostly generalists and should be able to adapt intervention programmes for adolescent clients. Occupational therapists in the educational system can be employed by different types of schools, from Learners with Special Needs (LSN) schools to mainstream and private schools where intervention may aim to promote health and prevent illness. In South Africa, there is a trend for a very small, privileged percentage of adolescents to attend private schools where an occupational therapist is employed who focuses on the subject of life orientation which incorporates life skills training and implements pre-vocational skills programmes. In these settings, habilitation programmes are the focus as they assist adolescents to develop normally and to learn new skills. In the social development system, occupational therapists are employed by children’s homes, places of safety and juvenile detention centres where habilitation, remediation and rehabilitation programmes are implemented.
Assessment methods
In some mental health settings in South Africa and possibly in other Third World countries where there is a poor ratio between patient and occupational therapist, assessments are often neglected in order for treatment to start as soon as possible due to the limited time of admission. However, assessments are essential for effective treatment. Without a good assessment, occupational therapists cannot provide evidence of quality treatment. Time should be taken to conduct a comprehensive assessment. The assessment of adolescents does not differ significantly from occupational therapy assessments for adults, but there are however a couple of additional aspects that need to be kept in mind. The occupational therapist should investigate the advantages of each assessment within the mental health setting and decide which assessments would work best. However, the focus should be on occupation-based assessments in order to create an occupational profile.
In short, all aspects required by the Occupational Therapy Practice Framework (AOTA 2008) need to be assessed although other practice models may be selected to form an integrated client assessment. The different assessment methods with adolescents include interviews, collateral information, observations in structured and unstructured situations, formal/standardised and informal tests and participation in occupation-based activities including grooming.
Interviewing
Depending on the role divisions within a multidisciplinary team, different members may perform the first interview. Since interviewing is a generic skill, it does not matter who conducts the interview. It is important that all necessary information is obtained and a rapport is established with the client. The interview should, if possible, include the mother, the father and the client. Even if the parents are divorced, both should be present. Later in the interview, the parents can be requested to leave so that more personal questions can be asked. The occupational therapist should observe the client’s relationship with both parents and their relationship with each other.
The occupational therapist starts with open-ended questions (Morrison & Anders 1999) and follows up with milestones and general background history, including questions regarding the client’s occupational performance areas. The adolescent’s school progress and recent functioning at school are essential. Generally, a decline in schoolwork is a positive indicator of emotional problems in children and adolescents. The occupational therapist should ascertain what performance areas are the most problematic for the client and what he/she would like to change. Questions such as ‘What do you do after school?’ or ‘What do you do with your friends?’ are helpful (Morrison & Anders 1999).
After the parents have been asked to leave, the interview will continue with the client. It is important to reassure the client of confidentiality, explaining that the information will be shared with all the team members to ensure optimal treatment but that his/her parents will not be informed unless he/she gives permission. Only then is it more likely that the personal information concerning sexual development, relationship with peers and use of substances will yield truthful answers. The way the questions are posed and the occupational therapist’s non-verbal communication are important when the sensitive questions are asked. The therapist should rather ask, ‘Have you experimented with drugs?’ instead of ‘You haven’t used drugs before, have you?’ Other meaningful questions are such as ‘What would your best friend say if I asked him about you?’ Questions about suicidal ideation and attempts are indicated in adolescents that present with depressive symptoms.
Irrespective of the questions asked, the occupational therapist must remember that he/she is interviewing an adolescent who sometimes approaches interviews with suspicion, hostility and indifference (Hoge 1999). It is therefore important that time is spent building a rapport. The occupational therapist must be non-judgemental, empathetic, warm and trustworthy. Adolescents are particularly sensitive to adults that come across as being ‘fake’, and it is important to be congruent and monitor transparency. Initial resistance, vulgar language or testing behaviour should not shock the occupational therapist. However, the occupational therapist is advised not to try to be a peer by using slang and vulgar language in return. The interviewer should find a middle ground between being excessively formal and inappropriately familiar and project genuine interest and attention for the adolescent (Morrison & Anders 1999).
Collateral information
The occupational therapist should select appropriate people to verify information obtained by making use of collateral information. The nursing staff who observe the client continuously in the ward provide valuable information. An aunt or uncle in the family may provide information from another perspective. The current and/or previous school educators, friends, siblings, previous therapists, medical doctor, employer of a holiday job, for example, are possible sources of information. However, it is essential that the occupational therapist receives permission from the client and his/her parents (as he/she is still a minor) in writing, before gathering collateral information.
Assessment activities
There is advantage in the use of activities with the adolescent during occupational therapy assessment and intervention. Poor insight and poor self-concept on the part of the client may cause inaccurate accounts of abilities provided in pen-and-paper activities and interviewing. However, participation in activities yields a wealth of information. Over the years, occupational therapists have observed that the manner in which adolescents approach and carry out an activity is indicative of the way they lead their lives. For example, adolescents who find it difficult to make decisions within a craft activity are highly likely to exhibit problems concerning decision-making in their schoolwork or in intimate relationships. The same holds true for other performance components which can be observed during the activity.
An example of an assessment activity is as follows: making a collage of himself/herself and then explaining it is a valuable activity for an assessment as it covers so many performance components and functional aspects of his/her schoolwork and pre-vocational skills especially work competency, which includes planning, neatness, accuracy, ability to evaluate own work, ability to recognise mistakes, perseverance, etc. It is also an easy and affordable assessment. The themes of the collage can give the occupational therapist an indication of issues that are uppermost in the client’s mind. Another advantage of selecting the making of a collage is that it is non-threatening to adolescents and they can express themselves freely and creatively.
Standardised tests
Occupational therapists must ensure that the standardised tests used during assessments are suitable for the client’s culture as well as age group. Assessment results of tests standardised for adults cannot be generalised to the adolescent population group. Similarly, tests standardised for children cannot be used for adolescents. For example, the Developmental Test of Visual-Motor Integration (Beery 1997) is reliable for adolescents only up to the ceiling age of 15 years (Boyt Schell et al. 2013). Tests like the Canadian Occupational Performance Measure (COPM) (Law et al. 1999), Hospital Anxiety and Depression Scale (HADS) (Milne 1992), Inventory of Interpersonal Problems (Milne 1992), Coping Responses Inventory (Milne 1992) and Cognitive Assessment of Minnesota (CAM) (Rustad et al. 1993) are tests that occupational therapists may administer to adolescents. Repeated mood assessments over time are more accurate (Morrison & Anders 1999). Numerous informal questionnaires are available on the Internet. However, when using any self-reporting questionnaire, the occupational therapist should ensure that the client has the necessary insight and introspection to be able to answer the questions; otherwise, the answer will be invalid and unreliable.
The clients may also be referred to a counselling psychologist for additional tests, for example, personality, aptitude and study skills.
Occupational group therapy
Occupational group therapy is highly recommended as a method of assessing adolescents as peer relationships are essential to their development. Adolescents should be placed in unstructured and structured groups as part of their assessment. The occupational therapist can observe in particular social participation.
Observations
During assessments, the occupational therapist should observe both content (i.e. what is he/she actually saying) and process (e.g. What does he/she avoid? When is he/she eager? What has been left unsaid?). Another important observation is, ‘What should be present and is not?’ Additional observations can be made when the client is in an unstructured situation, for example, eating lunch and playing outside in free time or during sport. These observations may bring new insights. It is especially useful when assessing clients with anxiety disorders as their anxiety can influence test results. Observations need to be used together with clinical reasoning.
Forensic Psychiatry and Occupational Therapy
Sensory Integration in Mental Health
