Domain 6 - Social and environmental stressors (Contextual Domain)

Overview

This domain considers the extent and severity of a range of factors in the adolescent’s environment that might contribute to the onset or continuation of the mental health issue. Significant environmental stressors and adversity can lead to increased symptom severity and compromise the capacity of the adolescent and their family to participate in or benefit from the recommended resources or services. Furthermore, understanding the complexities the adolescent is experiencing (or has experienced) may alter the type of service offered or indicate that additional service referrals are required (e.g., a referral to a social support service).

Assessment on this domain should consider the degree to which any or all of the following factors are relevant to the adolescent’s current circumstances and the referral decision:

  • Significant losses (e.g., loss of friends or social connections, death of a loved one).

  • Significant transitions (e.g., disruption to educational activities, parental separation/divorce, death of a loved one, transitions relating to gender identity or sexual orientation).

  • Peer group stress (e.g., bullying, conflict with or isolation from the peer group, loss of friendships).

  • Trauma (e.g., emotional, physical, psychological, or sexual abuse, exploitation, witnessing or being a victim of violence, family and domestic violence, natural disaster, exposure to suicide in family/community/school or peer group, loss, conflict).

  • Victimisation (e.g., human rights abuses, discrimination, racial abuse, victim of crime, refugee, or asylum-seeking experiences).

  • Family or household stress (e.g., household drug or alcohol abuse, the parent or family member with an illness or disability, carer stress or stress associated with a caregiver role).

  • Performance-related pressure (e.g., unrealistic role expectations or responsibilities, schooling demands, caregiving responsibilities) and stressors related to high-performance demands in school, dance, sport, and other relevant extra-curricular activities.

  • Socioeconomic disadvantage (e.g., poverty, parental unemployment, unstable or insecure housing).

  • Legal issues (e.g., the juvenile justice system or family court involvement, enforced separation from family).

Evidence points to the contribution made by historical childhood adverse events to longer-term mental health development. Assessment on this domain should consider the adolescent’s history but only record higher ratings where earlier experiences impact the current situation and require additional specific resources and services.

PRACTICE POINT - childhood experiences of trauma

Adverse Childhood Experiences (ACEs) are stressful events or circumstances that people may experience throughout their childhood. They may relate to childhood physical, sexual, or emotional abuse, physical or emotional neglect, exposure to family violence, parental substance use, parental mental illness, parental separation or divorce, or parental incarceration.

A summary of the evidence and impacts by Emerging Minds reiterates that:

“Exposure to ACEs does not mean poor outcomes are inevitable. If present and reinforced in a child’s life, there are known protective factors that can build the child’s resilience and reduce the impacts of adversity. Nurturing relationships form the basis of healthy brain development, effective early learning, and a child’s capacity to positively respond and adapt to life challenges. Many adults who experienced significant adversity in their childhood have had successful lives and happy relationships” – (Marie-Mitchell & Kostolansky, 2019; Traub & Boynton-Jarrett, 2017).

How a person responds to trauma is highly variable, and many individuals who have been exposed to ACEs will not require a mental health service. Immediate assignment of a level of care based on the experience of trauma alone is problematic and should be avoided. The ACEs study demonstrated a strong relationship between a person’s exposure to ACEs and their physical and mental health throughout their lives. Researchers have established a dose-response association for ACEs – for instance, four or more ACEs are associated with an increased risk of adverse impacts

PRACTICE POINT - bullying (online and in-person)

Bullying can impact the mental health of adolescents. Adolescents who experience bullying can experience feelings like shame, fear, embarrassment, anger, and worry. There is a marked increase in the risk of poor mental health outcomes, self-harm and suicidal ideation and behaviours among people who experience bullying, particularly if the experience of bullying is severe or prolonged.

Bullying, whilst common, is not a normal part of growing up, and an initial assessment with an adolescent should explore the adolescent’s experience of bullying and the impacts of these experiences.

Bullying should be considered in the context of social and environmental stressors (domain 6). The impacts of bullying on the adolescent (if present) will be captured in symptom severity and distress (domain 1), harm (domain 2), and functioning (domain 3).

When considering the level of care, consideration should be given to the informal supports that an adolescent might require outside the formal mental health system- social, school, family and community supports are generally important for adolescents experiencing bullying.

Scoring

0 = No problem in this domain

1 = Mildly stressful environment

  1. The adolescent is experiencing (or has experienced) one or more stressors that are currently having or are likely to have only a minor impact on the adolescent’s mental health.

2 = Moderately stressful environment

  1. The adolescent is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a moderate impact on the adolescent’s mental health.

3 = Highly stressful environment

  1. The adolescent is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a significant impact on the adolescent’s mental health.

4 = Extremely stressful environment

  1. The adolescent is experiencing (or has experienced) one or more stressors that are extreme, enduring, or recurring and are currently having, or are likely to have, a severe impact on the adolescent’s mental health.