An Evolutionary Preamble Towards a Multilevel Framework to Understand Adolescent Mental Health: An International Delphi Study
Abstract
1. Introduction
1.1. The Weight of the Issue
- Biological skills: Hormonal, sexual, and cerebral maturation processes.
- Cognitive skills: The emergence of abstract thinking, advanced reasoning and a stable sense of identity.
- Emotional skills: Differentiation, recognition, and self-regulation of emotions.
- Social skills: The ability to decentrate and manage social roles within (peer) groups.
1.2. Limitations of Current Approaches on Adolescents’ Mental Health
1.3. Proposed Focal Domains and Aims
- The “social” brain during adolescence: Neuroscientific literature highlights adolescence as a period of heightened neuroplasticity in socio-emotional brain circuits. Social experiences, including peer interactions, acceptance, and rejection, play a crucial role in shaping neural development, identity formation, and emotional regulation during this phase.
- Social determinants, macro-social and environmental factors: As underscored by ecological models, adolescents are particularly exposed to structural risk factors such as poverty, housing insecurity, neighborhood violence, and inequality, all of which have enduring effects on mental health trajectories.
- Discrimination, social stigma, and adolescents’ beliefs about mental health: Stigma-related barriers often deter help-seeking behaviors and shape internalized beliefs, particularly among youth with marginalized identities. This area addresses the need to counteract social exclusion and to understand how beliefs and values about mental illness develop and impact behavior.
- Online behaviors, socialization, and loneliness: Digital environments profoundly influence peer interactions, identity negotiation, and exposure to cyberbullying or unrealistic social comparisons. Adolescents’ mental health is increasingly shaped by online dynamics, which can amplify both risk and protective processes.
- Pre-clinical conditions: Many disorders emerge gradually, with prodromal symptoms or non-specific psychological distress preceding clinical onset. A developmental and evolutionary lens allows us to capture these transitional states and informs transdiagnostic clinical staging models aimed at early prevention.
2. Materials and Methods
2.1. Description of the First Draft of the Framework
2.2. Panel Selection
2.3. Consensus Process
- Relevance: The degree to which the item aligns with the research objectives and contributes meaningfully to the topic under investigation.
- Consistency: The extent to which the item maintains logical coherence and aligns with the overall structure of the research.
- Clarity: The item is well-defined, unambiguous, and structured coherently, without contradictions or confusing elements.
- Ease of understanding: The item is accessible in terms of language complexity and comprehensibility for readers with varying levels of expertise.
- Updating: The extent to which the item reflects the most current evidence, theories, and advancements in the field.
- In the second round, in addition to the five categories used in the first round, the following were added:
- Consistency with suggested changes: The extent to which the item incorporates and aligns with the modifications proposed in the previous round.
- Improvement compared with the initial draft: The degree to which the item demonstrates enhancements in clarity, coherence, and overall quality relative to the original version.
- Suitability for publication: The item’s appropriateness for dissemination, considering its scientific rigor, completeness, and adherence to academic standards.
3. Results
3.1. Panel Composition
3.2. Delphi Process
3.2.1. Round 1
3.2.2. Round 2
3.2.3. Development of the Framework on Adolescents’ Mental Health
4. Discussion
4.1. Focal Point 1: The “Social” Brain in Adolescence
4.1.1. Brain Development
4.1.2. Genes and Environmental Factors
4.1.3. Social Bonds and Networks
4.1.4. Attachment Styles and Epigenetics
4.2. Focal Point 2: Social Determinants, Macro-Social and Environmental Factors
4.3. Focal Point 3: Discrimination, Social Stigma and Adolescents’ Beliefs About Mental Health
4.4. Focal Point 4: Online Behaviors, Socialization and Loneliness
4.5. Focal Point 5: Focus on Pre-Clinical Conditions
4.6. From a Multi-Level Framework to a Matrix of Measures for Research
4.7. Practical Implications
4.8. Constraints and Challenges
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Structure | Item | |
---|---|---|
Title | An evolutionary preamble towards a shared conceptual framework to understand adolescent mental health and well-being. | |
Paragraphs | ||
Background | 1 | The Weight of the Issue. |
2 | Limitations of Current Approaches. | |
Focal domain 1 | 3 | The Social Brain in Adolescence and Social Functioning. |
4 | The Role of Social and Physical Environments in Neurodevelopment. | |
5 | Status, Social Roles and well-being in adolescence. | |
6 | Attachment Avoidance and Epigenetic Modifications. | |
Focal domain 2 | 7 | The Role of Macro-Social and Environmental Factors. |
Focal domain 3 | 8 | Exploring Adolescents’ Beliefs: Can Stigma Exacerbate the Impact? |
Focal domain 4 | 9 | The Influence of Peers, Online Behavior, Leisure Activities, and Social Rhythms. |
Focal domain 5 | 10 | Focus on pre-clinical conditions. |
Multi-level matrix | 11 | From a Shared Conceptual Framework to a Matrix of Measures for Research. |
Paragraphs of the Initial Draft Version | ||||||||||||
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Panel Member | Title of the Initial Draft Version | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
1 | ||||||||||||
2 | ||||||||||||
3 | ||||||||||||
4 | ||||||||||||
5 | ||||||||||||
6 | ||||||||||||
7 | ||||||||||||
8 | ||||||||||||
9 | ||||||||||||
10 | ||||||||||||
11 | ||||||||||||
12 |
Item | Relevance | Consistency | Clarity | Easy of Understanding | Updating | Total Score | Consensus Index | |
---|---|---|---|---|---|---|---|---|
Initial draft version | Title | 12/12 | 9/12 | 10/12 | 9/12 | 11/12 | 51/60 | 0.85 |
1 Paragraph | 12/12 | 8/12 | 9/12 | 10/12 | 11/12 | 50/60 | 0.83 | |
2 Paragraph | 11/12 | 10/12 | 8/12 | 10/12 | 8/12 | 47/60 | 0.78 | |
3 Paragraph | 11/12 | 9/12 | 9/12 | 11/12 | 8/12 | 48/60 | 0.8 | |
4 Paragraph | 10/12 | 9/12 | 9/12 | 11/12 | 9/12 | 48/60 | 0.8 | |
5 Paragraph | 10/12 | 9/12 | 7/12 | 9/12 | 8/12 | 43/60 | 0.72 | |
6 Paragraph | 8/12 | 9/12 | 10/12 | 11/12 | 9/12 | 47/60 | 0.78 | |
7 Paragraph | 10/12 | 9/12 | 9/12 | 10/12 | 8/12 | 46/60 | 0.77 | |
8 Paragraph | 10/12 | 6/12 | 9/12 | 11/12 | 10/12 | 46/60 | 0.77 | |
9 Paragraph | 10/12 | 8/12 | 9/12 | 11/12 | 8/12 | 46/60 | 0.77 | |
10 Paragraph | 10/12 | 9/12 | 9/12 | 11/12 | 8/12 | 47/60 | 0.78 | |
11 Paragraph | 10/12 | 8/12 | 10/12 | 10/12 | 8/12 | 46/60 | 0.77 | |
Total score | 124/144 | 103/144 | 108/144 | 124/144 | 106/144 | 565/720 | 0.78 | |
Consensus index | 0.86 | 0.71 | 0.75 | 0.86 | 0.74 | 0.78 |
New Version of the Draft After Round 1 | ||||||||
---|---|---|---|---|---|---|---|---|
Panel Member | Relevant | Consistent | Clear | Easy to Understand | Up to Date | Consistent with the Changes You Suggested | Improved When Compared to the First Version | Suitable for Publication |
1 | ||||||||
2 | ||||||||
3 | ||||||||
4 | ||||||||
5 | / | / | / | / | / | / | / | / |
6 | ||||||||
7 | ||||||||
8 | ||||||||
9 | ||||||||
10 | ||||||||
11 | ||||||||
12 |
Item | Relevance | Consistency | Clarity | Easy of Understanding | Updating | Consistency with the Changes You Suggested | Improvement When Compared to the First Version | Suitability for Publication | Total Score | Consensus Index |
---|---|---|---|---|---|---|---|---|---|---|
New version of the draft after Round 1 | 11/11 | 10/11 | 11/11 | 11/11 | 10/11 | 11/11 | 11/11 | 9/11 | 84/88 | 0.95 |
Consensus index | 1.0 | 0.91 | 1.0 | 1.0 | 0.91 | 1.0 | 1.0 | 0.82 | 0.95 |
Section | Main Revisions After the Round 1 | Main Revisions After the Round 2 | |
---|---|---|---|
Title | The study design has been explicitly stated in the title. | It has been clarified that this is an international Delphi study. | |
Abstract | It has been added. | ||
1. Introduction | The Weight of the Issue | More specific epidemiological data have been included. The section on suicide has been further elaborated. The bibliography has been updated. | Additional epidemiological considerations regarding gender differences and the prevalence of mental disorders have been incorporated into the manuscript. |
Limitations of Current Approaches on adolescents’ mental health | The section on categorical and dimensional models has been further elaborated. The utility of the evolutionary approach to adolescent mental health in capturing the interplay between risk and protective factors has been explicitly stated. | The importance of the interrelationship between macro-social factors and adolescents’ mental health outcomes has been introduced, as well as to the protective role of factors such as social support, healthy diet, physical activity, and regular sleep habits. Additionally, a statement about the ecological model of health has been incorporated. Additional bibliography has been introduced. | |
Proposed Focal Points and Aims | The five focal points have been separated into a dedicated sub-paragraph. They have been more specifically defined as the basis to develop the framework and described. The study objective has been explicitly stated. | The importance of a multidisciplinary approach for the development of a multi-level framework on adolescent mental health has been further clarified. | |
2. Methods | The Delphi methodology has been introduced and described in detail, specifically: the composition of the research group and the selection of the panel, the first version of the draft that formed the basis of the Delphi study (with a figure), and the rules for the consensus-reaching procedure. | ||
3. Results | The composition of the panel, as well as the results of the first Delphi round and the achieved consensus indices have been reported (also with tables). The process through which the framework was developed has been presented. | The results of the second Delphi round and the achieved consensus indices have been reported (also with updated tables). | |
4. Discussion | Focal point 1: The “Social” Brain in Adolescence | It has been divided into four sub-sections. The section on the asynchronous development of the brain has been further elaborated. The section on attachment theory has been more clearly specified. The bibliography has been updated. | A statement has been included with examples of how certain disorders with a strong genetic component, such as ADHD and bipolar disorder, can “shape” the patient’s environmental exposure. The bibliography has been updated. |
Focal point 2: Social determinants, macro-social and environmental factors | The social determinants that most impact adolescent mental health have been explicitly stated. Among these, macro-social and environmental factors have been distinguished. Additional bibliography has been introduced. | It has been further specified how macro-social factors, such as lower family income or limited economic opportunities, may increase exposure to additional stressors such as food insecurity and unstable housing. The role of social factors—such as access to quality education and characteristics of the neighborhood context—on adolescent mental health has also been explicitly addressed. Additional bibliography has been introduced. | |
Focal point 3: Discrimination, social stigma and adolescents’ beliefs about mental health | The concept of discrimination and its relationship with stigma phenomenon has been introduced. The main sources of discrimination among adolescents have been described. The concept of stigmatization and self-stigmatization of adolescents with mental health problems has been more clearly specified. Additional bibliography has been introduced. | ||
Focal point 4: Online behaviors, socialization and loneliness | A substantial revision has been made regarding the definition and description of online behaviors, particularly related to the use of social media platforms, associated risks, and problematic internet use. The relationship between social networking site use and the phenomenon of loneliness has been more clearly defined. Additional bibliography has been added, especially supporting the relationship between the acquisition of emotional and social skills through fictional environments (i.e., virtual ones). | ||
Focal point 5: Focus on Pre-Clinical Conditions | A section on transdiagnostic clinical staging models has been introduced. The part on “sub-threshold” and “threshold-level” disorders has been more clearly explained. In this way, the evolutionary approach to the bipolar spectrum serves as an example for approaching adolescent mental health from a pre-clinical perspective (i.e., regarding hyperactivity, hyper-exploration and novelty-seeking). Additional bibliography has been introduced. | ||
From a Multi-level Framework to a Matrix of Measures for Research | A substantial revision has been made regarding how to use the framework through a multi-level indicators matrix. An anchoring to the “Rainbow model” has been proposed, allowing for multi-level analysis to test specific research hypotheses developed based on the framework. Additional bibliography has been introduced. | The areas to be considered in the construction of the matrix have been more clearly defined for macro-level data on social and environmental factors, medium-level data on family and community, and adolescent-level data on risk and protective factors for mental health. | |
5. Conclusion | Some conclusions have been added, summarizing the main contents of the study. |
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© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Sancassiani, F.; Barrui, V.; Bert, F.; Carucci, S.; Charfi, F.; Cossu, G.; Holte, A.; Lindert, J.; Marchini, S.; Perra, A.; et al. An Evolutionary Preamble Towards a Multilevel Framework to Understand Adolescent Mental Health: An International Delphi Study. Children 2025, 12, 1189. https://doi.org/10.3390/children12091189
Sancassiani F, Barrui V, Bert F, Carucci S, Charfi F, Cossu G, Holte A, Lindert J, Marchini S, Perra A, et al. An Evolutionary Preamble Towards a Multilevel Framework to Understand Adolescent Mental Health: An International Delphi Study. Children. 2025; 12(9):1189. https://doi.org/10.3390/children12091189
Chicago/Turabian StyleSancassiani, Federica, Vanessa Barrui, Fabrizio Bert, Sara Carucci, Fatma Charfi, Giulia Cossu, Arne Holte, Jutta Lindert, Simone Marchini, Alessandra Perra, and et al. 2025. "An Evolutionary Preamble Towards a Multilevel Framework to Understand Adolescent Mental Health: An International Delphi Study" Children 12, no. 9: 1189. https://doi.org/10.3390/children12091189
APA StyleSancassiani, F., Barrui, V., Bert, F., Carucci, S., Charfi, F., Cossu, G., Holte, A., Lindert, J., Marchini, S., Perra, A., Pinna, S., Nardi, A. E., Scano, A., Soutullo, C. A., Tusconi, M., & Primavera, D. (2025). An Evolutionary Preamble Towards a Multilevel Framework to Understand Adolescent Mental Health: An International Delphi Study. Children, 12(9), 1189. https://doi.org/10.3390/children12091189