Towards a good mental health care for adolescents in Europe

European Parliament in Brussels October 16th, 2014

This comprehensive report is also available as PDF-file for download.

Among the last invitations for EPA a new thematic focus emerged recently: mental health.

Mental health can be seen as a rather wide area linked to the holistic WHO definition of health as a concept of wellbeing. It covers physical, mental and social aspects. Mental health care deals with developmental needs during puberty, personality problems, anorexia, bulimia, substance abuse, addiction to tobacco, alcohol or illegal drugs and phenomena that need psychiatric treatment. It covers learning difficulties like dyslexia and dyscalculia, ADHD etc. Physical and mental health cannot be separated. Still the mental health approach requires independent strategies to gain equal recognition and improve service and care.

ADOCARE is a project financed by the European Commission’s Directorate for Health (DG SANCO). It runs a scientific programme co-ordinated by the LUCAS-group at the University in Leuwen (BE) and is based on the NGO “Action for Teens” resident in Brussels. The purpose of this conference was to present the results of meta-studies, listen to experts in the field, present practical policies and initiatives as exemplary models and discuss the research questions and policies with experts and stakeholder representatives.

As soon as an official documentation is available EPA will share this with all members and partners. This brief review should highlight the lessons learned and comments contributed from our parental view.

The conference was hosted by Beatriz Beccera, MEP (ES, ALDE group). She presented her political movement as small but therefore open, flexible and innovative. Quoting Khalil Gibran she set the scene and defined the roles for us parents: “Your Children are not your children …” – valuable message for all social service providers and educators.

Marc Derély introduced the movement Action for Teens aisbl. Founded 2009 by about 40 experts it started with pilot programmes in Belgium to create “… structures to help teenagers in crisis”. Follow-up projects in France followed. It seems proven that in every community with more than 100.000 citizens dedicated teen-facilities are required.
The scientific experts Chantal Van Audenhove and Jean-Paul Matot outlined their views and motives. Both are key perons involved in the project. Discussions and thinking together among researchers, practitioners and administrative institutions should contribute to the final ADOCARE policy recommendation for DG SANCO.

On behalf of the European Commission’s Directorate for Health Jürgen Scheftlein congratulated the consortium Action for Teens and outlined the utmost need for concepts and co-ordinated actions. Depression is found to be 1 out of 3 causes for early retirement. In time of austerity the challenges increase as treatment gaps and waiting times for therapy grow. The expenditure of European health systems generally show a discrepancy of 97 % spent for treatment and only 3 % in preventive programmes.

I had the opportunity to talk to Mr. Scheftlein and offer EPA’s co-operation an all family and child related issues. He seemed to be interested and I was told that DG SANCO was looking for more and better ways to work in and with schools. A perfect task for EPA …

Expert Presentations

Prof. Giovanni de Girolamo (Brecia, IT) presented empirical studies on the age of onset (AoO) of clinically relevant phenomena on mental disorders and the habit of drug consumption. The strategies of public health services needed to be adapted to these findings. Not only in relation with age but to spot patterns of risk and counteract targeted.

Dr. Jean Chambry (France) is a medical doctor who developed a multi factor approach to deal with adolescent development associated disorders. He pointed out that the “development gap” between emotional and cognitive development of brains during puberty could caus the development of behavioural strategies that could lead to disorders.
Teens in troubles needed to be identified and low threshold services be offered. Earlier treatment would reduce the number and severeness of later disorders.
Also in theory there is a lack of indicators to identify the initial phase of critical development.
Prof. Pierre-André Michaud from the University Hospital Centre in Lausanne (Suisse) linked the WHO policy approach with practical evidence based concepts. He stressed that adolescents could contribute many (innovative) ideas how preventive and care measures need to be structured. Adolescents’ services need to be deployed as adolescent friendly care.
Among seven ingredients that need to be respected but could be implemented in diverse ways he mentioned: accessibility, nun judging attitude of staff, participative concepts (not for but with adolescents.
To find evidence of what worked he referred to EUteach (European training in effective adolescent care and health)
After a coffee break three presentations of practical examples complemented and prepared for the discussion.

Practitioners' Presentations

Prof. Riittakerttu Kaltiala-Heino from Tampere (FI) outlined the historical development and concept of integrated care for adolescents with mental health problems in Finland. Primary services and secondary services run by municipalities. School services involve medical doctors, nurses, social workers and psychologists co-operating in every school. School nurses bridge to the secondary services supplied outside schools in 21 hospital districts covering the whole country. Tertiary services are available for rare and severe cases in five university complexes.
Today all hospitals provide special adolescent mental health services realising a low level approach.
According to my understanding Finland shows several exemplary principles that are based on a homogenous society and a service oriented approach towards citizens. Citizenship is taken as a responsible role of every mature individual and interaction of citizens with fellow citizens and institutions seems to be based on mutual trust – compared to several central European systems that rather seem to be service systems the client has to adapt to.

Dr. Jonathan Mark Wilson presented the Norfolk Youth Mental Health Service project (UK).Development of youth service started five years ago. Having identified a range of clients’ needs the development of youth services started.

Success criteria are:
  • Youth orientated, not stigmatising, and recovery focused processes
  • Repect of diagnostic uncertainty and support by evidence based development.
  • Outreaching into schools – the daily environment of typical adolescents
  • Simple and low threshold interface – one-stop shop
Adult services treat “conditions” which is not an appropriate concept for adolescents
From EPA’s point of view this programme is based on a strong participative concept. Good examples verify that responsibility and trust open up many new perspectives. 
Ingrid de Jonghe had started her academic career as a lawyer specialised in youth issues. Being confronted with cases of mental disorders she followed up with further studies and specialised on psychotherapy for children and youth, behavioural therapy and children’s right. Her non-profit association TEJO (Youth Therapists without borders) started a service network in Antwerp.
Her motivation arose from the prevalence of mental problems in Belgium with increasing tendency especially among youngsters. Mental problems can cause criminality, but systems restrict the access to appropriate services.
The speaker assigned political and main stream causes for those developments: neo-liberal trends and mediocrity. Holistic concepts are required. During adolescence mental problems are often caused by life stress and relational problems.
The services of TEJO are run in sponsored facilities by volunteering professionals. Services are offered for free. Though non-commercial it is a good example of social entrepreneurship.
EPA is to follow-up with contacts with this volunteer initiative. The touching evidence of individuals analysing their own situation and how they overcame depressive reflection and suicide plans can be found in the initiative’s documentation. The services adapt to each individual, offer valuing environment and acceptance and target on empowering and self-governed development.

Project presentation and Discussion

The afternoon session was opened by Martine De Clerck who outlined the scientific programme of the ADOCARE project. Among the activities EPA may be involved in several planned workshops and conferences.
ADOCARE did a comparative study in the ten countries participating to see the national policy framework:
  • Only 4 countries have recent data on prevalence. For different reasons administrative data are incomplete and not processed.
  • There is a lack of overall visions and no priority is set. Only one country assigns a budget to mental health of adolescents.
  • There is hardly any legislation. Only one country has a professional definition.Four types of services could be distinguished.
  • Only two countries proved targeted services for adolescents integrated in child- or adult care.
Details on the concept and the questions for the research were discussed in the final workshop.
During the discussion one of the panellists raised the question of how to define “adolescence”. A curious statement as it questions a key word in the title of the conference.
Concluding from the expert presentations and the parental experience adolescence starts with puberty and can last up to the twenties. It is marked by development, incomplete maturity with respect to (economic) responsibility and independence. The role of parents and families is highly relevant through this period of individual development. The balance of conflicting rights and interests of parents and their adolescent children are one of the challenges. All successful strategies need to tackle this challenge.


The Portuguese psychiatrist sitting next to me told a very significant observation. Running adolescent services in an institute also working with small children she found that drawings by little children pinned to the walls made adolescents feel strange and do not open in trust. They are not willing to be treated like children and thus the care-giver needs to prepare an appropriate environment.
I had the opportunity to contribute to this debate:
  • Participation is a very important aspect of all strategies. To work with not for or on behalf of adolescent clients, to listen to them and respect their suggestions and opinion.
  • Partnership should be a seen as the ideal state of co-operation. This means mutual respect, valuing and trust, empathy and engagement.
  • “Evidence based” is normally linked to large scale studies. As they are based on a big number of “samples” they should create more statistically significant “evidence” than smaller or sec-torial studies. It is frequently ignored that data interpretation is highly influenced by the ini-tial model development.
  • Correlations can only be modelled if data describing the co-ordinates are acquired. Bad mod-els generate useless evidence. But the validity of any study is not easily verified from reading the results. It requires critical consideration of initial assumptions, detailed analysis of ques-tionnaires, questioning the ruggedness of figures describing observations in different envi-ronments etc.This kind of statistical evidence should always be complemented by individual case studies. They lack statistical evidence. But a lot of small and concrete factors can be linked together. causal relations between situations, actions and observed developments can be interpreted and discussed. The methodology enables individual therapists and groups to learn from their own experience and develop strategies from observations. Learning to reflect ones work to create this kind of case studies should even be part of secondary school education and help students to become masters of their own learning.In the EU-Directorate of Education and Culture (DG EAC) policy debates Trans-sectoral co- emerged as a magic programme to fight Early School Leaving. It proposed to in-operationvolve services from the health and social sector into school services. I had pointed out that political segmentation even on the European level made this motive a challenge: No-one from DG SANCO or any other directorate had been involved into the EAC-debates.
  • Even more, the same idea was phrased in other word during the ADOCARE conference. They used “cross-sectorial” to introduce the same concept. But those concepts – well established in Finland – have to overcome administrative and political barriers in many state systems and in the European Commission.During the European Year of Volunteering (2011) EPA shared experiences and concepts with many other European NGOs. Volunteer organisations are able to provide high standards of services and can go beyond limitations of state systems. TEJO (see above) can be seen as such a successful programme.
  • The tasks of community services can be supplemented or complemented by such services. But the state – the democratic community – should not save money and let volunteers take over public services. Such initiatives deserve financial and administrative public support.
Johannes Theiner
EPA Ambassador

1 comment:

  1. My 16 year's old son suffered a psychotic episode on May 2014. Once he recovered from acute phase in hospital he entered Sant Pere Claver center which covers daily assistance in mental health for adolescents 12-18. Since the very first moment I realised the importance of working with teenagers in small groups. He not only found medical assistance but real friends who understand his problem: they all form a group and help each other a lot. The evolution of the whole group has been wonderful and all the families are highly involved.