105 Mental Health and Behavioral Issues
105.1 Introduction
Adolescence marks a period of profound developmental transitions—biological, cognitive, and psychosocial. While it is often viewed as a healthy phase of life, it is also the time when many mental health disorders first emerge. Globally, mental health conditions account for a significant portion of the disease burden among adolescents, and the situation in Ghana and West Africa is no exception. Yet, these conditions frequently go unrecognised due to stigma, limited mental health literacy, poor access to specialised services, and the cultural tendency to interpret emotional distress as misbehaviour or spiritual affliction.
This chapter explores the key mental health and behavioural issues in adolescents, integrating biological, psychosocial, and environmental influences. It provides practical guidance on assessment, early identification, and clinical management suitable for resident doctors and medical students working in Ghana and similar settings.
105.2 Overview of Adolescent Mental Health
Mental health in adolescence is shaped by the interaction of genetic predisposition, developmental vulnerabilities, family dynamics, peer influences, community safety, and sociocultural norms. Experiences such as academic pressure, social media exposure, and transitioning roles within the family may contribute to psychological stress.
In Ghana, additional influences include:
- Boarding school pressures
- Socioeconomic constraints
- Religious expectations
- Early responsibility within households
- Exposure to domestic or community violence
- Limited availability of adolescent-friendly mental health services
Mental health disorders in adolescents can significantly undermine academic performance, relationships, physical health, and long-term wellbeing. Early detection is essential.
105.3 Common Mental Health and Behavioral Conditions
105.3.1 Depression
Depression often presents differently in adolescents than in adults. Irritability, behavioural problems, academic decline, and somatic complaints may be prominent.
Features may include: - Persistent sadness or irritability
- Loss of interest in usual activities
- Poor sleep or oversleeping
- Changes in appetite or weight
- Fatigue
- Poor concentration
- Feelings of hopelessness or worthlessness
In Ghanaian adolescents, depression may manifest as frequent unexplained headaches, school refusal, social withdrawal, or behavioural outbursts.
105.3.2 Anxiety Disorders
Anxiety may present as generalised anxiety, social anxiety, panic disorder, or school-related anxiety.
Presentations include:
- Excessive worry
- Avoidance of social interactions
- Palpitations, chest discomfort, tingling, or shortness of breath
- Perfectionism and academic fear
Excessive religious fear, fear of witchcraft or spiritual harm, and performance anxiety during major national examinations (e.g., BECE, WASSCE) are culturally relevant manifestations.
105.3.3 Behavioral Disorders
Behavioral issues often cause significant family and school conflict.
Oppositional Defiant Disorder (ODD):
- Frequent arguing
- Defiance of authority
- Irritable mood
Conduct Disorder (CD):
- Truancy
- Fighting or bullying
- Stealing
- Property destruction
- Risk of substance misuse
Urbanisation, overcrowded schools, and peer gang influence contribute to rising behavioural problems in some regions.
105.3.4 Attention-Deficit/Hyperactivity Disorder (ADHD)
Often underdiagnosed in West Africa, ADHD presents as:
- Inattention
- Hyperactivity
- Impulsivity
- Academic challenges
Teachers may describe such adolescents as “restless” or “not serious,” leading to punitive responses rather than support.
105.3.5 Substance Use Problems
Substance use is increasing among adolescents in Ghana, particularly:
- Alcohol
- Cannabis
- Tobacco and shisha
- Tramadol and other opioids
- Misuse of cough syrups or energy drinks
Risky use is often linked to peer influence, social media trends, stress, and curiosity.
105.3.6 Eating Disorders
While less commonly diagnosed in West Africa, eating disorders are emerging with globalisation and social media influence.
They include:
- Anorexia nervosa
- Bulimia nervosa
- Binge-eating disorder
Body image dissatisfaction is increasingly seen among urban adolescents.
105.3.7 7. Self-Harm and Suicide Risk
Self-harm behaviours—such as cutting or intentional poisoning—may emerge from emotional distress, relationship problems, or feelings of hopelessness.
Clinicians should sensitively ask about:
- Thoughts of self-harm
- Feelings of hopelessness
- Exposure to peers who self-harm
- Access to means
Any self-harm behaviour requires urgent, supportive, nonjudgmental intervention.
105.4 Contributing Factors to Adolescent Mental Health Challenges
105.4.1 Biological Factors
- Hormonal changes
- Genetic predisposition
- Chronic illnesses such as epilepsy or diabetes
105.4.3 Environmental Factors
- Poverty
- Unsafe neighbourhoods
- Academic pressure
- Social media influence
- Stigma around mental illness
105.4.4 Cultural and Religious Influences
- Misinterpretation of mental illness as spiritual weakness
- Fear of stigma delaying help-seeking
- Strong family and community structures may serve as protective factors
105.5 Assessment of Mental Health in Adolescents
105.5.1 Approach to Assessment
The clinician must establish rapport, maintain confidentiality, and assure the adolescent that their concerns will be taken seriously.
Use structured approaches such as:
- HEEADSSS interview
- HEADS-ED for acute assessments
105.5.2 Screening Tools
Use simple, validated tools when available:
- PHQ-9 for depression
- GAD-7 for anxiety
- CRAFFT for substance use
105.5.3 Collateral Information
With adolescent consent, input from parents and teachers may provide essential context to behavioural or academic concerns.
105.5.4 Risk Assessment
Always assess for:
- Suicidal thoughts
- Self-harm behaviours
- Substance misuse
- Violence exposure
Urgent psychiatric evaluation is needed when safety is compromised.
105.6 Management Principles
105.6.1 Psychoeducation
Explain the condition in simple, culturally respectful terms. Correct common myths—for example, that depression is a moral weakness or that ADHD is simply stubbornness.
105.6.3 Pharmacotherapy
Medication should be used when indicated and with caution.
- SSRIs for moderate to severe depression or anxiety
- Stimulant or non-stimulant medications for ADHD
- Antipsychotics for severe behavioural disorders
Regular monitoring is essential.
105.6.5 Referral
Referral to mental health specialists (psychiatrists, psychologists) should be arranged when:
- Symptoms are severe or persistent
- Suicide risk is high
- There is suspected psychosis
- Complex family or behavioural dynamics exist
In Ghana, referral pathways may include teaching hospitals, district hospitals with mental health units, or community mental health officers.
105.7 Preventive Strategies
- Promote resilience and life skills in adolescents
- Strengthen school health programmes
- Provide adolescent-friendly services
- Improve public awareness to reduce stigma
- Promote responsible media portrayals of mental health
105.8 Ghana and West Africa–Specific Considerations
- Limited mental health infrastructure
- High stigma associated with mental illness
- Increased exposure to academic and economic pressures
- Growing concerns about substance misuse, particularly tramadol
- Boarding school systems may mask or worsen mental health problems
- Strong family systems can either protect or exacerbate stress
105.9 Key Points
- Mental health issues are common but often overlooked in adolescents.
- Presentations may be atypical, especially in cultural contexts where emotional expression is constrained.
- Early detection requires sensitive, confidential, developmentally appropriate care.
- Psychosocial interventions remain the cornerstone of management.
- Safety assessment is essential, especially for self-harm or suicide risk.
105.10 Further Reading
- World Health Organization. Adolescent Mental Health: Key Facts.
- Ghana Health Service. Adolescent Health Strategy (2021–2025).
- Patel V et al. Adolescent mental health: a global priority. Lancet Psychiatry.
- Kieling C et al. Child and adolescent mental health worldwide. Lancet.
- UNICEF. The State of the World’s Children: Mental Health.