Second Level Schools
The artist is particularly interested in running the project in second-level schools, as an early mental health intervention, and the pilot was successfully run in Pobalscoil Ghaoth Dobhair, Co. Donegal. In the essay below, she reflects on the unique challenges present in school settings. (Written in late 2020, it only touches upon the many changes to the mental health landscape brought by the COVID-19 situation.)
Promoting Mental Health Awareness: Youth Mental Health with a focus on the Irish and School Setting.
© Maria Coleman, 2020
The WHO definition of mental health as "a state of wellbeing in which every individual realises 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" (www.who.int, 2018). The WHO also estimate that in a given lifetime, up to a quarter of all people will experience some form of mental disorder that could impair their wellbeing. Mental ill health is therefore one of the leading causes of disability worldwide (www.who.int, 2001). In this essay, I will look in particular at the mental health of adolescents with reference to the situation in Ireland, and where relevant, the school setting. Many psychiatric disorders have their onset in teen years. The WHO reports that half of all psychological conditions start by 14 years of age. (WHO) From a survey of 41 affluent countries, Unicef found that one adolescent in four reported experiencing two or more psychological symptoms more than once a week. (Unicef, 2017)
At the most severe end of the spectrum, suicide is the third leading cause of death in 15-19 years old globally. (who.int, 2020) Using Unicef's narrowed focus on high-income countries, suicide was actually the leading cause of death among this age cohort, accounting for 17.6 per cent of all deaths, with Ireland's teen suicide rates fourth highest in the forty one countries assessed. (Unicef, 2017) Problems of this magnitude do not arise suddenly, and as far back as 1998 the UN was concerned about the lack of a national policy in Ireland addressing the mental health of children (UN, 1998). In 2001, the Irish Chief Medical Officer admitted that "the promotion and development of sound mental health for children, and the identification and treatment of psychological and psychiatric disorders, have been patchy, uncoordinated and under resourced" (Department of Health and Children, 2001).
Adolescents in need of mental health provision in Ireland are referred to CAMHS (Child and Adolescent Mental Health Services). There are 70 of these community-based, multidisciplinary teams nationally, and approximately 18,100 referrals were expected in 2019 (oireachtas.ie, 2019). Writing from the 'frontline' of acute youth mental health care in late 2018, Prof. Fiona MacNicholas wrote
CAMHS are currently fragmented, over stretched, and under resourced [...] there are 2,700 children on a waiting list, with 14% of these waiting longer than 12 months. [...] There has been recognition of staff burn out, consultant resignations, and services being viewed as 'untenable and unsafe'. Clinicians have perceived themselves to be placed in 'ethically compromising situations' by virtue of inadequate resources. [...] [The Mental Health] budget having consistently decreased from 13% in 1984 to the current 6.1%. (McNicholas, 2018)
The system she describes appears to be a struggling one. Anecdotally, and speaking from personal experience, parents are aware of wait times and frequently seek private supports in order to get help in a timely manner.
Where early intervention is not possible, or where more acute cases present, service needs can escalate to inpatient care. Due to a lack of dedicated beds, in 2017, an overflow of 82 Irish teens needing acute care were referred to adult facilities. This fact, along with lengthy waiting lists, funding variances and inequalities of care across different CAHMS settings were highlighted as particular weaknesses in youth care in the 2017 Mental Health Commission Annual Report (www.mhcirl.ie, 2017). As of 2019 there were just four acute CAMHS units nationally, with 76 inpatient psychiatric adolescent beds available in total (oireachtas.ie, 2019). Given that the overflow figure quoted above is higher than the system's capacity, one could reasonably judge inpatient provision to be under resourced.
High rates of illness, and a history of patchy service provision, are exacerbated by barriers to seeking help such as cultural or personal beliefs, stigma, fear, or gaps in education. In Ireland, the 2019 My World Survey 2 (MWS2) indicated that 12% of male and 21% of female secondary school students, reported needing professional help but not seeking it. (Dooley et al., 2019). In what follows, I will look at some neurobiological facts that inform and predict possible problems, examine prevalence indicators arising from available research and look at what interventions could help to improve the situation.
Causes and Symptoms of Mental Health Problems
The myth persists that the root cause of 'teen angst' and the emotional distress that frequently arises during this phase, is 'raging hormones.' Certainly, the onset of sexual maturity can bring with it an emotional rollercoaster of joy and pain, infatuation and rejection that can take its toll on mental wellbeing. MWS2 indicated that 24% of second level Irish teens had a recent relationship break-up and 18% reported relationships as a cause of stress. (Dooley et.al, 2019) In the case of LGBQT+ youth, sexual maturation can be particularly complicated. An estimated 7-13% of the Irish secondary school population (Dooley et.al, 2019), identify as non-heterosexual. This marginalised group can often feel stigmatised and afraid to open up about their sexuality/gender identification. Although not specific to the Irish youth or school context, it is perhaps informative to consider how exposed marginal groups can be to mental ill-health by looking at a 2019 study from the UK. It was reported that over half of LGBT people (52%) have experienced depression and 61% had anxiety in the last year (www.stonewall.org.uk, 2018). Puberty, hormones, relationship troubles and LGBTQ+ marginalisation, do not account for all of the struggles underpinning teen experience however.
The WHO definition of mental health as a 'state of wellbeing, in which the individual realizes his or her abilities,' is particularly relevant to the adolescent experience. It is a time of immense neurological remodelling as the brain undergoes a phase called 'neural pruning.' This process audits the vast amount of links that were forged during formative childhood years, dispensing with unused pathways and making useful neural connections more efficient through myelination (this is the laying down of a fatty sheath around neurons that improves their efficiency by up to 3000 times.) In this way, the youth literally 'finds themselves' and begin to realise and hone their own particular abilities, interests and tendencies, shaping the adult they will become.
Child and adolescent psychiatrist, Dan Siegel, has written about the adolescent brain, and understands neural pruning as a huge opportunity for specialisation and innovation, but also a time of immense psychological susceptibility. (Siegel, 2015) In any system undergoing rapid change, vulnerabilities are likely to be exposed by testing situations. These challenges are often sought out by the young person, since this phase of independent learning is characterized by a need to take risks and to explore unfamiliar, uncertain and uncomfortable territories beyond secure childhood boundaries. This risky time of rapid development, can trigger mental imbalances that could then deteriorate towards issues such as low self-esteem, anxiety, panic attacks, depression, eating disorders, self-harm, suicidal ideation, attention deficit hyperactivity disorder (ADHD) or disruptive conduct. With an eye to their common underpinnings, this essay will consider a selection of these.
Neurological pruning and optimizing begins in the back of the brain, meaning a youth's ability to cope, can be coloured by an over-reliance on evolutionarily older parts of the brain, namely the brain stem and amygdala. Brainstem function include instinct, motor control, survival and arousal. The amygdala, often referred to as the emotional brain, is a more reactive part of the mind, associated with the fight or flight response, impulsivity and aggression. The better coping skills like forethought, self-control, decision making, perspective and reflective response are not honed until the prefrontal cortex is reorganized and myelinated in late teens or early twenties. Considering the WHO mental health definition and its reference to an ability to 'cope with the normal stresses of life,' it seems that neurological particularities, stack the odds somewhat against young minds.
Resilience to stress is undermined by the pruning process, but to raise the stakes, the process itself is actually accelerated by stress. This can leave the teen brain not only reliant upon, but actually reinforcing, circuitry that does not allow for favorable self-regulation. Innate stress responses become amplified, leaving young brains optimized for reactive, rather than responsive interactions. Stressed, remodeling brains can, for example, have a heightened propensity towards aggressive, disruptive behaviors, which can lead to conflict in family, school or community settings. In extreme cases this can lead to diagnoses such as DBD (Disruptive Behavior Disorder), an illness predominantly identified in late childhood and adolescence. With no figures available for Ireland, it's informative to look to the US, where the Dept. of Health estimates that 3% of teens have it, with the majority of these being boys aged over 12yrs. (www. ahrq.gov, 2016).
Over-reliance on hind and mid-brain networks, can open other precarious susceptibilities. The mid-brain amygdala, is the mind's central switchboard for fear, and stressed, remodeling teen brains can sometimes become optimized for anxiety. Mechanisms developed through evolution to register dangers (a predator for example), mobilize for survival, creating strong, psychological and physiological responses. Nowadays, predators are less likely, but young minds have natural hyper-vigilance, being instinctively programmed to leave safety and seek independence. This innate watchfulness means strong fear responses can be triggered by modern stressors like media distractions, crowds, exams or pandemics, prompting panicky feelings and sometimes leading to anxiety related disorders.
These can include generalized anxiety, panic attacks, agoraphobia, social anxiety, obsessive compulsive disorder, phobias and post-traumatic stress disorder. My World Survey 1 (MWS1) was published in 2012 (Dooley & Fitzgerald, 2012) and the aforementioned MWS2 was published in 2019. In those 7 years, severe or very severe anxiety reported by Irish teens doubled from 11% to 22%, with females more likely to present outside the normal range. (Dooley et.al., 2019). St. Patrick's Hospital approximates that 20% of people will experience a panic attack at least once in their lives. In cases of anxiety, they promote the use of Cognitive Behavioural Therapy, with sedative medication possibly used to stabilize the situation initially. The hospital, which has a specialist teen unit, acknowledges that a growing understanding of the problem has led to good outcomes once support is sought in a timely manner (www.stpatricks.ie, 2020). Unfortunately, as was outlined in the introduction, timely, preventative interventions could not be assumed as a typical experience at the current time in Ireland.
MWS 2 surveyed 19,000 young Irish students, over 10,000 of which were attending secondary school. One methodology used to assess respondent's wellbeing was the Depression Anxiety Stress Scale (Lovibond, 1995). DASS results showed that 40%, of those surveyed were classified outside the normal range for depression. Of these, 10% were in the mild range, 15% were categorized as moderate, 6% as severe and 9% as very severe. The combined figure for those reporting as severe, to very severe is 15%. This is a concerning rise from MWS1 that had a comparable figure of 8% just 7 years earlier. Males were more likely to be in the normal range, and females were much more likely to report being in the severe to very severe range. Depression increased across school year with 50% of sixth-years reporting being outside the normal range (Dooley et. al, 2019).The stress of exams must therefore be considered as a mitigating factor.
In relation to suicidal thoughts, 41% of those surveyed in secondary schools said they had considered taking their own life, even though they would not do it. Following the same pattern as depression, females were more likely to report suicidal thoughts (females 46%, males 34%) and senior cycle students were more likely than junior (48%, and 36% respectively). Significant emotional turmoil clearly underlie these startling findings, and the dangerous thinking patterns do show concerning actualization in the form of suicide attempts reported at a rate of 6%, and self-harm at a rate of 23%. Self-harm tendencies are higher in females (26%) than males (18%), and highest in the sixth year cohort (26%). Again exam pressure and concerns over third level attainment no doubt contributing factors.
The survey results speak of considerable difficulties being experienced by Irish school-going adolescents. The waiting lists and severity thresholds used by CAHMS can leave a vacuum where help is needed but not available. Worried parents consult their GPs where, it seems medication is frequently prescribed, possibly as a 'stop-gap' solution. In 2018 it was reported that there was a whooping 512% rise in Sertraline prescriptions and a 181% rise in Prozac prescriptions issued to under 18s over a ten year period to 2017 in Ireland (thejournal.ie, 2018). Sertraline is a Select Serotonin Reuptake Inhibitor, (SSRI) typically prescribed for depression, OCD, panic disorder, PTSD and various dysphoric and anxiety disorders. It has a long list of child and adolescent specific side-effects including slowed growth and menstrual complications. Other uncommon but serious side effects include an exacerbation of psychiatric symptoms. Prozac is generally well tolerated by young people, but likewise, rare side effects can include panic, mania, violent and suicidal states.
These figures could, by some, be interpreted as an encouraging increase in help-seeking but the rate at which prescriptions are increasing is nothing short of alarming. It is essential that medication is used with caution as part of a holistic treatment plan. This is theoretically possible once inside the CAHMS multidisciplinary and specialist system. Although not necessarily reflective of the Irish situation, it is informative to acknowledge a 2016 study from the UK that points to a tendency for primary care practitioners to fail to make necessary referrals beyond medication (O'Brien et al, 2016). In my personal view, there is an over-reliance on medication. If judged correctly, this, together with treatment bottlenecks paint a challenging picture regarding the trajectory of Ireland's youth mental health situation.
Given my understanding of the neurological underpinnings of the teen mind, however, I believe there are further mitigating factors unique to the teens of this generation. The midbrain, which is being actively reorganised in adolescence, is also home to the brain's motivation and reward circuitry. The neurotransmitter dopamine is key to this pathway, and it is an unfortunate fact that when smart phone and social media designers set about making their products desirable, they knowingly sought to hijack these neural pathways, in the same way that gambling and addictive drugs do. Building in 'rewards' such as 'likes' and pings, they ensured addictive feedback loops to keep users returning to the interface, forming strong habitual and compulsive behaviours.
Through repeated usage, these hijacked pathways are then optimised by the myelination process, further embedding the habit. This leaves young people particularly susceptible to the habit of checking devices, as unthinkingly as if scratching an itch, to seek a technologically mediated dopamine hit. Add to this a teen's hardwired and amplified need for social engagement and acceptance with peer groups, and one begins to realise the power that social networks can wield over a young mind. A leaked internal Facebook memo confirmed that the company can granularly identify when a teen user feels insecure, worthless, or needs a confidence boost (thegaurdian.com, 2017). Knowing this allows the company to provide a timely boost and further cement the young person's relationship with the technology and, by association, the advertisers that fund the platform.
Dystopian coercive control aside, it's worth remembering that the developing architecture of the teen brain, means that impulse is a more organised pathway than intention is, and the devices exploit and intensify this imbalance. Phones undermine one's ability to focus and plan, leaving only continuous partial attention, a state not conducive to learning, memory, or mental wellbeing. MWS2 showed that 96% of secondary school students have a social media profile. Concerning trends in device use include the excessive time spent online, (34% of students spend more than 3 hours, and 29% spend 2-3hrs/day), and 44% of males also reported accessing pornography online more than once a week.
Phone use has a negative impact on sleep and physical activity, and low levels of both, as well as social media and pornography use were strongly associated with depression and anxiety. (Dooley et al.,2019). A study from the US found showed that 13-18 yr olds who spent more time on screens were more likely to report mental health issues, than those who engaged in more non-screen activities. Between 2010 and 2015 they correlated device usage with a rise in suicide deaths and depressive symptoms, especially among females who spent excessive time on their devices. In extreme cases where seven hours or more are spent online, the chances of depression doubled (Twenge et al., 2017) Additionally, phone use is an avenue for cyber-bullying, a form of abuse that is on the rise in Ireland, and sometimes linked to suicides. Campaigners (for what has become known as Coco's Law) are looking to have the posting of abusive comments made illegal in Ireland.
This year, the pandemic interrupted important teen rites of passage including the Leaving Certificate and the transition from national school to secondary school. Importantly, the lockdown also temporarily robbed our ability to socially engage. Stephen Porges' Polyvagal theory recognizes that our nervous systems are at their most relaxed, and our minds are accessing their most evolved neural networks, when we are using our social engagement system (Porges, 2011). Subtle cues such as the tone of particular facial muscles trigger feelings of safety that fuel social cohesion. With teens now spending up to seven hours a day, five days a week behind face masks and interacting with masked teachers and classmates, it is important to recognize that a new barrier now exists to relaxed social interaction.
Neural reactions to facial cues have been used in research to ascertain how the mind works. One such study with adolescents who had major depression showed how the teen brain's tendency to over rely on the mid-brain amygdala contributed to the test subjects misinterpreting neutral facial cues as hostile. (Hall et al, 2014). These insights show how masks can form a layer of ambiguity that removes richness and affirmation from social interaction, create opportunities for misperception, and becomes yet another challenge to maintaining wellbeing for young minds.
Evidence based interventions
Given the high level of adolescent mental ill health, the CAHMS waiting lists, the prevalence of medication and the barriers to help seeking created by fear and stigma, there are compelling arguments for universal interventions actioned in the school setting. Research shows that group interventions are particularly useful for anxiety, with the normalising effect and peer support of the group. School provides access to large numbers of young people in a single, structured setting. When looked at through the prism of Maslow's theory of the hierarchy of human needs, (Maslow, 1943) schools provide a sheltered, safe environment where the cohesive sense of belonging to the school community provides a base from which positive outcomes can happen, like esteem building and self-actualisation. Teachers are well placed to identify teens at risk of mental ill health, or to identify risky social dynamics such as bullying that can lead to poor wellbeing outcomes. Additionally, peer groups can be exposed to interpersonal contexts they might otherwise avoid, providing them with a safe, shared context through which they can socially interact and examine problem situations. Despite the obvious care provision opportunities, research has found that some 80% of young people in need of mental health services do not have the opportunity to participate in school-based interventions (Cobham, 2012).
A rapid evidence review from the US considered various intervention types for teens (www.academyhealth.org, 2018), and where small improvements were recorded in most interventions considered, resilience-based cognitive behavioral therapy interventions indicated some of the most promising outcomes. Researchers from Canada reviewed 49 universal school-based resilience-focused interventions, to ascertain their effectiveness. They found a reduction in depressive symptoms, internalizing problems (anxious feelings, low mood, somatic complaints) and externalizing problems (aggressive, disruptive behaviour), and general psychological distress across all ages. Where a measurable positive effect was found on anxiety in children, this was not as consistent with adolescents, possibly due to a need for more age appropriate materials. Follow ups revealed a significant effect on depressive symptoms (Herzig-Anderson et al, 2012).
Developed by the Penn Positive Psychology Center and Dr. Karen Reivich, The Penn Resilience Program is a leading evidence-based resilience and positive psychology program used in various settings worldwide, including schools. Based on 25 years of research, the program claims to a huge range of positive outcomes. Resilience skills look to build the ability to 'bounce back' and also to grow from adversity. Resilience is built by addressing individual and environmental protective factors, such as self-esteem or school connectedness, harnessing their capacity to bring stability and capacity for adaptation to challenging situations. It employs CBT (Cognitive Behavioural Therapy), where people learn to recognise, explore and alter relationships between negative thinking, behaviours, emotions and sensations, and adds a variety of other positive psychology techniques including gratitude and mindfulness. Although this program, according to my research, is one of the best available resources in the field, research in an Irish schools context is not available. Although not specifically resilience-based, another CBT-based program with a similar universal delivery has been studied in Ireland.
Friends for Life, an evidenced-based prevention program from Australia, (Barrett, et al, 2000) is endorsed by the WHO. It has been adopted by Ireland's National Behaviour Support Service and assessed by them in a paper from 2013. Prior to the program they studied, 18.8% of the 244 student participants rated themselves as having 'elevated' anxiety levels. This reduced to 10.2% following completion of the 10 session programme. Continued improvements were recorded following 'booster' sessions four months later. (Henefer et al, 2013) Although the results from the Irish study are very positive, once existing school staff deliver the intervention, a lot of other research points towards weaker outcomes in school-based interventions. Evidence suggests that outside specialists are more effective than school staff (Herzig-Anderson, et al, 2012).
With a view 'from the inside' in an Irish second level school, albeit on a part time basis, I would forward another possible reason that interventions by regular teachers do not always hit the target. Irish secondary schools have to cope with overcrowded class rooms, under funding, loss of home-liaison officers and reduced hours for guidance counsellors, not to mention the challenges of online teaching during rolling lockdowns. Secondary teachers are trained to teach their core subject, they are ill equipped to deal with this dangerous rise in mental problems affecting students. Although 'Wellbeing' courses on the Junior Certificate seek to address issues such as stress, the nature of the course delivery may mean it does not have the desired impact. Schools, and teachers it seems, are energetically at their limits, and although wellbeing programs delivered 'in house' have good intentions, I do not believe it fair to expect teachers to quickly up-skill beyond their core subjects when teaching is known to be a high-stress profession. A number of in-service trainings do not constitute good resources to deal with an issue as salient as mental health.
Concluding with Hope
Given the sizeable mental illness burden on young shoulders there are very compelling reasons to ensure that interventions are applied at the earliest possible stage in order to ensure positive outcomes into the future. CAHMS aims to give individualised treatments but the current system is unable to deal with demand. It seems that there is much merit in universal interventions, at a school level, but research indicates that teachers might not be the ideal facilitators for such programs. Dan Siegel, the expert on the neurological restructuring of the adolescent brain, reminds us of the huge potential of the teenage brain.
Siegel in fact credits the ability of the adolescent brain to forge new ground as the cutting edge of human evolution. Greta Thunberg for example, has demonstrated to the world how ambitious, positive and single-minded, young people can be. The WHO definition of mental health concludes that wellbeing underlies a person's ability to 'work productively and fruitfully, and [be] able to make a contribution to her or his community.' In this generation, a teen's 'work' is too often associated with their ability to perform academically, or to engage in school or sports activities. I believe this is too narrow, and competitive a playing field for teen potential. Additionally, the Leaving Certificate points system is a blunt instrument that can become a corrosive mental health influence in a young person's life.
I wonder instead what growth, empowerment and resilience would ensue if opportunities like transition year were used to train teens to engage fruitfully in community settings? Rather than adults approaching student populations as a passive receptive mass that need to be taught, or, in the case of wellbeing, somehow steered towards rehabilitation, what might happen if adults stepped back, and acknowledged young people's own innate abilities? What might happen were teens trained to actually deliver group mental health interventions in their school communities? Those delivering the material might have a confidence boost and a sense of empowerment. Those attending might react well to a peer learning setting. With appropriate guidance could youth groups play a role in the development of material?
Why confine such an activity to the school setting? What could happen, if teens could be trained as community mental health ambassadors? In the style universal psychosocial interventions what might happen were youths trained as facilitators? They could teach the generation before them about stress management, or perhaps about advocacy, instructing them on the skills needed to help themselves and others. The My World Surveys asked a simple and very insightful question of their respondents. They enquired if young people felt they had the listening ear of 'One Good Adult,' who they could confide in when going through turmoil. The results were very encouraging. MWS1 reports for example over 70% of young people reported receiving positive support from a special adult (Dooley & Fitzgerald, 2012). What if resources, such as the immense youth potential Siegel proposes and the adult compassion Dooley et al. have identified, could be harnessed and interwoven? Sometimes the most elegant solutions to seemingly intractable problems are the simplest.
World Health Organisation (2018). World Health Organisation. Available at: https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response [Accessed 3 November 2020].
World Health Organisation (2001). World Health Organisation. Available at: https://www.who.int/news/item/28-09-2001-the-world-health-report-2001-mental-disorders-affect-one-in-four-people [Accessed 4 November 2020].
UNICEF (2017). Unicef Office of Research-Innocenti. Available at: https://www.unicef-irc.org/publications/pdf/RC14_eng.pdf [Accessed 5 November 2020].
World Health Organisation (2020). World Health Organisation. Available at: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health [Accessed 3 November 2020].
United Nations (1998) UN Treaty Body Database. Available at: https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CRC%2FC%2F15%2FAdd.85&Lang=en [Accessed 3 November 2020].
Department of Health and Children (2001) The Health of our Children', Second Annual Report of the Chief Medical Officer Quoted in Amnesty International (2002) Mental Illness The Neglected Quarter. Available at: https://www.amnesty.ie/wp-content/uploads/2016/02/Mental-Illness-The-neglected-quarter-summary.pdf [Accessed 3 November 2020].
McNicholas F. (2018) 'Child & Adolescent Emergency Mental Health Crisis: A Neglected Cohort', Irish Medical Journal 111(10), pp. 841.
Oireachtas (2019). Tithe an Oireachtais. Available at: https://www.oireachtas.ie/en/debates/question/2019-03-13/8/ [Accessed 12 November 2020].
The Mental Health Commission (2017) Mental Health Commission Annual Report 2017. Available at https://www.mhcirl.ie/File/2017_AR_Incl_OIMS.pdf [Accessed 10 November 2020].
Dooley, B, O'Connor, C, Fitzgerald, A, O'Reilly, A. (2019). My World Survey 2: The National Study of Youth Mental Health in Ireland. Available at :https://www.myworldsurvey.ie/content/docs/My_World_Survey_2.pdf [Accessed 3 November 2020].
Stonewall (2018). LGBT in Britain Health Report. Available at: https://www.stonewall.org.uk/lgbt-britain-health [Accessed 10 November 2020].
Siegel, D. J. (2015). Brainstorm: the power and purpose of the teenage brain. New York: Jeremy P. Tarcher/Penguin.
US Department of Health and Human Services (2016). Agency for Heathcare Research and Quality. Available at: https://effectivehealthcare.ahrq.gov/products/disruptive-behavior-disorder/consumer [Accessed 10 November 2020].
Dooley, B, O'Connor, C, Fitzgerald, A, O'Reilly, A. (2012). My World Survey National Study of Youth Mental Health in Ireland. Available at : https://www.myworldsurvey.ie/content/docs/My_World_Survey_2012_Online.pdf [Accessed 3 November 2020].
St. Patrick's Hospital (2020). St. Patrick's Mental Health Services. Available at: https://www.stpatricks.ie/mental-health/anxiety [Accessed 6 November 2020].
Lovibond, S.H. & Lovibond, P.F. (1995) Manual for the Depression Anxiety Stress Scales. 2nd. Ed. Sydney: Psychology Foundation.
The Journal (July 2018). thejournal.ie. Available at: https://www.thejournal.ie/ireland-antidepressant-anxiety-medicine-prescriptions-4157452-Aug2018/ [Accessed 10 November 2020].
O'Brien D, Harvey, K, Howse, J, Reardon, T, Creswell, C. (2016) 'Barriers to managing child and adolescent health problems', The British Journal of General Practice: The Journal of the Royal College of General Practitioners, 66 (651), pp. 693-707.
The Gaurdian (2017). The Gaurdian. Available at: https://www.theguardian.com/technology/2017/may/01/facebook-advertising-data-insecure-teens [Accessed 10 November 2020].
Twenge JM, Joiner TE, Rogers ML, Martin GN. (2018) 'Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time', Clinical Psychological Science, (6), pp. s3-17.
Porges, S. W. (2011) The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W.W. Norton.
Hall L.M, Klimes-Dougan B, Hunt R.H, Thomas K.M, Houri A, Noack E, Mueller B.A, Lim K.O, Cullen K.R. (2014) 'An fMRI study of emotional face processing in adolescent major depression', Journal of Affective Disorders. Oct (168), pp. 44-50.
Maslow, A. H. (1943) 'A theory of human motivation', Psychological Review, 50 (4), pp. 370-96.
Cobham, V.E. (2012) 'Do anxiety-disordered children need to come into the clinic for efficacious treatment?', Journal of Consulting and Clinical Psychology, 80 (3), pp. 465-476.
Academy Health (2017) Rapid Evidence Review. Available at: https://academyhealth.org/sites/default/files/Rapid_Evidence_Review_Behavioral_HealthJan2018.pdf [Accessed 12 November 2020].
Herzig-Anderson, K, Colognori, D, Fox, J, Stewart, C. E, Masia-Warner, C. (2012). 'School-based anxiety treatments for children and adolescents' , Child and Adolescent Psychiatric Clinics of North America, (21), pp. 655-668.
Barrett, P. M, Lowry-Webster, H, & Turner, C. (2000) FRIENDS program for children: Participants workbook. Brisbane: Australian Academic Press
Henefer, J, Rodgers, A . (2013 )FRIENDS for Life': a School-based Positive Mental Health Programme. Research Project Overview and Findings. Available at:https://www.nbss.ie/sites/default/files/friends_report_final_lr.pdf [Accessed 12 November 2020].