“We had no idea that things were this bad.”  I hear that so often from parents when they find out their teen has been struggling with a mental disorder. And it never fails to break my heart.  I can relate to their bewilderment – that feeling of being totally blindsided.  I said exactly these words when my own daughter made a suicide attempt some years ago.   I knew that she had been withdrawn, but I chalked it up to typical teen behavior.  I thought I knew my child and that if something was seriously wrong I could tell.  I would just know it.  But my intuition let me down. 

 When a crisis blows up, we’re astonished.  As parents, we are certain we know our kids better than anyone else.  But mental health issues can be confusing and hard to detect.  As a mental health advocate, I have seen stunned and caring parents coming to terms with the fact that their seemingly OK teen was actually in despair – with depression, serious anxiety, a substance use disorder or even suicidal thinking.  To make it even more difficult, teens are rarely forthcoming – especially to parents.  While we think we know all that may be going on in their lives, my own experience tells me that we don’t.  The new communication environment we live in, where so much of a teen’s world is lived on Facebook and through text-messaging makes meaningful discussion even more challenging.

 This adolescent tendency to keep things private, particularly from parents, is especially important when it comes to their mental health.  New research tells us that it is precisely those teens who “keep things to themselves” who are at highest risk for mental disorders. A new study published in the Journal of Youth and Adolescence identified a strong link between what the researchers call “restrictive emotionality”, and depression, suicidal thinking and attempts.  As they define it, teens with restrictive emotionality have difficulty not only expressing their emotions but understanding them at all. In short, they don’t know what they’re feeling.  They simply can’t sort it all out.  These teens are 11 times more likely to be depressed.  They are also at higher risk of both thinking about and attempting suicide. 

 Of course, we should continue to aim for as much communication with our teenagers as possible.   But I don’t think we can rely on our hunches or on our teens just opening up to us when they are in turmoil.  Thankfully, there are some great organizations that offer practical tools for parents. The American Academy of Child and Adolescent Psychiatry has helpful Facts for Families, and NAMI and Mental Health America also offer resources on how to be alert to the signs of depression and suicide in teens.  Pediatricians are being urged by their professional organization to build mental health care into their routine practice. Checking for depression and other disorders with a brief screening questionnaire, which is now a covered service under the new federal health care legislation, just makes sense and is proven effective.  A mental health checkup at the doctor’s office can reassure you that your teen’s moodiness is just that – teen moodiness – and nothing more.  Or it can raise a red flag.  In either case, you’ll have the information you need.   

 Many teens find it difficult to communicate their problems and reach out, but that doesn’t mean we need to stay in the dark.  As parents, we can get the support and information that we need to raise teenagers in an increasingly complicated, challenging world.

There has been a good deal of news lately about mental health screenings. Recently the American Academy of Pediatrics urged doctors to regularly screen for mental health disorders in adolescents and children. Those of us in the mental health community welcomed this development, but I can understand why parents might question what it means.

I’d like to take some time, here and in the in the next couple of posts, to help answer that question.  Your pediatrician may offer a screening at your teen’s next annual checkup as a way to assess depression, anxiety or other mental health conditions.   

 In the Doctor’s Office: When Teens Are Screened

 A mental health screen is a questionnaire, given on paper or via computer, that has been shown through research to be safe and effective in helping to determine whether a teen may have depression, another mental health problem, or is thinking about or has attempted suicide.  There are numerous mental health screens that have been evaluated for use in adolescents, with anywhere from two to 50 or more questions. 

Your teen will sit quietly answering questions that help assess how they’re doing and shed light on whether there is the possibility of depression, anxiety, substance abuse or another mental health problem.  Screens, however, are not diagnoses.  Like other medical screens, they only serve to give doctors a clue that something could be wrong and a reason to check further.  At The TeenScreen National Center we advocate a two-step process.  Once your youngster has finished taking the questionnaire, the physician reviews it.  If it is positive for a possible mental health condition — which happens approximately 10% of the time — he or she conducts an additional assessment. Our own research has found that this additional step is important, as it minimizes false-positives.    

In a large majority of cases, your teen will be fine.  If the doctor does identify a mental health concern then he or she will discuss the options for further evaluation and treatment with you.  You can then make an informed decision that’s best for your teen and your family.       

 How Do Teens React to Screening?

In ways that may surprise you.

First, the majority of teens complete the questionnaire, regardless of how long, and they do not become upset or distressed. They respond well to being asked about their emotional and mental well-being, whether or not they have a problem. Many adolescents are eager to talk about their feelings and welcome the chance. Sometimes it’s easier opening up in a questionnaire or to a doctor instead of a parent. Often times, it’s just that no one ever asked. But they communicate what’s troubling them, and that’s beneficial. Second, the research shows that screening does not “put ideas” in a teen’s head about suicide.  If the thoughts are there, the screen will get them out in the open.  If they aren’t, the screen won’t put them there.

Teens who are depressed or anxious want to feel better.  They want help.  Mental health checkups can open the door to getting that help.    

We often think of summertime as the season when ‘the livin’ is easy’, but I think it’s one of the hardest times of the year for teens and their parents.  Yes, school is out, freeing youngsters from homework, studying and other pressures, but parents’ days don’t change.  They still have to get to work.

When kids are younger, we’re careful to find a good camp, a recreational or enrichment program or a sitter we can trust to mind them.  We leave the house every morning knowing that they’ll be active and well-cared for throughout the day.  Summers can be far more challenging with teenagers, who have outgrown camps and sitters, yet are too young for a summer job (or unable to find one).  Their days can leave them bored and at loose ends, with too much unstructured time.  With no routine, they hang out in town, at the local park, the mall or pool, or in each others’ homes.  As parents, we wonder what they’re up to, even as we text and call when we get the chance.  We worry.

I think we should be somewhat concerned.  Summer can be a risky season for teens.  All the unstructured time can push some to take the kinds of risks that they’re known to take.  Drinking, substance abuse, relationship stress, and cyber-bullying are all known to increase the risk of depression and other mental health problems in teens.  Even if they don’t engage in risky behaviors, some teens won’t fare well with lack of routine.  They may not tell you how they’re feeling and you won’t catch the signs, but teens can sometimes slide from bored inactivity into anxiety and depression.

Summertime with teens at home might be difficult, but, thankfully, finding out if there is a problem can be fairly simple.  More and more pediatricians are taking on the important job of checking for any signs of depression or other behavior disorders, so your teen’s mental health can be assessed as part of a back-to-school wellness visit.  As I talked about in my previous blog, the American Academy of Pediatrics has launched a major new initiative to bring mental health care into every pediatric office.   Now you no longer have to guess about your adolescent’s mental health or try to pry out some answers (which you most likely won’t get) if you have concerns.   It’s a scientifically sound and effective way to make sure your teen is healthy, with a lot less wondering and worrying for you.  So make a plan to check in with your teen’s doctor at some point this summer, and relax (a little).  It’s your summer, too.

Two terrific things happened to me in the last few weeks that reminded me of why our mission is important.  First, I have a new little grandchild!  I know this sort of happy event occurs every day to millions of people, but it still feels very special when it happens to you.   Welcoming a little granddaughter to my growing clan is exciting and joyful.  Nothing brings a smile to everyone’s face more quickly than word of a new baby.   Children and grandchildren touch our deepest emotions.  We love them so much and want to keep them safe always.  Their health and well being becomes more important than our own.   Holding a tiny newborn in your arms is to possess the greatest treasure on earth.  OK, I know I’m gushing, but for me it’s true!!

In the middle of a busy first week helping my daughter and her new baby, the American Academy of Pediatrics gave us a wonderful gift.  AAP announced new recommendations, published in the June issue of their journal Pediatrics, urging doctors to offer their young patients a mental health checkup at each visit. This important guidance was accompanied by detailed information on how pediatricians can move ahead to embrace this critical component of total health for children and adolescents. AAP’s mental health task force chair Dr Jane M. Foy led a multi-stakeholder effort to create the recommendations.  A comprehensive tool kit will soon be available to all AAP member physicians.

Think about what this all means.  Very soon when youngsters go to see their pediatrician for routine immunizations or their annual physical, or even for an ear infection or a sprained ankle, they will also be offered a mental health checkup.  Including mental health screening in routine primary care is a huge advance in early detection of mental disorders. The great majority of children and adolescents receive their health care from the pediatrician or family doctor.  These are the medical professionals on the front lines with children and they’re in a good position to give mental health checkups.  Over time, pediatricians will become attuned to both the physical and mental health of kids in their care.  They will be able to identify youth at risk and can offer the help they need before an emerging issue becomes a crisis.  That’s great news for families like mine with a history of mental illness. We know the reality of genetic vulnerability to depression and other serious mental disorders. But it’s an important step forward for all families. The earlier we spot a possible problem the sooner effective care can be provided.  After all, good health and happiness is what we all want for the children and grandchildren we cherish.

What is the best way to treat a teenager with depression?  It’s an issue that has been the subject of sharp debate in the medical and mental health communities, particularly in light of reports that question the effectiveness and safety of antidepressants.

The issue of antidepressant treatment in adolescents deserves the attention it is getting from researchers and clinicians.  We need to learn more about all aspects of teen mental health – from effective treatment to the science of brain development to how best to engage youth in education and support to maintain health.   But as an advocate and the parent of an adolescent who struggled with mental health issues, I find it frustrating that the debate about overtreatment with antidepressants overwhelms the critically important discussion of the undertreatment of teen depression.   Despite the fact that depression is one of the most common conditions in adolescence, the majority of teens will go unindentified and never get any help at all.  Most teens that do get help will go more than two years before receiving an accurate diagnosis. Not only is that a long time to suffer, but it can aggravate the problem.  As with physical conditions, the longer you wait, the worse it gets. Even more troubling, 80% of teens with depression are never identified at all.   Millions of youth are so depressed that it interferes with the activities of their lives.  Their depression puts them at risk for many other health problems, including substance abuse, poor school performance, obesity and sexually transmitted diseases.   Some depressed teens will attempt suicide and tragically, some will succeed.

The reasons for under identification and under treatment are complex.  Societal stigma and the unfounded guilt parents often feel about the problem can foster an understandable tendency to minimize the problem.  But, other factors also contribute — notably inadequate mental health care coverage and an unfortunate tendency to separate physical and mental health.

I believe the tide is shifting in teens’ favor.   The US Preventive Task Force (USPSTF) and the American Academy of Pediatrics (AAP) have recognized adolescent depression as a major public health issue.  They have recommended mental health checkups as standard of care at the pediatrician or family doctor’s office – where most teens receive their health care. In responding to the USPSTF and AAP recommendations, pediatricians and family doctors will now be offering annual depression screenings and forging alliances with mental health professionals.  Mental health parity and national health reform will improve access to care by removing barriers and inequities in coverage for mental disorders.

There is no one right answer or one right treatment that works for adolescent depression.  But, today we have a range of choices and many evidence-based therapies.  There is still much that needs to be done on all fronts, but parents can look forward to more support from physicians and insurers.  Taking advantage of these advances, however, will require that we begin to see teen mental health through a clearer lens.  Today, too many teens struggle in despair and keep their parents in the dark.   With resolve to build on recent gains, we can look forward to a future where depression is found early and treated effectively, so that teen suicide almost never happens.

Community leaders, educators and especially parents have been shocked by the recent adolescent suicides by high school students in South Hadley, Massachusetts and Palo Alto, California.

Tragically, these high profile suicides are among 5,000 that will occur in teens and young adults this year.  The most recent statistics from the Centers for Disease Control and Prevention show that youth suicide appears to be on the rise after a 15-year decline.  As adults, it is difficult to get our minds around these heartbreaking events.  In our search for understanding, we look for reasons.  Did parents and teachers overlook warning signs?  Were they too busy, disengaged, or distracted to see that their teen was despondent?  Surely, there must have been clues, signs of distress.  How, we wonder, could you not know that a teenager was planning to commit suicide?   The truth is, it isn’t easy, regardless of how involved a parent is in their child’s life.

The signs of emotional and mental distress in teenagers are extremely difficult to discern.  Adolescence is a stormy time and most teens are moody and mercurial. Researchers tell us that teens typically don’t reveal suicidal thoughts to parents, and only 10 percent of all teen suicide attempts are known to parents.

It’s important that parents learn the warning signs of teen depression and suicide risk.  As youth suicides begin to creep upward, we need to make adolescent mental health a national priority.  Talking about these issues isn’t easy – they still carry a stigma in too many communities, schools and families.  But, we are clearly making progress.  Mental health parity legislation, signed into law in 2008, is now being implemented.  This landmark policy advance will end discrimination in insurance coverage for mental disorders.  Health care reform is also a major step forward.  With its emphasis on prevention, depression screenings will be offered in new plans and through the  insurance exchange at no cost as part of a teenager’s annual wellness checkup.   In most cases, parents will learn that their child is perfectly healthy.  But, for others, a screening will sound an early alarm that their teen could be in trouble.  Armed with this information, parents can get their son or daughter the help they need before the situation turns serious, whether they suspected there was a problem, or not.