There are high levels of alcohol in the UK population, with a particularly damaging pattern of ‘binge drinking’. Extreme alcohol use remains embedded in university culture. Since COVID and lockdown, male students, postgraduates and academic staff are likely to have increased their alcohol consumption. Starting university marks a rise in alcohol intake, to reduce social anxiety and ‘belong’ to the prevailing culture. High risk sexual behaviours rise significantly when alcohol is taken. Death by suicide, and deliberate self-harming, are associated with alcohol use. This is an important modifiable risk factor in addressing sexual violence and suicide. Mental disorders are strongly associated in complex interactions with alcohol use. Heavy alcohol use may be associated with other substance misuse and addictive behaviours. Abstaining from alcohol may result in striking improvements in mental health and academic performance. The rights and wellbeing of non-drinkers need to be acknowledged too. Information campaigns and paying lip service to disapproval do not work. The student age group tends to be less risk-averse than older groups. It falls to university authorities in partnership with local communities to control high risk alcohol intake.

Universities should recognise neurodiversity as conferring risk for mental health conditions and suicide. Evidence-based support and monitoring can reduce the risk of these occurring and can also reduce dropout and improve academic and psychosocial outcomes for these students and staff members. Staff training in recognition and management of neurodiverse conditions should be delivered at levels appropriate to staff roles. Despite growing interest in both ASD and ADHD in adults, many people who could benefit from diagnosis have not received it. Professionals need to be aware of underdiagnosis of both ASD and ADHD in girls and probably in ethnic and other minority groups. Lack of recognition deprives these vulnerable people of the supports universities can offer to people with neurodiversity. Lay people who take on caring or ‘buddying’ roles for people with neurodiversity need to be well-supported within a helping community rather than expected to shoulder responsibility alone. Waiting lists at many NHS clinics are too long to provide timely assessment for students. University mental health staff may be able to create recognised training programmes and negotiate agreements about diagnosis and prescribing with local GPs.

This, the first of two chapters on the transition from school and home to university, addresses general principles of the nature of transitions. All significant transitions involve normal healthy grieving what is lost (‘homesickness’), alongside rebuilding helpful structures and finding new relationships. Concepts of ‘thresholders’ and ‘transition aged youth’ are discussed alongside growing evidence that dynamic changes in the adolescent brain and mind continue longer than previously thought. Other life transitions are considered from an interpersonal perspective, acknowledging that parents and other family members simultaneously experience disruptive role transitions when a student leaves the family. Individual differences and diverse backgrounds make it difficult to know how much adult capacity can be realistically expected of new students. A list of ‘readiness skills’ is provided for consideration, without the expectation that these will all be mastered before leaving home and school. The author suggests that university need not be the automatic immediate option for school leavers and discusses benefits of using wider criteria than the purely academic to choose a university. Finally induction courses, summer schools and other ways of preparing for university are discussed. These include the peer expectation of using alcohol to manage the inevitable social challenges.

Suicide is a leading causes of student death, especially in young men, and appears to be increasing in prevalence. The most effective preventative measures so far involve limiting access to the means of self-destruction. Institutions can monitor the built environment for ‘suicide hotspots’ such as towers, bridges and car parks, and reduce access to chemicals and drugs on campus. Social media and other online activity appear to increase the likelihood of suicide. Alcohol and recreational drugs are strong risk factors. Individuals with autism are at high risk, as are those with a diagnosis of bipolar disorder. Students who have to take time out of academic studies – or to leave – are especially vulnerable. Warning signs include social withdrawal, academic failure and low mood. Asking about suicidal thoughts appears not to increase the likelihood of suicide, but may be protective. Support pathways for distressed students and staff should be regularly reviewed. Websites should be kept updated with helpful links, including simple instructions for crisis management. Information-sharing agreements should be reviewed to consider permissions to contact next of kin. All institutions need a suicide ‘postvention’ plan and team in readiness to compassionately manage the rare but devastating occurrence of suicide.

Families continue to provide immense financial and psychosocial support to their student age children. ‘Estranged students’ and those who are themselves carers suffer financial, academic and social obstacles to a successful university experience. Parents now expect greater participation in the lives of their student children, as financial realities empower them to influence their children’s choices. From age 18 students are deemed ‘adults’, but without adult rights to an independent student loan, or legal compulsion on their parents to provide finance. Parents have little feedback or power over the resource they are asked to finance. Communication between universities and parents has attracted controversy. Universities are experimenting with ways to clarify how nominated carers can be consulted about students at risk. Families may become the unsupported carers when a student has left university in an unplanned way, as well as when the course comes to an end. The chapter considers the value of developing a ‘leavers’ programme’, analogous to freshers weeks, as well as a specific package of supports for students who leave in an unplanned way.

UK university life lends itself to experimentation in sexual behaviour, orientation and gender identity. The experience of sexual liberation can affect trust and communication with students’ culture and family of origin. Casual sexual encounters (‘hooking up’) are common at first. Those who settle into more monogamous ‘dating’ enjoy better mental health. Mental illness is associated with less healthy sexual experiences. The sexual dimension of life is important to the student age group and should be considered in assessment and treatment. Despite the relatively tolerant environment, university LGBTQ+ communities are at higher risk of mental illness. Students with ASD may also need extra support to negotiate sexual development. Some students have previous sexual trauma, which may still be unaddressed. Some school sex education protects students from gender-based violence throughout university, but classes are often delivered without awareness of pupils’ ethical and relational concerns. Social media provides influential, but often misleading sex education. High reliance on online dating is associated with poorer levels of mental health. Excessive alcohol and drug consumption are strongly associated with both perpetrating gender-based violence and becoming a victim.