Deze samenvatting is geschreven in collegejaar 2012-2013.
Homeless youth are young people between ages 12 and 25 who have no regular place to stay. This includes runaways (those who left home without parent’s/guardian’s consent), throwaways, systemkids (those who left problematic social service placements) and street kids, those who lack basic shelter.
The younger and female runaways are those who are found in shelters. Youth are barred from welfare hotels. 90% return home after a month, 99% return within 12 months.
Situation in the Netherlands
There are about 25,000-35,000 homeless people. Homeless youth are difficult to measure, because they often lie about their age. The estimated number of homeless youth is 3200, but this is an underestimation. The actual number is estimated to be 5000-10,000. There are 320 beds available in shelters. But interventions are improving.
70% of homeless youth is male. Most are between ages 16 and 21 (58%). 33% belongs to an ethnic minority. The degree of homeless children has increased in recent years, which is likely due to changes of intake services of people with learning disabilities.
2 out of 5 homeless youth form a risk to safety of other people, because of threats or petty crimes. 33% have frequent contact with crisis services. It is a good thing that they are getting help in crises.
The services are poorly organized. There is no comprehensive shelter and support services for homeless youngsters. There are fierce criteria for excluding people from shelters, such as serious mental problems, addiction, undocumented immigration status, health problems requiring considerable physical care, aggressive behavior and learning problems. The question is who is left? You cut out a lot of people. But the shelters have to be safe. Shelters are needed for those with serious problems.
Precursors of homelessness
Stressful family backgrounds, economic instability, problem behaviors of the child and residential instability are the most important precursors of homelessness. There are precipitating events for youngsters to leave, such as parental substance abuse, sexual abuse, violence, neglectful parenting.
There are multiple pathways to homelessness. Do drugs problems lead to homelessness or does homelessness leads to drugs problems? In 38%, the young person’s substance use caused family conflicts, which lead to homelessness. Family conflicts can also lead to youngster’s drug use. Family member’s substance use can also lead to family conflict, which in turns leads to homelessness.
For LGBT youth, their sexual orientation can be a cause of homelessness because of family rejection (in 46%).
Homeless youth engage in survival sex, which poses a risk for contracting AIDS. There is a greater risk for internalizing and externalizing problems, poor health and nutrition, low self esteem. Most homeless youngsters do not go to school. Many jobs require diplomas, so they lack job skills to support themselves financially. They are at greater risk for premature death.
The mortality rate for homeless youth is 921 per 100,000 persons-years of observation, extremely high compared to non-homeless youth. Particularly among males, suicide is the main cause of death. Also drug overdose is a major cause of death. Substance use (especially injection and heavy alcohol use) and HIV infection are important predictors of mortality.
A qualitative study examined the circumstances surrounding a youngster’s decision to trade sex for food, money, shelter or drugs. About a third of the sample engages in survival sex. The sex traders grew up in abusive families where they experienced physical abuse, sexual abuse, emotional abuse or neglect. Most had been removed at least once from their parents’ care. Their life histories are highly unstable and often troubled.
Four children refused trade sex. All four had experienced one or more types of maltreatment during their childhood. But they had alternative places to stay and had extensively used services. Because of modern communication, it has become easier to stay or become in contact with services or parents.
In outreach programs, street-corner work, the primary aim is to establish contact. When contact is established, youngsters are encouraged to accept other types of help. Emergency shelters are places where the youngsters can stay, eat, shower and sleep.
Many people left the street with the help of others, family, friends and professionals. They went into the services to get help. These youth also have individual strengths, such as intelligence. They have more resources to leave the streets.
Risk amplification and abatement model: You should not only look at factors which makes things worse, but also to factors which can help the youngsters on the streets. Factors that can help are family and peers. Many youngsters still have a peer network from home, and this network can help them. They provide a place to stay, money or food. Social services can also help. Formal institutions help youth to get back to school. They give them tools to get a job. Social support from mother and friends is an important resource.
Four trajectories of homelessness
The low group is the comparison group, this is the category which is low in homelessness. The medium-high-low, the high-high-low and high-medium-high groups are the other groups. The medium-high-low group have low social stability, are more likely to be male, and are not latino. The high-low-low group had high social stability and were not anglo. The high-medium-high group have a high HIV risk. They have low social stability and are more likely to be native American.
Developing trust and linkages between homeless youth and service providers may be a more powerful immediate target of intervention than targeting child abuse issues, substance use and mental health problems.
The lack of attention to the identity and value system shifts of homeless youth is striking given the emphasis upon such shifts and developments in mid-late adolescence, which is the time when most homeless youth are first faced with the changes and challenges of the street environment.
Alcohol and substance use.
Three types of substances are often used in adolescence. One out of two American adolescents use marijuana, 8 out of 10 use alcohol, more than 60% use cigarettes. This lecture focuses mostly on Dutch adolescents, because there are cultural differences in substance use.
Trends over time
Research use on substance use in adolescence is often conducted. ‘Comazuipen’, drinking to the extent that adolescents have black-outs and even get into a coma. There is a lot of research to alcohol, the most influential is ‘Monitoring the future’, a research conducted in the USA. They monitor alcohol use from 6th grade (groep 8 in the Netherlands) to 12th grade. Across time, the percentage of youth who used alcohol in the last 30 days has declined, with approximately 40%. There are differences between ages, 12th graders drink more than 8th graders.
There are various ways to measure substance use. You can measure alcohol use, or more than 5 glasses in a row at least once in the past two weeks (binge drinking). Over time, binge drinking has also decreased and younger adolescents do it less than older adolescents. In general, the smoking trend has the same decrease as alcohol use.
What can explain these changes? Health education, policies and hypes can serve as an explanation. For trends in the Netherlands, there is the HBSC (health behavior of school aged children) study. It makes comparisons between countries and trends over time.
Differences between countries
There are also differences between countries in substance use. It is important to look at the measure. Look at the pictures with a focus on Greenland. Young males in Greenland are drunk on a very young age (more than 25% is drunk for the first time before age 13), but they do not drink regular.
The prevalence of smoking are lower than prevalence on alcohol use. The Dutch are somewhere in the middle, but the surrounding countries have somewhat lower initiation rates of smoking. Greenland has an unusual position again, with more than 30% regular smoking.
The Netherlands is famous abroad because of the liberal cannabis use. However, cannabis use ever compared to Spain, USA, Canada, France, etcetera, is much lower in the Netherlands. The Netherlands has a middle position. Lately, cannabis use has risen a bit, but is still not in the high ranks of cannabis use.
There are national and regional differences in cannabis use. Cannabis use in the Netherlands, 15% has ever used, 2.5% has ever used. But in Amsterdam, 37% has ever used, with 8% regular users. In rural areas, the rates are lower than the national rate. But it is unclear whether it is a selection or influence effect. Trends in cannabis use in the Netherlands are rather similar to those in other European countries, so the policy does not necessarily influences substance use.
Alcohol use peaks in young adulthood, especially among college students. 46% of 12 year old boys have ever used alcohol. Drinking among 16 year olds is the norm, only 18% have never had an alcoholic consumption. First drink on average is on 12.6 years for boys and 13 years for girls. The first episode of drunkenness is hardly a year later, on average at age 14.
The prevalence of alcohol use is higher than the prevalence of smoking, cannabis use and hard drug use. Therefore, there seems to be a hierarchy. The gateway hypothesis states that you start with the ‘softer’ drugs before you use hard drugs. You start with the use of alcohol and cigarettes, before you start to use soft drugs and after that hard drugs. But there is not much evidence that prohibition of one substance (e.g. soft drugs) will prevent other drug use.
Substance use increases steep in adolescence and there is an order in which they use drugs. Adolescents do not start with using heroin, alcohol and cigarettes come first in the sequence.
Effects of substance use
The alcohol intoxicated adolescent is exposed to many risks. One risk is the risk of accidents. Most adults do not drink and drive. Adolescents however, are often involved in traffic after drinking. Also small accidents like falling are common in alcohol intoxicated adolescents. Violence (e.g. bar fights) are associated with alcohol use. Adolescents are cognitively not really able to respect their own boundaries considering sexual behavior while intoxicated. Alcohol intoxication increases the probability of risky sexual behavior.
The adolescent brain is still developing. Substance use has long time consequences, because the brain is vulnerable. Compared to adults, adolescents are more susceptible to effects related to learning and memory, and they are less susceptible to the sedation produced by alcohol. Adolescents get stimulated instead of getting tired.
Because the adolescent brain is still developing, it is more susceptible to damage than the adult brain. This damage during adolescence may be permanent, because it hinders normal development.
Role of parents
Why do adolescents use alcohol? The book stresses two important ways to think about this. First, it has to do with opportunities. Adolescents spend more time with peers, they are more away from the parental house. The second thing is motivation. In adolescence, there is a discrepancy to the tendency to act and regulating the behavior. There is a maturity gap, adolescents feel mature but they are treated as children. Substance use is a way to demonstrate your maturity in terms of risk behavior. If society treats adolescents as children, they want to show how mature they are. But adolescents cannot regulate their behavior as well, resulting in getting drunk for instance.
The motivation to use is equal in adolescence and emerging adulthood. But in emerging adulthood, there are much more opportunities to use substances. It is the time of moving out of the parental house, much less control and less legal boundaries.
Parents vastly underestimate how much their children drink. Parents are clueless of the drinking behavior of their children, but they think they know. This is also the case with cannabis use and smoking. Even when it comes to parenting, whether they are strict in rules about substance use, there are differences between parent’s en children’s view. Perceived parenting and real parenting is not the same. If you think you have strict parents, you are more likely to obey the rules. The perceived parenting is the predictor of behavior.
Parents only prohibit alcohol use in early adolescence. 50% of the parents allows their 15-year-olds to drink. Regarding to smoking and cannabis use, parents are much stricter. Parents find alcohol more acceptable than smoking, and smoking more acceptable than cannabis use.
Parents can set rules regarding to substance use. A Dutch, democratic way of parenting is to ‘polder’, to talk about substance use. Parents may also response in a negative way to experimenting and heavy drinking. But what is the best way? Communication is a bad predictor of alcohol use, and it is a positive correlation. More communication is correlated with more drinking. The more parents set rules, the fewer adolescents drink. Setting rules is strongly negatively correlated with alcohol use, therefore, is the best strategy for preventing alcohol use.
Parents also use alcohol and this is related to the drinking behavior of their children. There are modeling effects. Drinking parents are more tolerant towards alcohol consumption of their children.
It is not wise for parents to teach their children to drink, so they can handle it in a responsible way later. Children who start earlier are at higher risk for abuse and dependence later on. Parents who drink a lot are a bad example for their children, the children incorporate parental norms.
The views of parenting regarding alcohol use are changing. Parents have become more strict and are less tolerant of alcohol use in their children, especially below the age of 16. The Trimbos Institute incorporated the idea that strict rules are an effective strategy. Parents implemented this new knowledge in their parenting. Adolescents understand better why their parents are stricter if the intervention also targets them.
The influence of friends is often overestimated. Birds of a feather flock together. It is a matter of selection. If you drink, you find other friends who also like to drink. There is hardly any evidence for influence effects.
Depression, self harm and suicide.
Moods and emotions
We can have a depressed mood, times we feel sad. This sadness can move into more serious symptoms of depression and a full-blown disorder. There is a continuum of behaviors that we call depression.
During the adolescent period, sparked by the onset of puberty, there are relatively sudden changes in both positively- and negatively-valenced affect. Moods go up and down and fluctuate much more than what we were used to. The intensity and/or frequency of negative emotion peaks in early adolescence.
Adolescent become more capable of the comprehension of more complex mixed emotions. This increased understanding of emotions also is about masking emotions. There are dramatic changes in mood. The incidence of dysphonic or depressed moods radically increases, mostly for girls.
Social aspects of emotion expression and regulation become more developed. There is an increase in the ability to mask emotions, but also of emotional expression. With age, you learn when to show your emotions and when not, you learn to regulate emotions. The social referencing aspects of emotion become highly attuned. The emotions about the self becomes stronger as development occurs because of the sharp increase in awareness of other’s perceptions of the self. Adolescents are not random in their emotions, there are contacts that spark this variable moods. Adolescents are more bored in school than with friends.
Developmental affective neuroscience results suggest that in adolescence, you increase in emotionality and sensitivity to stress. There is a decreased sensitivity to rewards, this is also linked with risk behavior. There is a lag of years before the regulatory capacities of the pre-frontal cortex become fully engaged. Adolescents lack the sense to regulate themselves. This period has been metaphorically identified as ‘starting the engines without a skilled driver’.
There is an increased risk for negative emotions and thus for depression. We need to have emotional regulation skills, we have to be able to dope with emotions. Adolescents are more prone to emotional outbursts and they have poor skills anticipating their own emotions. They don’t know what triggers this outburst.
Emotionality is not just driven by the biological changes in adolescence. There is an interaction with the environment. Adolescence is a time of change, which is stressful. There are higher academic expectations, there is the transition to middle school, pets can die. Those things puts the adolescent at risk for psychopathology. Adolescents lack coping skills.
Depression is an enduring period of sadness. Depressed moods is an enduring period of sadness, without any other related symptoms. Depressive syndrome is sadness plus other symptoms such as crying, feelings of worthlessness, feeling guilty or lonely.
Major depressive disorder is a full-blown disorder, a depressed mood or loss of interest or pleasure in almost all activities, plus 4 other symptoms. With adolescence, the disorder can be acted out as irritability instead of sadness. Some people are happier than others. To speak about major depressive disorder, it has to be a change from the person’s normal mood. It has to affect important functioning.
Across adolescence, there is a significant drop in positive mood. There is no change in negative mood. There are gender differences in depression. There is a slight decrease in depression in mid adolescence, but girls are more depressed than boys. Before puberty, boys are more likely to be depressed than girls, after puberty girls are more depressed than boys. It is believed that testosterone has a protective effect on depression.
There is a variety of methods that can be used as self harm, it is to inflict harm on your own body. Tattoos do not count as self harm, but cutting, burning, stratching, hair pulling etcetera are considered as self harm. 4% of adults report a history of self harm, 14% of adolescents report self harm. Amy Winehouse was famous for self harm.
Early onset of self-injury is common around age 7. Most often, however, it begins in middle adolescence, between ages 12-15. It can last for weeks, months or years. 30-40% of college respondents report initiating self-injury while 17 years old or older and stop within 5 years.
The frequency varies dramatically, from once to hundreds of incidentsa. Cutting is one of the most common and well documented forms. Most often it occurs on hands, wrists, stomach and thighs. The severity can vary from superficial wounds to those resulting in lasting disfigurement. 1 in 5 self-injurious university students indicated that they have had hurt themselves more than intended. 1 in 10 had hurt themselves so badly that they should have been seen by a medical professional.
Why do people self-harm?
There is an emotional trigger, overwhelming sadness, anxiety or emotional numbness. People can self-harm so that they feel something or feel more pain than the emotional pain. Others do it to feel in control, to relieve negative feelings, to communicate needs or to purify themselves.
Precursors to self-injury has two different pathways. One is hyperstress, where you are overwhelmed by your situation. If you are unable to cope, it is expressed as self injury. After that, you feel relieved, in control or calm. The other pathway is dissociation, the lack of connection to experience. One feels lost, alone, they feel numb and the world does not feel real. They self injury so they can feel, they feel alive. People can have both pathways.
The leaders in thinking about self harm are looking at it in terms of the function self harm serves. There is either an automatic function or a social function. Auto refers to the self. There is positive reinforcement or negative reinforcement. Automatic function and positive reinforcement is self harm to feel something. Automatic function and negative reinforcement is self harm to remove a negative stimulus, to stop bad feelings. To look at it as a social function, the positive reinforcement is to get attention. The negative reinforcement is to avoid punishment from others, if I self harm, and the other person feels sorry for me, they are going to treat me different.
It is an odd kind of category, because 12% of adolescent self-injurers do not fit the criteria for any mental disorder. Skin cutters report more anxiety. People with eating disorders are more likely to self harm. Endorsers of automatic functions are more likely to attempt suicide, feel hopeless and have PTSD symptoms. Users of a range of methods and those who experience less pain are more likely to have attempted suicide. Suicide is the far extreme end of the self harm continuum.
There is a self harm cycle. Self harm leads to release of negative feelings. But the release leads to shame, which causes emotional pain/hurt, which leads again to self harm.
Klonsky and Olino tried to identify subgroups of self-injurers, who are at risk for suicide and who are not? They looked at the functions self harm served. Automatically reinforcing functions are anti-dissociation, self harm as a substitute for suicide, affect regulations. Or socially reinforcing function, seeking care or help, fitting in with others or sensation seeking.
They identified four groups of self injurers. The Low NSSI have low scores on almost anything, except moderate-high banging/hitting. They were low on social and automatically reinforcing functions. This is the lowest depression group, the experimental self injurers.
The High NSSI low functioning group were high on self injury, but did not report reasons for self harm. They have the earliest onset, but mild self injry and low borderline.
Mod high NSSI and high social and reinforcing functions are high on most behaviors and have high levels of socially and automatically reinforcing functions. This group has early onset, high depression and highest anxiety.
The high cutters, high levels. automatically reinforcement, low social group don’t do it for others, they self injure almost exclusively alone. They are high on depression, high on anxiety. This group is more likely to have borderline. They have the most suicide ideation and attempts. They need medical attention often and have a longer time between the urge to self harm and the act.
The last two groups need the most therapy, they require aggressive treatment. These groups have the most serious problems.
Is self-injury a suicidal act?
Self-injury is often undertaken as a means of avoiding suicide. But individuals who report self harm are also more likely to report having considered or attempted suicide. The majority of individuals who self harm do not consider suicide. The low NSSI group consists of 61% of the self-harmers, they do not have signs of serious problems. Non-suicidal self-injury may be best understood as a symptom of distress that, if unsuccessfully mitigated, may lead to suicidal behavior.
What distinguishes NSSI that attempt suicide from those who do not? 21% of the sample did self harm only. 4% did self harm and suicide attempts. 75% did not self harm and did not attempt suicide. These individuals differed on certain characteristics. Adolescents who did attempt suicide had lower self esteem, negative self view and had a more negative mood. NSSI+suicide attempt had lower levels of parental support. There was a lot of variability in disordered eating, eating disorders can be a risk factor for self injury. As you accumulate more problems, individuals are cumulating risk for self injury. Peers are not as important as parents at times of distress.
Females are significantly more likely to self-injure than males in clinical samples. Among non-clinical samples, males are equally likely to self-injury as females. Some studies say NSSI is more common among Caucasians, but others show similar rates in minority samples.
Clinical populations report more childhood abuse and childhood sexual abuse. Earlier and more severe abuse and abuse by a family-member may lead to greater dissociation, which in turns leads to greater self-injury. Self harm is linked to a range of psychiatric syndromes such as PTSD, borderline and eating disorders.
In non-clinical populations, it is linked with impulsivity, poor problem solving skills, lower tolerance of stressful events, etcetera. There are groups of friends who self harm together, but it is unclear whether it is contagious. There is the suggestion that people flock together.
Hilt, Cha and Nolen-Hoeksma tested the Nock & Prinstein model. If you have a trigger, either victimization or depression, is it linked with the automatic function or the social function? If depression is the trigger, self harm is more likely to serve the automatic function. If victimization is the trigger, it is more likely to serve the social function. High rumination is a moderator between depression and the automatic function, thinking: why can’t I handle things better? Poor peer communication is the moderator between victimization and the social function. The function is important for understanding self harm.
Self-injury is most common in youth having trouble coping with anxiety, depression or other conditions that overwhelm their capacity to regulate their emotion. The intervention focus is on enhancing awareness of the environmental stressors.
Suicide peaks around age 40-49. But young people are not very likely to die, when a youngster dies, it is a tragedy. Traffic accidents are the main cause of death for youngsters, but suicide is the number 2 cause. Firearms is the preferred methods in the USA, because they are highly available. Hanging and suffocation is the second used method.
Men are more likely to use a violent method than women. 50% hang themselves, 1 in 9 jump in front of a train, more often among youth. 25% of women dies from a medication overdose. There is about 1 suicide a year on the Domtower. In age 10-12, suicide is a rare event. There is a big increase in suicide ages 16-18. Native Americans are at greatest risk for suicide, followed by whites.
There is a much higher rate for thinking about suicide than attempting suicide and actual suicide. Of the teen suicide attempters, 53% attempted one, 30% 2 or 3 times and 17% 4 or more times. Quite often, there is a psychiatric disorder, especially depression. Depressed teens who commit suicide do not take their medications. 24% had prescribed antidepressants, but with 0%, medication was found at autopsy. SSRI prescriptions can really help to prevent suicide. Females are more likely to be on medication than depressed males, this can account for the higher suicide rate among males.
Eating disorders rank as the third most common chronic illness in adolescent females. Adolescence comes from the Latin word ‘Ad Olesco’: to grow up. Most adolescents have voracious appetite, caloric intake increases a lot.
When we talk about eating disorders, there are four disorders: anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified. A BMI under 18 is a suspect of malnutrition. Normal BMI is from 18-24.
There is the idea of more intense in dieting or food restrictions resulting in weight loss or failure to gain weight as expected, but not enough to qualify for an eating disorder. Sometimes they become obsessed with the pursuit of thinness and a fear of becoming fat. There is a consistent disturbance in body perception and start to deny that weight loss is a problem. This can lead to a full blown disorder.
Anorexia is an old illness. Saint Catherine of Sienna is one of the saints which is described as holy anorexia. In 1689 it is called ‘nervous consumption’ by Richard Morton. In 1874, William Gull came up with the term of anorexia nervosa.
The core features of anorexia nervosa is a relentless pursuit of thinness, an intense fear of gaining weight and being underweight. There is the delusion of being fat. These obsessions to be thinner does not diminish with weight loss. It is not just about eating, it is about self image.
The behavioral features are obsession with food, peculiar eating habits and compulsive behavior. They may develop a ritual around food, a range of behavioral changes surround the ritual of eating.
The ‘classic’ presentation is less likely in younger patients. They are mostly thin of themselves, they have a shorter duration of the illness. Often, they are taken to the doctor to find out why they do not gain weight.
There are two types of anorexics. The first is the restrictive type, they have strict weight-control behavior. They have the psychical effects of starvation. The second type is the purging-binging type. They eat sometimes, but purge. They have the physical effects of starvation and the effects of purging.
The female to male ratio is 10:1 or 9:1. 25-50% of the patients also binge. The mortality rate is high, 5% die per decade. The body tries to compensate for the maintenance of body heat, by lanugo (soft hairs) and muscle wasting. Because our body gets into a starvation mode. We are lowering our body temperature, our blood flow and heartbeat decreases, they lack the energy of physical activity. 70% of their regained weight is lean body mass, the muscles.
There are consequences for their physical health and mental health. There are mental disconnections. Sometimes, it is there before the onset of anorexia nervosa, but sometimes it is the result of starvation.
Risk factors is being female, it usually starts in adolescence. It is a risk factor among middle/upper middle class girls, Caucasian girls, premorbid psychopathology. Although it gets a lot of media attention, anorexia nervosa is relatively uncommon, the prevalence is 0.5% of women.
The long term outcome of anorexia nervosa: one third to one half of the individuals recover. 5% die per decade. The rest are alive but have not recovered. It is very rare to become obese after recovering from anorexia. Most frequently are patients encountered in young post-pubertal females of college age, but it typically begins in adolescence.
Bulimia nervosa is sometimes seen as a new problem. It is first recognized in 1969. The core features are recurrent episodes of binge eating and recurrent inappropriate compensatory behavior.
These individuals have a dear of not being able to stop eating and the awareness that their eating pattern is abnormal. They use fasting, self-induced vomiting, laxatives or exercise a lot to burn the calories. There is an obsession with food and eating.
90% of the patients are females. Their weight is usually normal. The onset is a bit older than anorexia, on average 18 years. Presentation is on average at 23 years. The binges are usually about 2000 kcal. It is usually not healthy food people binge on. 90% of bulimics use vomiting, 33% use laxatives.
Psychical complications can be gastric rupture, because of the compensating behaviors. Vomiting affects the liquids in your body. Some genetic factors may be involved, but cultural attitudes towards standards of physical attractiveness are most important. There is an erosion of the teeth because of the vomiting, the acid that comes up. There are abnormalities in the electrolytes.
Life threatening situations are rarer among bulimics than among anorexics, because of their normal body weight. Edema (swelling in the feet) happens because of the imbalance in electrolytes. There can be a reticular, lacy pattern on the skin, because of problems with temperature regulations.
Binge eating disorder
This is also a relatively new eating disorder. In 1959, it was first called the night-eating syndrome. Depressed people would eat a lot at night. In 1994, it got a classification in DSM-IV. Key features are recurrent binge eating, which is similar to bulimia, but there are no compensatory behaviors. There is marked distress about the behavior.
The symptoms are weight gain, bloating, salivary gland enlargement, disconnection, guilt, depression and anxiety. The interesting thing is that this eating disorder is more common among middle aged people, instead of in adolescence. There are more frequently males than in the other eating disorders (40-50% are men). These individuals are overweight or obese. Low levels of mood and anxiety are common. Rituals surrounding food are less common in binge eating disorder.
Development of eating disorders
There are predisposing factors, such as being female, the genes, and the social emphasis on thinness. Precipitating factors can be stresses in our lives. Perpetrating factors is a cycle of dieting, binge eating and dieting.
Over time, the winners of the Miss America competition have become thinner. But there are also biological factors. There is a genetic component in anorexia, there is a serotonin dysregulation. Testosterone is a protective factor against developing anorexia. Early puberty is a risk factor. A perfectionistic character and depression are also risk factors. With bulimia, there is also serotonin dysregulation and a change of acids in the stomach. Early puberty is also a risk factor in bulimia, and being active, high achieving.
Prevalence and correlates of eating disorders
The lifetime prevalence 13-18 years old is 0.3%, 0.9% bulimia and 1.6% binge-eating disorder. There are correlates with mood disorder, anxiety disorder, substance abuse or dependence. It is unclear if they are correlates or consequences. If you ask adolescents, you get much younger ages of onset than when you ask adults. The median age of onset now is 12 years. It could be that the age of onset has become younger, but we cannot say for sure. If overweight stays as it is, life expectancies will become shorter, people will die because of the complications of obesity. It can be that for this reason binge eating disorder is taken more seriously.
Individuals with anorexia nervosa have some other problems, 55% has co morbid problems. With bulimia, comorbidity rates are even higher, up to 88%. Anorexics have a lot of problems of impairment in their lives, and 24% have severe problems. The primary problem type is social. With bulimia, 78% have impairment, 10% have severe problems of social type and family. BED has much less impairment, only 8.7% have severe impairments. 35% of the bulimics have attempted suicide.
77% of anorexics have had some type of help. For bulimics it is 88%, for binge eating disorder it is 72.6%. With anorexia, you see immediately that this person has anorexia because of the weight loss. With bulimia, it is much less clear. Do they get the help they need?
Family, peer and media predictors
Binge eating and purging increases between young adolescents and older adolescents. What factors can predict starting to binge eat? A high level of concern about weight, trying to look like persons in the media and dieting are predictors for females. For males, the importance of weight for the father is a predictor. If your mother had an eating disorder, you are at higher risk for extreme eating behaviors. For purging behavior among males, if weight is important for peers is most important.
Being a frequent dieter and a high level of concern about weight is pushing the binging and purging behavior cycle. Their conclusion is that there is a progression from dieting behavior (which is linked with factors such as peers and media) to more serious eating problems.
Biological, psychological and sociocultural correlates
This research studies Dutch youth. How do BMI, pubertal development, self-esteem, parents, peer and the media pressure relate to body change strategies? Body change strategies are wanting to decrease body size or increase muscle size. Media and parents and peers have indirect effects on muscle development scores, through body comparison. It is not related to how important we see our body size.
Parent and peer pressure and media increase muscle size have also an indirect effect on dieting, through body comparison. Females have both direct effects and indirect effects through body comparison on decrease in body size. The conclusion is that many of the correlations run through comparison.
The female athlete triad
Many times, female athletes end up with three problems. They have disordered eating, amenorrhea and they can develop osteoporosis. This is a paradox, considering that athletes are seen as healthy.
High risk sports for developing this problem, is an elite and highly competitive sport, such as gymnastics, ballet dancing or distance running. Individual sports are more at risk than team sports. During adolescence and young adulthood, skeletal integrity is at significant risk due to the rapid growth. Risks for disordered eating in athletes are believes that low body weight improves their performance, revealing uniforms or sport attire, competitive thinness and coping with pressures associated with the sport.
Lean sports increase the risk for eating disorders. These are judged sports, with as lot of aesthetic and appearance. Also sports in which you have to fit in weight-classes, such as lightweight rowing, are at risk.
Treatment varies by the type of disorder. Weight gain is essential in treating anorexia. Intense and structured nursing care is usually successful. Parenteral methods such as tube feeding are rarely needed, it is not a cure for the disorder, it can be only a method to prevent death. Psychotherapy can be effective and family behavioral treatment are indicated for younger patients. No medications are indicated.
With bulimia, cognitive behavioral therapy has proven effective. Medication can work, but placebo medication also has an effect. Antidepressants are often given, Prozac is approved for treatment. Family behavioral therapy is also effective for younger adolescents.
With binge eating disorder, treatment is directed at cessation of binge eating. There is a reduction of overall distress, a psychological intervention. Psychotherapy and antidepressants can be used. Weight loss is more difficult, it is only effective targeted towards obesity (to become overweight). There is a high response to placebo.
Work and the transition to adulthood.
The normative transitions that are part of being an adolescent is the topic today. We have to become psychologically independent and financially independent. This is why we will talk about work and career choices.
Work and adolescence
Work makes up an important part of our identity, you have a vocational identity according to Erikson. We begin this program during adolescence and we consolidate this process in emerging adulthood. We have a developmental perspective of winners and losers. Some are unemployed for a life time, but others have high class jobs.
Before the 20th century, it was rare to both attend school and work. Most people did not attend school past 8th grade, they started working at approximately 14 years. In Europe from about 1500-1700, it was common for youngsters to leave homes to take part in life-cycle service. As industrialization occurred, it became more common for adolescents to work in factories. These are low-skilled jobs. Adolescents who worked in cotton mills were only half as likely to live past age 20 as those working outside the mill.
In the 20th century, there is a huge shift. Around the 1930s, there was a trend that adolescents stayed in school longer. After WWII, youngsters started combining school with a part-time job. In 1990, over 80% of high school seniors worked. If we look at Holland, 46% of youngsters between 15 and 20 years worked part-time. Many students have a side job, 83% of the university students and 92% of HBO students.
Most American girls baby-sit as their first job. American boys usually do yard work as their first job. For older adolescents, the majority of work is done in restaurants or retail sales. On average high school sophomores (who are around 16 years old) work 15 hours a week. Seniors work even 20 hours per week. In Europe, students work less hours.
Negative effects of work
Adolescents have jobs so they have extra money. It depends on whether it takes your orientation away from school if work has negative effects. You cannot focus on both to do well. It is a concern that adolescents start to earn a lot of money, they sacrifice long term schooling to get short term rewards. In those situations, there is a lot of high school drop-out. The problem about that is that it takes adolescents away from their current role, it limits the opportunity to explore other roles.
Beyond 20 hours work per week, problems become considerably worse. There is an increase in substance use, because they have more money to buy drugs. There is less engagement in schooling. Beyond 10 hours per week, anxiety, depression increases and there is a decline in sleep per night. Up to 10 hours work per week is fine.
Over 60% of working adolescents had engaged in at least one type of occupational deviance after being employed for 9 months. Such occupational deviance is called in sick when they were not or worked while under the influence.
Holland’s career choice theory
Even with having regular part-time work, it does give people a feeling of responsibility. They learn social and work skills and learn money management. There are many theories about career choice.
The theory of content says it relates to the characteristics of the individual and the context they live in. Influences on career development are thought to be either intrinsic to the individual or originate from the context in which the individual lives. It is both what kind of jobs are available and what the individual likes. It is best if there is a match between what the individual wants and what the job offers. According to Holland’s theory of personality categories, there are 6 personality types and there are jobs which go along with those types. It is still used today in interest tests. The matching is aimed at job satisfaction and job stability.
Theory of Super
The theory of Super focuses on process, on development. Career choices relate to interaction and change over time. This is characterized by stages. What phase are we in, in our career? You can switch careers and start over, go back in earlier stages. There is the life space, the social situation in which an individual lives. There is the life span, the life stages such as adolescence, which are linked to certain career stages.
This theory focuses on how children develop career interests. It takes a developmental approach. There are different phases in life, starting with growth until age 13. At age 14, exploration begins. At age 25, you enter the phase of establishment. Exploration and establishment is subdivided in 5 sub phases, to see which goals are appropriate. Because of extending education, a lot of people are not in the establishment phase at age 25.
People seek occupations that they judge to be consistent with their interests and talents. Women are more likely to choose careers such as psychology.
Social cognitive career theory
The social cognitive career theory includes environment as an influence. We have person inputs, we bring our predispositions, our gender, our disabilities. If we come from a high class family, it brings stronger pressures. All of those things come into our learning experience. These learning experience affects our self-efficacy and our expectations, which are again linked to our interests, goals and actions. The individual’s unique learning experience over their lifespan develop primary influences that lead to career choice. \
Self-concordance model of personal goals
You have to have personal goals. If you have selected those goals for autonomous reasons, it increases our goal directed effort. It makes us strive for more attainable and more satisfying goals. Self-concordance goals are linked with goal effort. The more you feel the goals as your own, the more likely it is that you have goal progress and eventually you get better school outcomes.
Unlike adolescents, most emerging adults are looking for a job that will turn into a career. It is quite typical that you graduate and you try out jobs, it is normal to switch. Some people may try as much as 7 or 8 jobs.
In Europe and in the US, the unemployment rate for emerging adults is higher than for adults older than 25. Youth unemployment rates in Europe show that Spain has a bad job prospect. Holland is doing quite well, it is one of the countries that is not really feeling the crisis as much as other countries are.
With the economic crisis, females and males have become equal in unemployment. Europe and US have been hit by the crisis, in contrast to Japan. On average across Europe, youth unemployment is 21% and rising. From 2007 to 2012, the conditions have worsened a lot, it changes the prospects and views by youth. They are hit hard in countries such as Spain and Portugal. These employment rates vary by education level. The lower the education level, the higher the unemployment. It is less than 2,5% for German youth who finished university. Between the ages of 30-35, work participation for women drops. The working women mostly work part-time.
There are also problems in terms of ethnicity. For the UK, among white people, the unemployment rate is 8%. Among Black/African/Caribbean, the unemployment rate is 18%. For youth unemployment, these rates are respectively 20% and 45% for Blacks. When we look at the rates in Holland, much higher rates are seen in Non-Western populations.
SES is the best predictor of occupational choice. Education is equivalent to occupation. Middle class parents raise children in ways that foster achievement and career exploration. Economically disadvantaged youth do not have role models of achievement in education.
School to work
Drop outs are at risk for a lifetime of job instability and economic strain. Their jobs are often temporary, low paying and unskilled. A college degree equates to success and economic advantages. Holland is not very good at keeping their youth in school. They have implemented interventions.
In European countries, school-to-work programs are a basic part of the national government. In the US, there is not a political consensus about the value of such programs. High schools train their students to go to college, but it is probably better to have different tracks, such as vocational schools.
60% of all 16- to 18- year olds in Germany are in an apprenticeship. There is continued part-time schooling while apprenticing. When they come out of their training, they will have the skills they need for a job.
In the Netherlands, too many youngsters leave school too early. An upper secondary education is regarded as the minimum qualification to get a job in today’s labor market, but 12% of Dutch youth fail to get a diploma. Males are dropping out at a higher rate than females. Dutch reform plans aim to cut the numbers of school leavers through increased investment in vocational training.
Guest lecture from Pieter Baay School2Work
The transition from school to work is not always smooth. How do people get to the next life stage? You become more independent if you find a job. There are societal costs of unemployment, but also individual costs, such as marginalization.
The School2Work project follows MBO students from the final year into early career development, at five time points. 50% of the students plan to search for a job, the other half had plans to continue education. Because this project is about school to work, this last group is not very relevant.
Identity based work motivation
This is important because the ethnic minorities have a higher unemployment rate. There are several explanations for this difference. They lack skills such as language proficiency, they lack social capital such as network and they come across discrimination. The implicit assumption here is that everybody wants to work. Maybe the ethnic minorities do not want to work. Are we actually having a problem?
Employment changes is affected by job search behavior. Those who search more, find a job more easily. Work motivation increases this job search behavior. Work motivation might differ between groups.
To what extent do work norms differ between immigrant groups and natives? The social identity theory can be applied to this question. Groups distinguish themselves on attitudinal and behavioral norms. Which groups will identify with which norm? Higher status groups can claim valuable characteristics as in-group defining, they can claim what they think is important. The ethnic majority is the higher status group, they have claimed work motivation norms as characteristic. The ethnic minorities would distinguish by rejecting this norm.
Do this norms matter? Maybe the minorities do not have that much work motivation norms, but find a job anyway. People are more motivated for in-group defining behavior. The hypotheses are: The more someone perceives work to be in-group defining, the more he invests in job-searching, and the positive relation between work norms and job searching is explained by increased work motivation.
The first hypothesis was: Dutch perceive work as in-group defining to a larger extent than immigrant groups. This is partly confirmed. The ethnic minorities did perceive this as a Dutch group norm, they overestimate the importance of working to the Dutch. The ethnic minorities had more job search intentions than the Dutch majority.
The second hypothesis is supported. The more someone perceives work to be in-group defining, the more he invests in job-searching. There is a correlation between work norm in group and preparatory searching and job-search intentions.
The third hypothesis is also supported. The positive relation between work norms and job searching is explained by increased work motivation. Especially intrinsic motivation is important.
Emerging adulthood and the end of adolescence
In the past, criteria that have been used to mark entry into adulthood include events such as marriage and child-bearing, or important responsibilities to provide, protect, and procreate. There is the trend in delaying having children. The mean age of becoming mother is becoming older. People stay in school for longer periods of time. Over 60% go to some education after high school before going to work.
Arnett coined the term emerging adulthood. Emerging adulthood is in Western cultures, it could last from about 18 until the mid twenties. It is a period which is characterized by an ongoing exploration and experimentation with possible life directions. Young people have left the dependency of childhood and adolescence, but have not yet entered the responsibilities of adulthood. The criterion of being an adult is being self-sufficient. Individualistic characteristics are now defining adulthood.
Tasks of emerging adulthood are leaving home, completing an education, attaining economic independence and establishing a long term romantic relationship.
Five aspects of emerging adulthood
It is the age of identity explorations. People are trying out various possibilities, especially in love and work. It is the age of instability. People are moving a lot, work changes and unemployment are frequent and there are changes in romantic partner. There is a lot of variability.
It is also a self-focused age of life, free from institutional demands and obligations. Their own life is most important in this phase. Marriage and childbirth are delayed, there is a focus on enjoying freedom and fun. Family role transitions are negatively related to risk taking behavior. Marriage or parenthood cause a decrease in risk behaviors.
Romantic relationships replace the parental attachment, we go to our partner for help and support instead of going to our parents. Among adolescents, parental support is linked to emotional problems, but quality of the romantic relationships is not linked to emotional problems. Among young adults, commitment is linked to emotional problems and parental support is not strongly correlated to emotional problems anymore. This suggests that there have been a transition. Best friends do not seem to take over the parenting role.
These results support the saliency hypothesis. Only for having an intimate partner at an older age, the quality of the relationship with parents is important. It seems that in young adulthood romantic partners take over the role of parents in protecting against problems.
The fourth aspect of emerging adulthood is the age of feeling in-between. People feel ambivalent about their role, in some aspects they feel like they reached adulthood, but in other aspects they do not feel as an adult yet. The fifth aspect is the age of possibilities.
There are (sub) cultural differences with respect to the idea of emerging adulthood. Sub-cultures within the US combine the individualistic view with emphasis on obligation toward others. Religious cultures may have practices that lead to a shortened period of emerging adulthood than in the culture as a whole.
In neoliberal economic systems, the great majority is urban and educated middle class and the social class differences are quite narrow. There are postmaterialist values of autonomy and self-fulfillment. There is a changed emphasis in marriage, from children to the quality of the relationship.
In the Nordic European countries, there are socialist or social democratic regimes. They leave home earliest. In French and German speaking regions, there are conservative welfare regime, they are mid age at home leaving. In Anglo-Saxon liberal welfare regimes, there are early leavers, but there is a split between groups. In Mediterranean regions, there is little social support, therefore the family is very important. These emerging adults still live at home. In post-socialist Eastern Europe, there are many changes, which lead to role exploring.
Emerging adulthood, how we think about it, is affected by culture. Adolescence is also affected by culture. Should we consider emerging adulthood as a unique life phase, is it something all youth experience, or is it limited to college students? There is no definite answer to this question.
Today’s youth are the first to fully compete in a global economy, the first to experience instantaneous communication with the world, the first to grow up with the majority living a portion of childhood in a single parent household and the first to live with the knowledge of AIDS. These are radical historical changes that affect cohorts. The adolescent is embedded in a larger context.