Factors associated with common mental disorders during the transition to adulthood : do emerging adults and ‘early starters’ differ? Findings from an Australian birth cohort study

Background: Despite increasing diversity in pathways to adulthood, choices available to young people are influenced by environmental, familial and individual factors, namely access to socioeconomic resources, family support and mental and physical health status. Young people from families with higher socioeconomic position (SEP) are more likely to pursue tertiary education and delay entry to adulthood, whereas those from low socioeconomic backgrounds are less likely to attain higher education or training, and more likely to partner and become parents early. The first group are commonly termed ‘emerging adults’ and the latter group ‘early starters’. Mental health disorders during this transition can seriously disrupt psychological, social and academic development as well as employment prospects. Depression, anxiety and most substance use disorders have early onset during adolescence and early adulthood with approximately three quarters of lifetime psychiatric disorders having emerged by 24 years of age. Aims: This thesis aimed to explore the relationships between mental health, sociodemographic factors and family functioning during the transition to adulthood. Four areas were investigated: 1) The key differences between emerging adults and ‘early starters’, were examined and focused on a series of social, economic, and demographic factors as well as DSM-IV diagnoses; 2) Methodological issues associated with the measurement of depression and anxiety in young adults were explored by comparing a quantitative measure of symptoms of anxiety and depression (Achenbach’s YSR and YASR internalising scales) with DSM-IV diagnosed depression and anxiety. 3) The association between family SEP and DSM-IV depression and anxiety was examined in relation to the different pathways to adulthood. 4) Finally, the association between pregnancy loss, abortion and miscarriage, and DSM-IV diagnoses of common psychiatric disorders was assessed in young women who reported early parenting, experiencing a pregnancy loss, or who had never been pregnant. Methods: Data were taken from the Mater University Study of Pregnancy (MUSP), a large birth cohort started in 1981 in Brisbane, Australia. 7223 mothers and their children were assessed five times, at 6 months, 5, 14 and 21 years after birth. Over 3700 young adults, aged 18 to 23 years, were interviewed at the 21-year phase. Respondents completed an extensive series of self-reported questionnaires and a computerised structured psychiatric interview. Three outcomes were assessed at the 21-year phase. Mental health disorders diagnosed by a computerised structured psychiatric interview (CIDI-Auto), the prevalence of DSM-IV depression, anxiety and substance use disorders within the previous 12-month, during the transition (between ages of 18 and 23 years) or lifetime were examined. The primary outcome “current stage in the transition to adulthood” was developed using a measure conceptually constructed from the literature. The measure was based on important demographic markers, and these defined four independent groups: emerging adults (single with no children and living with parents), and three categories of ‘early starter’, singles (with no children or partner, living independently), those with a partner (married or cohabitating but without children) and parents. Early pregnancy loss was assessed using a measure that also defined four independent groups and was based on pregnancy outcomes in the young women This categorised the young women into those who were never pregnant, women who gave birth to a live child, and women who reported some form of pregnancy loss, either an abortion or a spontaneous miscarriage. A series of analyses were undertaken to test the study aims. Potential confounding and mediating factors were prospectively measured between the child’s birth and the 21-year phase. Binomial and multinomial logistic regression was used to estimate the risk of relevant outcomes, and the associations were reported as odds ratios (OR) and 95% confidence intervals (95%CI). Key findings: The thesis makes a number of important contributions to our understanding of the transition to adulthood, particularly in relation to the mental health consequences associated with different pathways. Firstly, findings from the thesis clearly showed that young people who parented or partnered early fared worse across most of the economic and social factors as well as the common mental disorders when compared to emerging adults. That is, young people who became early parents were also more likely to experience recent anxiety (OR=2.0, 95%CI 1.5-2.8) and depression (OR=1.7, 95%CI 1.1-2.7) than were emerging adults after taking into account a range of confounding factors. Singles and those partnering early also had higher rates of lifetime anxiety and depression than emerging adults. Young people who partnered early, but were without children, had decreased odds of recent depression; this may be due to the protective effect of early marriage against depression. It was also found that young people who form families early had an increased risk of cigarette smoking (parents OR=3.7, 95%CI 2.9-4.8) compared to emerging adults, but not heavy alcohol (parents OR=0.4, 95%CI 0.3-0.6) or recent illicit drug use. The high rates of cigarette smoking and tobacco use disorders in ‘early starters’ were explained by common risk factors related to early adversity and lower SEP. Having a child and early marriage may well function as a ‘turning point’ for some young people, it is not clear whether this is due to a conscious decision to disengage from a previous ‘substance using’ lifestyle or simply that they no longer have the time to devote to such activities because of child caring. In relation to the methodological issues associated with assessing common mental disorders in young adults, it was found that although the Achenbach empirical internalising scales successfully predicted both later DSM-IV depression (YSR OR=2.3, 95%CI 1.7-3.1) and concurrently diagnosed depression (YASR OR=6.9, 95%CI 5.0- 9.5) and anxiety (YASR OR=5.1, 95%CI 3.8- 6.7), the scales discriminated poorly between young people with or without DSM-IV diagnosed mood disorder. Sensitivity values (the proportion of true positives) for the internalising scales were surprisingly low. Only a third of young people with current DSM-IV depression (range for each of the scales was between 34% to 42%) were correctly identified as cases by the YASR internalising scales, and only a quarter with current anxiety disorder (range of 23% to 31%) were correctly identified. Also, use of the DSM-oriented scales increased sensitivity only marginally (for depression between 2-8%, and anxiety between 2-6%) above the standard Achenbach scales. This is despite the fact that the DSM-oriented scales were originally developed to overcome the poor prediction of DSM-IV diagnoses by the Achenbach scales. The internalising scales, both standard and DSM-oriented, were much more effective at identifying young people with comorbid depression and anxiety, with OR’s 10.1 to 21.7 depending on the internalising scale used. SEP is an important predictor of both an early transition to adulthood and the experience of anxiety during that time Family income during adolescence was a strong predictor of early parenting and partnering before age 24 but not early independent living. Compared to families in the upper quintile, young people from families with low income were nearly twice as likely to live with a partner and four times more likely to become parents (OR ranged from 2.6 to 4.0). This association remained after adjusting for current employment and education level. Children raised in low income families were 30% more likely to have an anxiety disorder (OR=1.3, 95%CI 0.9-1.9), but not depression, as young adults when compared to children from wealthier families. Emerging adults and ‘early starters’ from low income families did not differ in their likelihood of having a later anxiety disorder. Young women reporting a pregnancy loss had nearly three times the odds of experiencing a lifetime illicit drug disorder (excluding cannabis) [abortion OR=3.6, 95%CI 2.0-6.7 and miscarriage OR=2.6, 95%CI 1.2-5.4]. Abortion was associated with alcohol use disorder (OR=2.1, 95%CI 1.3- 3.5) and 12-month depression (OR=1.9, 95%CI 1.1- 3.1). These finding suggest that the association identified by Fergusson et al between abortion and later psychiatric disorders in young women may be due to pregnancy loss and not to abortion, per se. Conclusion: Findings from this thesis support the view that young people who parent or partner early have a greater burden of depression and anxiety when compared to emerging adults. As well, young women experiencing pregnancy loss, from either abortion or miscarriage, are more likely to experience depression and anxiety than are those who give birth to a live infant or who have never been pregnant. Depression, anxiety and substance use disorders often go unrecognised and untreated in young people; this is especially true in young people from lower SEP. Early identification of these common mental health disorders is important, as depression and anxiety experienced during the transition to adulthood have been found to seriously disrupt an individual’s social, educational and economic prospects in later life.

Supporting transition to law school and student well-being : the role of professional legal identity

The empirically established decline in law student well being during the first year of law school is a red-flagged imprimatur for first year curriculum change. This article suggests that by engaging law students with the concept of a positive professional identity, student engagement and intrinsic motivation will increase because they are working towards a career goal that has meaning and purpose. Law school is a time of professional transformation and the legal academy can take steps to ensure that this transformation is inculcated with positive messages. Literature from the fields of law and psychology is analysed in this article, to explain how a positive conception of the legal profession (and a student’s future role within it) can increase a student’s psychological well-being – at law school and beyond.

Transition to law school and law student well-being : The importance of professional legal identity

The empirically established decline in law student well-being during the first year of law school is a red-flagged imprimatur for first year curriculum change. This article suggests that by engaging law students with the concept of a positive professional identity, student engagement and intrinsic motivation will increase because they are working towards a career goal that has meaning and purpose. Law school is a time of professional transformation and the legal academy can take steps to ensure that this transformation is inculcated with positive messages. Literature from the fields of law and psychology is analysed in this article, to explain how a positive conception of the legal profession (and a student’s future role within it) can increase a student’s psychological well-being – at law school and beyond.

Transition to palliative care for people living with metastatic melanoma : preliminary findings from a grounded theory study

Melanoma is the most aggressive form of skin cancer. Five-year survival rates for patients with metastatic melanoma are less than 10%, with a median survival of 6 to 9 months. Despite a number of clinical trials for metastatic melanoma, the treatment options for patients are limited. Palliation is often the main goal of treatment. This constructivist grounded theory study is seeking to examine how people with metastatic melanoma negotiate the transition to palliative care. The method of sampling is purposive and data have been generated through semi-structured interviews with those with metastatic melanoma and partners. Open, focused and theoretical coding of data from 13 interviews conducted to date has produced analytical concepts that reflect how the transition is negotiated. These concepts depict ways in which individuals interact with a fragmented health care system and how meanings are constructed around the rapid progression of the disease and uncertain treatment decisions. The preliminary findings reported upon here are being further explored with a larger sample. The findings to date highlight the need for improved coordination of services for those living with metastatic melanoma, and improved support for individuals dealing with uncertainty.

Pedagogies of inclusive transition to school

Teachers in inclusive early education classrooms face competing pressures that are highlighted as children transition from play-based settings into formal school. Their challenge is to engage in pedagogical practice that caters for the complex range of school entrants. Yet the existing literature reports on transition challenges for separate groups of children rather than on shared needs or processes within diverse class populations. This study addressed this gap by investigating practices that supported transition in three Australian sites in which the populations represented different types of pedagogic challenge. Four themes regarding inclusion and transition were identified from a synthesis of the literature and applied to three cases. Results indicated that teachers adopted a range of approaches framed by the visibility of diversity, by classroom and school context and by the teachers’ professional transition in enacting changing policies. The results suggest that competing demands are balanced through dynamic, contextually framed strategies of relevance to both ECEC and schools.

Getting there, being there, staying and belonging: a case study of two indigenous Australian children’s transition to school

Indigenous Australians are among the most unhealthy populations in the world and yet they reside in a country where the non-Indigenous population enjoys high standards of well-being. Education has been identified as the key mechanism for closing this equity gap. At school commencement many Indigenous children are already at risk of disengagement. This four-year longitudinal study of two Indigenous boys from a socially marginalised community examined key factors affecting transitional trajectories into school. While child characteristics affected level of achievement the critical factors in sustaining positive educational engagement were social support, school practices, inclusion of family and positive expectation.

The importance of agency in facilitating the transition to a multifunctional countryside

We appreciate Holmes' body of work relating to transitions within the Australian landscape, and welcome the opportunity to engage in a discussion on this topic. The paper to which Holmes refers (Bjørkhaug and Richards, 2008) examined the application of agricultural (rather than landscape) multifunctionality in both Norway and Australia. Of specific focus was how non-tradeable concerns, such as environmental sustainability, faired under these divergent systems. We argued that Norway's multifunctionality was strong, due to it being embraced at both the policy and actor level, whereas Australia's could be described as weak. This ‘weak multifunctionality’ that we observed in Australia was due to an emerging bi-lateral (state and federal) policy framework that advocated the importance of environmental values which was rarely embraced by landholders who found themselves trapped on the ‘agricultural treadmill’. The nature of the treadmill is that alternative forms of land use are unthinkable when on-farm investments have been made that support the status quo – to get bigger and/or more efficient. For many of the Australian landholders interviewed in relation to this study, efficiency in production was at odds with the values necessary to effect a transition toward multifunctionality. For instance, graziers in Central Queensland were unconvinced of the value of conserving native flora and fauna when economic viability can be better assured through clear felling native forests to increase the productive capacity of the land.

Mentoring : improving transition to practice

Nurse graduates indicate the transition from student of nursing to registered nurse (RN) is a difficult conversion. This impending change of role and accompanying higher expectations placed upon newly graduating RNs causes concern for students as their Bachelor of Nursing program nears completion. A career mentor scheme is suggested as a way to better prepare final year students for this transition. Evaluations indicate the positive impact the scheme has made on both mentors and mentees as it has enhanced their career development.

Career mentoring : a career development-enhancing strategy for university students in transition to employment

In 1992 the Queensland University of Technology (QUT) Convocation initiated the Mentor Scheme to assist students to better prepare for the transition to employment. The scheme has developed over the past six years and in 1998 more than 130 pairs of employers and students from 12 different disciplines participated in it. Evaluations indicate the positive impact the scheme has made on both mentors and mentees, particularly in enhancing mentees' career development.

Negotiating futility, managing emotions : nursing the transition to palliative care

Nurses play a pivotal role in caring for patients during the transition from life-prolonging care to palliative care. This is an area of nursing prone to emotional difficulty, interpersonal complexity, and interprofessional conflict. It is situated within complex social dynamics, including those related to establishing and accepting futility and reconciling the desire to maintain hope. Here, drawing on interviews with 20 Australian nurses, we unpack their accounts of nursing the transition to palliative care, focusing on the purpose of nursing at the point of transition; accounts of communication and strategies for representing palliative care; emotional engagement and burden; and key interprofessional challenges. We argue that in caring for patients approaching the end of life, nurses occupy precarious interpersonal and interprofessional spaces that involve a negotiated order around sentimental work, providing them with both capital (privileged access) and burden (emotional suffering) within their day-to-day work.

On resilience and acceptance in the transition to palliative care at the end of life

Specialist palliative care is a prominent and expanding site of health service delivery, providing highly specialised care to people at the end of life. Its focus on the delivery of specialised life-enhancing care stands in contrast to biomedicine's general tendency towards life-prolonging intervention. This philosophical departure from curative or life-prolonging care means that transitioning patients can be problematic, with recent work suggesting a wide range of potential emotional, communication and relational difficulties for patients, families and health professionals. Yet, we know little about terminally ill patients' lived experiences of this complex transition. Here, through interviews with 40 inpatients in the last few weeks of life, we explore their embodied and relational experiences of the transition to inpatient care, including their accounts of an ethic of resilience in pre-palliative care and an ethic of acceptance as they move towards specialist palliative care. Exploring the relationship between resilience and acceptance reveals the opportunities, as well as the limitations, embedded in the normative constructs that inflect individual experience of this transition. This highlights a contradictory dynamic whereby participants' experiences were characterised by talk of initiating change, while also acquiescing to the terminal progression of their illness.

The professional socialisation of paramedics : the transition from intern to qualified paramedic

The professional socialisation of paramedics encompasses preconceptions developed during childhood and early adulthood, and subsequent changes in perceptions resulting from university studies, clinical placements and encountering the professional workplace as an employee. This study investigates the professional socialisation of university educated paramedics making the transition from paramedic intern to qualified paramedic. Participants were sought from several of Australia’s larger ambulance services and UK NHS Ambulance Trusts to take part in this study. Participants were recruited through Ambulance Service Research Institutes, Clinical Governance Departments and university databases. To be included in this study, participants were required to be university educated, have completed a professional internship year and achieved qualified or registered paramedic status. Data collection was via face to face semi-structured interviews. Transcripts were analysed using socialisation models from the nursing and allied health disciplines and a grounded theory approach. The study found that participants initially enjoyed their new professional status after completing their internship and becoming qualified paramedics. However, for many the excitement of becoming a qualified paramedic was short lived. Newly qualified paramedics experienced increased levels of responsibility and were required to develop mentoring skills while still adjusting to their new roles. Participants had to contend with inner conflicting views about the reality of paramedic work which were developed though preconceptions and experiences as paramedic interns. The transition from paramedic intern to qualified paramedic is reportedly a challenging experience, as newly qualified paramedics are required to deal with added complexities while still adjusting to their new roles.