Adolescence and health

Adolescents generally form a very healthy population. Health behavior patterns are largely adopted at a young age in psychosocial and cultural contexts. However, development from childhood to adulthood is related to an increased risk of health complaints, of which mental health problems are often the most severe. In addition, psychosocial background factors have a significant role in the health development of adolescents.

2.1.1 Somatic and psychosocial development in adolescence

Adolescence (age 12–22 years) is an important developmental and maturational period between childhood and adulthood. Adolescents share similar developmental challenges as they disengage from their parents and increase individual autonomy with help from their peer relationships. Youth culture is a form of social cohesion. Together, adolescents have similar norms, values, behaviors, styles, and interests, which are purposely different from those among adults (Aalberg and Siimes 2007). Personal identity, behavior, and ambitions in life are established in late adolescence and early adulthood (Aalberg and Siimes 2007).

Development in adolescence is affected by individual, environmental, and cultural factors, and especially by the childhood family (THL, Lasten ja nuorten mielenterveys 2014).

Puberty changes the body image and sexuality, which are adopted during the physical, mental, and behavioral developmental phase in adolescence (Aalberg and Siimes 2007).

Rapid alterations in mood, behavior, and health complaints in adolescence are considered to be strongly related to hormonal changes in puberty and bodily maturation (Buchanan, Eccles and Becker 1992). Greater social activity and a stronger interest in the body and health among adolescent girls might be related to biological gender differences. Regardless, insecurity towards developmental bodily changes occurs even among the healthiest teenagers (Aalberg and Siimes 2007).

During puberty, healthy adolescents become more vulnerable to transient health concerns. Adolescent girls have more somatic complaints than boys (Poikolainen, Kanerva and Lönnqvist 1995). Headache, stomach ache, and sleeping problems are common symptoms among adolescents and often occur among the same individuals (Luntamo, Sourander and Aromaa 2015). The increase in somatic complaints in adolescence has been related to psychosocial problems such as mental health symptoms, substance use, and negative life events (Poikolainen, Kanerva and Lönnqvist 1995; Luntamo, Sourander and Aromaa 2015). Compared to the normal timing of puberty, the early or late occurrence of puberty has been associated with an increased prevalence of somatic symptoms, especially among girls. Of these somatic symptoms, headaches and musculoskeletal pains are the most common (Rhee et al. 2005). In addition, medically unexplained symptoms are common in adolescence, and are associated with female gender, a lower parental socioeconomic status, parental separation, and mood and behavior problems (Campo et al. 1999).

Compared to adults, adolescents need enhanced privacy and more intensive support from health care professionals to make decisions concerning health issues (Aalberg and Siimes 2007). Adolescents are already able to make most of the decisions concerning their own health, but they require family support in evaluating the need to seek help from health care services. Parents are still the primary decision makers for younger adolescents, while older adolescents are more autonomous (Ryan et al. 2011). Adolescents with health complaints need to be interviewed both alone and with their parents (Aalberg and Siimes 2007). Furthermore, it has also been recommended to investigate the psychosocial situation of adolescents with somatic complaints (Luntamo, Sourander and Aromaa 2015). Compared to older patients, access to a reliable and regular doctor might be more important to young patients in this transitional phase from childhood to adulthood (Ryan et al. 2011).

2.1.2 Mental health in adolescence One-fifth of all adolescents suffer from psychiatric disorders. The rates of mental health problems such as depression, panic disorder, agoraphobia, and substance use increase in puberty. Of the most serious mental health concerns, about 5% of adolescents have psychotic symptoms (Costello, Copeland and Angold 2011). Over half of mental health disorders in adults appear before the age of 14, and adolescents double the rates compared to mental health disorders as children (THL, Lasten ja nuorten mielenterveys 2014).

There are gender differences in adolescent mental health. For example, the incidence of depression is two times greater among adolescent females compared to adolescent males (Evans et al. 2005). Thus, social phobia may be a stronger predictor of depression among adolescent males compared to females (Väänänen et al. 2011). During adolescence in general, girls show more internalizing symptoms, while boys show more externalizing symptoms (Ormel et al. 2012). Conduct disorder is two or three times more common among adolescent boys than girls (Hipwell and Loeber 2006). Nevertheless, problem behavior is more serious in adolescent girls and predicts a range of adverse outcomes such as poor somatic and mental health, substance abuse and dependence, and antisocial behavior (Hipwell and Loeber 2006). Adolescents are in a vulnerable age for adverse life events and experiences. Psychological trauma is strongly related to an increased risk of anxiety disorders, depression, and substance use among adolescents (Haravuori, Suomalainen and Marttunen 2009). Mental health problems also continue over generations, as shown among offspring of depressed parents who have a 2–4 fold higher risk of depression compared to the offspring of non-depressed parents (Evans et al. 2005). In addition, first-degree relatives of schizophrenia patients have an approximately 10 times greater risk of schizophrenia compared to the general population (Gur et al. 2005).

Alcohol use increases in adolescence, and drinking is associated with a number of health risks and social problems (Skala and Walter 2013). Although the prevalence of adolescent alcohol use has decreased during the past few decades, binge drinking in particular is still very common among adolescents, and girls have become equal to boys (Raitasalo et al.

2012). Binge drinking in adolescence has been related to mental health and behavior problems, school problems, increased risky behavior, and parental mental health and substance use disorders (Brown et al. 2008; Niemelä 2010). Evidence is especially strong for

an association between external behavioral symptoms and substance use among adolescents. It is also possible that the early initiation of substance use may predict internalizing mental health symptoms in adulthood, especially among females (Miettunen et al. 2014). Alcohol-related psychosocial problems often occur among the same individuals and lead to social exclusion (Kekkonen, Kivimäki and Laukkanen 2014). Alcohol consumption appears to be more common among adolescents from single-parent families and adolescents with abundant allowances (Ahlström and Karvonen 2010). The Finnish drinking culture has been considered to be very permissive (Härkönen and Österberg 2010).

Adolescents taste alcohol in the presence of their family, but their real alcohol consumption occurs with peers (Foltran et al. 2011). Among adults, alcohol is mainly consumed at home, and an alarming proportion of children are affected by their parents’ alcohol use and may consider it a frightening experience (Raitasalo 2010).

Mortality among Finnish young people is low (SVT, Kuolemansyyt 2014). Due to higher morbidity related to suicides, accidents, and violence, males are overrepresented in the death statistics of young people (SVT, Kuolemansyyt 2014). However, during the past decades, there has been an alarming increase in suicide rates and more violent suicide methods among females (Lahti et al. 2011). Among deceased 15–24-year-olds, over one-third have died by committing suicide. Therefore, suicide is a common cause of death among young people, especially among males, who commit three-quarters of all suicides (SVT, Kuolemansyyt 2014). Psychopathology is the most significant risk factor for both suicides and suicide attempts among adolescents (Hendin et al. 2005). Furthermore, suicide risk increases in relation to the number of psychiatric disorders, especially comorbid affect disorders and substance use disorders, among adolescents (Hendin et al. 2005).

Unfortunately, adolescents who commit suicide have experienced severe problems for several years (Hendin et al. 2005). However, less than half of young suicide victims have received psychiatric care (Pelkonen and Marttunen 2003).

Mental health disorders are closely related to restricted performance in studies and working life. Difficulties in school performance, a short educational career, and remaining without an education are related to mental health problems in adolescence (Ostamo et al.

2007). For example, depression among adolescents and young adults is related to an increased rate of somatic health concerns and days off from school when compared to their non-depressed peers (Haarasilta 2003).

Mental health disorder is the most common reason for receiving disability allowance in young adults (Ahola et al. 2014). In addition, a long-lasting and severe history of mental health illness is related to disability allowance among young adults (Ahola et al. 2014).

Compared to young people with other reasons leading to disability, a major proportion of young adults with mental health disorder have experienced many psychosocial difficulties in their childhood, such as parental divorce, parental alcohol problems, bullying, learning disabilities, severe somatic disorders, and experiences of physical or sexual abuse (Ahola et al. 2014).

2.1.3 Health behavior patterns and psychosocial factors in adolescence The concept of health capital, “good health” as commodity, assumes that individual health depreciates with age and can be increased by investments such as education and health care (Grossman 1972). Health behavior can be defined as personal actions to maintain good health and as a reflection of personal health beliefs (Mosby 2009). There are differences in individual health behavior among adolescents. Individual health behavior patterns are largely adopted at a young age, concurrently with the development of personality and lifestyle from a wider perspective. Individual health behavior patterns in adolescence may also be reflections of youth culture.

The milieu in which adolescents grow up has an important role in supporting and enhancing the development of normative health behavior (THL, Lasten ja nuorten mielenterveys 2014). The adolescent health status is lowered by poor wealth, income inequality, lower educational possibilities, an adverse growth milieu, and poor family and peer relationships (Viner et al. 2012). Therefore, psychosocial factors such as psychological and somatic development, social affairs, and experiences in childhood and adolescence form a basis for health and welfare in adulthood (THL, Lasten ja nuorten mielenterveys 2014).

Differences in socioeconomic status and psychosocial circumstances are closely related to health. Environmental background factors such as material circumstances are crucial in defining individual health and predicted health behavior. According to Finnish statistics, compared to lower socioeconomic groups, adults in higher socioeconomic groups follow dietary recommendations, exercise more often, and live longer and healthier lives (Roos et al. 2007). The parental socioeconomic status has an effect on factors associating with the socioeconomic status and educational level of adolescents (Lahelma et al. 2007). A lower socioeconomic status has been related to poorer daily health behaviors such as diet, exercise, and cigarette smoking among adolescents (Hanson and Chen 2007). Students in vocational schools drink excessive amounts of alcohol and are cigarette smokers more often compared to students in high schools (Helakorpi et al. 2007; Laaksonen et al. 2007). Furthermore, the peer relationships of adolescents might have a significant role in adopting weight-related behavior such as regular exercise and fast food consumption (Ali, Amialchuk and Heiland 2011). Regardless, daily health behaviors are mostly adopted and modeled from caregivers, whereas substance use is learned in peer relationships (Hanson and Chen 2007).

The concept of social exclusion has not been stabilized, but it has been used to describe a fall into chronic poor economic and social circumstances by an individual or whole family (SVT, Tulonjakotilasto 2009). The risk factors and manifestations of social exclusion appear to continue over generations from parents to their offspring. Dropping out from school, unemployment, chronic poverty, and health problems often occur concurrently, and are associated with social exclusion (Mohajer and Earnest 2010).

2.2 HEALTH CARE SERVICES UTILIZATION AMONG ADOLESCENTS