Recognizing depression in teens is our communal responsibility
Thinking about teen depression is like wrestling an alligator. Maybe that’s because ‘typical’ teen behavior and ‘depressive’ teen behavior look—and sound—suspiciously alike. For example: is your teen irritable, moody, hyper-sensitive to criticism, needful of privacy, difficult to get along with? Does she seem to lack focus and concentration at school or at home? Does he seem to need an awful lot of sleep?
Increased hormonal activity contributes to a teenager’s already intense moodiness and heightened emotional pitch. Dr. Steven Schlozman, a staff psychiatrist at the Massachusetts General Hospital, points out that there are huge social pressures for teens to conform, and to look like they are not depressed. This means that it's easy for even the most vigilant of parents to completely miss the signs of depression in their own kids.
A Children’s Hospital Boston newsletter warns pediatricians to be on the lookout for teen depression, since “adolescents are socialized to disguise their feelings.” And mental health experts who work with teens say that because the differences between typical and depressed teens can seem subtle—and because teens often actively mask how they are feeling—adults around teens should be both persistent and watchful.
Dr. Arnold Kerzner, Chief of Clinical Services at Human Relations Services in Wellesley, says it’s often difficult for parents to tell adolescent depression from normal teen turmoil, and it may help them to meet with a counselor just to sort it out. Too, the counselor can help parents find a way to bring even the most recalcitrant teen in for evaluation. “It may be important to instigate a family crisis in order to get started,” he says.
“We don’t understand the etiology of depression,” says Dr. Schlozman, “and there’s no diagnostic test, like an X-ray, that can decrease the risk of our not seeing something. It’s better if parents, teachers, and counselors act, rather than waiting to see whether more, or more severe, symptoms appear. With depression, you don’t want to find yourself wishing you had acted earlier.”
An Epidemic? Or Not.
Why are we hearing so much lately about depression and suicide among teens? Thom Hughart, Director of Guidance at Wellesley High School, says that depression among teens is either much more widespread than it used to be, or, more likely, that we’re significantly more attuned to the problem now, and finding more ways to address it. Julie Totten, Director and President of Families for Depression Awareness, a non-profit organization that supports families and caregivers when depression is present, thinks there’s another important factor. “There’s always been a lot of stigma around mental illness,” she says. “In some families it still exists, but there’s not nearly as much of a tendency to cover it up. Before, depression and suicide didn’t get reported or discussed; they got swept under the rug. Now, someone always notifies the media when tragedy strikes. Word gets out quickly when something happens to one of our teens, and a lot more attention gets paid.”
Symptoms of Teen Depression
Teens are mercurial creatures. For example, some moodiness and irritability is normal adolescent (and, in fact, human) behavior. Too, adolescence is a classic time to try out new identities, fashions, and appearances. However, clinicians say that a good rule of thumb for parents is to note certain changes in their teen’s behavior and/or demeanor that last more than two weeks, and to be aware that the appearance of one or more such changes may be indicative of teen depression.
Such changes include (but are not limited to):
• Moodiness (sadness, irritability, anger) that lasts longer than usual
• Decreased connections with friends
• Dropping out of previously important activities
• Change in tone of voice or a downcast facial expression
• Eyes red or sad-seeming
• Quiet sobbing
• Pronounced silent periods
• Slower body movements; a drop in energy
• Hyper- or hyposomnia (marked changes in sleep patterns)
• Obsessive interest in or involvement with a girlfriend or boyfriend
Changes at school might include:
• Trouble concentrating and/or processing information
• Difficulty forming thoughts
• Acting out; challenging authority; flaunting rules
• Increased absenteeism or tardiness
• Not completing assignments
• Decreased academic performance
• Verbal and physical fighting
• Substance use and abuse
• Lack of motivation or interest
Hughart and Totten know a lot about teens, and about the spectrum of depression. Hughart says that we tend to use the word ‘depressed’ to mean ‘sad,’ as in ‘I’m depressed because I broke up with my boyfriend.’ “When we use the word to mean sadness, well, it can lose some meaning,” he explains. “There’s sadness, and then somewhere else on the spectrum, there’s real illness; clinical depression, which requires intervention. As an educational facility, we try to be as enlightened as we can about the adolescent psyche, and we are always going to let parents know if we see any indication of depression. I think awareness has been heightened—at local and national levels—for every high school. We want to identify and address depression in a teen before it gets to an extreme level, where there are clear ties, along with bipolar disorder, to violence and suicide.”
Totten and other experts believe that we all need, desperately, to understand the significance of those ties. “It’s especially important for parents to recognize the links between depression, bipolar disorders, and suicide, which is the third-leading cause of death among teenagers. You know, the fact is that teens don’t kill themselves just because they got bad grades, or because they didn’t get the lead in the school play. They kill themselves because they are [clinically] depressed, and depression is a mental illness. It’s also the leading cause of suicide in teens.”
Dr. Schlozman suggests that you “think about the difference between a fourteen-year-old and a sixteen-year-old. It’s dramatic. Now think about the difference between a thirty-year-old and a thirty-two-year-old. There’s little difference, there. Because adolescent development—physical, emotional, and cognitive—is so compressed, a lot more bad can come of it, if the growth trajectory is interrupted. Clinical depression in an adolescent can be a massive interruption. It ‘depresses’ a kid’s ability to develop a strong sense of self…and when that happens, the kid gets stuck.”
“Absolutely, you want to catch depression early,” agrees Bob Anthony, founder of Adolescent Wellness (see sidebar), whose programs help community members of every stripe understand, identify, and get treatment for teens who exhibit symptoms of depression. Anthony points out that half of all adults diagnosed with depression showed some symptoms by age fourteen that, significantly, went untreated. “That statistic tells us that we as a community should be as knowledgeable and aggressive as we can about diagnosing and getting treatment for at-risk teens now, while they’re still teens, so that they can develop into healthy adults.”
Echoing Totten and Anthony, Dr. Kerzner says that it behooves parents, counselors, teachers, and friends to be vigilant, and to take action when they see the signs and symptoms of depression in a teen. “It takes a village,” Dr. Kerzner says, pointing out that once confronted, no matter how gently, teens will vehemently deny to their parents that anything’s wrong. “But it’s the parents’ right to protect the health of their child,” Dr. Kerzner declares, “and parents should not let go if they feel intuitively that something’s wrong. Call the school to investigate, despite what your teen wants. Follow up with a second call. Your teen will say ‘I don’t want you to call my guidance counselor/coach/teacher.’ Although it can be very difficult for a parent to challenge that, in my experience, a parent’s intuition is usually correct.”
Dr. Schlozman agrees. “Be watchful,” he says. They’re not ‘little adults.’ But we have a real tendency to view them that way, and so we become less watchful as they progress through adolescence. Let them express their independence, but don’t ignore them. Ask your teen how he or she is feeling. It will register. They may say ‘leave me alone,’ but you should never stop asking.”
It’s apparent that there is no single formula for keeping the teen depression wolf from the door. What is too much pressure for one child might, in fact, be just enough for another. The mother of one boy, whose friends came to tell her they were worried about her son, says “we watched our neighbors. They put way more pressure on their kids than we did on ours.” What she thought was a downward academic spiral turned out to be a symptom of her son’s severe and chronic depression. “His friends saved him,” she says, two treatment-intensive years later. “He was right on the precipice.”
Mental health experts say that the key to catching depression in teens is connecting closely with them, not always an easy task. Jon Mattleman, Director of the Needham Youth Commission, explains why he thinks parents can so easily miss it. “We filter what our teens tell us through our own, healthy minds,” he points out. We think ‘she has everything…a nice house, a car, trips and summer programs…and she goes to a great school.’ Then we tell her ‘hey, don’t worry, you’ll feel better tomorrow,’ because that’s what works for us. But things can look completely different to someone with a mood disorder. To her, things might look even more hopeless, the next day.”
Studies show that chances are good the teen won’t feel better, unless he or she gets treatment. And treatment helps, according to the experts, over 85 percent of the time. Depending on the severity of the problem, treatment for teens means talk therapy, medication, or some combination of the two. It also means making some serious modifications to family life; slowing down, and connecting more as a family.
“One needs to be driven and accomplished just to live in our kind of community,” says Dr. Ingrid Raab, a Clinical Psychologist whose private practice is in Wellesley. “Such accomplishment is not necessarily bad, but what if it comes at the expense of having an ear for your teen’s struggles and fears? Sometimes families are just too busy to develop any kind of emotional language; there’s no space for ‘just being together.’ Having a child who is diagnosed with depression is very challenging for parents. Among other things, they really have to scale back and reset their expectations for her.” How? By minimizing stress and making fewer demands, for a start.
Rob Evans, Executive Director of Human Relations Services in Wellesley, explains. “There’s little correlation between what college you go to, and how well you do in life. The premium in salary that an Ivy League education used to confer is gone.” What does this have to do with depression? “A lot of parents now are under-engaged with their kids, and over-expecting of them,” he says. “We’ve forgotten, as a community, that ‘it’s not just the destination, it’s the journey.’ Most kids are not fragile. They need a chance to learn from their mistakes and not to be protected from every error in judgment. Parents need to turn the TV off and be in real contact with their teen, in ways not limited to the soccer sidelines, and not focused only on their kids’ competitive capacities.”
What can parents do?
Clinicians who work with teens say to keep these depression facts firmly in mind:
• A family history of depression, especially if it has occurred in first-degree relatives (that is, the teen’s siblings or parents) can be a predictor for teen depression.
• Alcohol or drug use can be a symptom of depression, rather than a diagnosis in and of itself. Substance abuse can also interfere with treatment.
• Sleep deprivation can cause the same symptoms as—or exacerbate—depression. Making sure that teens get enough sleep is critical.
• Carbohydrate cravings—including an appetite for junk food—can be a symptom of depression, and it’s one that can affect a teenager’s appearance, making him feel worse about himself.
• Stress (for example, an illness, a death in the family, or a divorce) can bring out a depression, especially if a teen is predisposed to it for other reasons.
Evans contends that when parents know their kids well—who their kids’ friends are, and where they are spending their time, for example—those kids do better, and become more resilient. Resilience, all of the experts say, is the key to helping teens avoid depression. “Parents need to be available,” says Evans. “When a kid says ‘leave me alone,’ it doesn’t mean that the parent should get too far away.”
Evans feels strongly that, in general, parents need to take more responsibility for teens and their well-being. “It’s learning to be resilient that lowers a teen’s risk for depression,” he insists. “By not being there in the right ways for them, we’re inadvertently increasing their vulnerability to depression. In the rising tide of parental anxiety, there’s the very real sense that our kids’ futures are less certain than ever. But because we feel like that, we give them less room for play, and we have little tolerance for failure, which is crucial to their learning how to function in the world.”
All of the experts stress that good communication with teens is key. Ask open-ended questions, they say, and then really listen when your teen answers. Mattleman says “we don’t make the time to ask them how they really feel about soccer camp, or all those music lessons. And here in the suburbs, there are times when everyone in the family is in a different room, pursuing a solitary activity, like watching TV or using the computer. When we grew up, there was one phone, and it was in the kitchen. If you were feeling badly, there was a pretty good chance that someone in your family knew about it! Now, every teenager has her own phone. Teenagers text each other, or IM [Instant Message], and no one else knows. It’s very isolating.”
Dr. Lyn Styczynski, a Clinical Psychologist whose private practice is in Watertown, has adolescents of her own. Like Evans, Dr. Styczynski stresses that although sometimes they feel like an unwanted presence, parents are critical in the life of a teen. “Parents need to find the balance between being there and giving space, and they shouldn’t underestimate their own power. Parents should declare where they stand, take positions about values, and provide a strong counterpoint to unhealthy images, such as those of teenagers, in the media. When parents assume their teenager needs them less now than he or she did in childhood, well, that’s an entirely incorrect assumption. Teens count on their parents to provide what amounts to the stable edge of a very deep pool.”
Gary E. Nelson, A Relentless Hope; Surviving the Storm of Teen Depression, Cascade Books, 2007.
Bev Cobain, R.N.C., When Nothing Matters Any More: A Survival Guide for Depressed Teens, Free Spirit Publishing, 2007.
Help Me, I’m Sad: Recognizing, Treating, and Preventing Childhood and Adolescent Depression, Penguin, 1997.
Harold Koplewicz, More Than Moody: Recognizing and Treating Adolescent Depression, G.P. Putnam's Sons, 2002.
Rob Brooks, Ph.D, and Sam Goldstein, Ph.D, The Power of Resilience: Achieving Balance, Confidence, and Personal Strength in Your Life, McGraw-Hill, 2004.
Lerner, Richard Ph.D, The Good Teen: Rescuing Adolescence from the Myths of the Storm and Stress Years, Crown Publishing Group 2007.
Anthony E. Wolf, Ph.D, Get Out of My Life, but First Can You Drive Me and Cheryl to the Mall?, Farrar, Strauss, and Giroux, 1991, 2002.
Robert Evans, Family Matters: How Schools Can Cope with the Crisis in Childrearing, John Wiley and Sons, 2004.
David Walsh, Ph. D, Why Do They Act That Way? A Survival Guide to the Adolescent Brain for You and Your Teen, Simon and Shuster, 2004.
Adolescent Wellness is a non-profit organization whose goal is to simplify the prevention of depression and suicide in teens (see sidebar).
Bob Anthony, Director
Families for Depression Awareness is a non-profit organization whose purpose is to “help families recognize and manage the various forms of depression and associated mood disorders and prevent suicides, reduce stigma associated with depressive disorders, and unite families and help them heal in coping with depression.” From their website, they offer a free Depression and Bipolar Wellness Guide for Parents of Children and Teens and the brochure Helping Someone Who Is Depressed. To make a tax-deductible donation or find out more, contact:
Julie Totten, Founder and President
395 Totten Pond Road
Waltham, MA 02451
Needham Youth Commission
Jon Mattleman, Director
1471 Highland Avenue
Needham, MA 02492
National Institute of Mental Health
David DeMaso, M.D., Editor & Director
Joseph Gonzalez-Heydrich, M.D., Associate Editor & Co-Director
Published by Children’s Hospital Boston, “the Experience Journals are designed to promote the healthy coping of children and their families who must contend with significant physical and emotional illnesses…they represent the ‘collective wisdom’ of these children and their parents as well as their health care providers.”
Information, along with links to state and local mental health resources for parents and teens. Sponsored by the Boston Public Health Commission with support from Children’s Hospital, Boston.
The National Alliance on Mental Illness (NAMI) is “the nation’s largest grassroots mental health organization dedicated to improving the lives of persons living with serious mental illness and their families.”
Substance Abuse and Mental Health Services Administration
A Department of Health and Human Services organization whose mission is “…building resilience and facilitating recovery for people with or at risk for mental or substance use disorders.”
“A non-profit professional medical association composed of over 7,500 child and adolescent psychiatrists and other interested physicians…whose members actively research, evaluate, diagnose, and treat psychiatric disorders…the organization distributes information to promote an understanding of mental illnesses and remove the stigma associated with them; advance efforts in prevention of mental illnesses, and assure proper treatment and access to services for children and adolescents.”
Human Relations Services
11 Chapel Place
Wellesley Hills, MA 02481
Rob Evans, Ed.D., Executive Director
Dr. Arnold Kerzner, M.D., Chief of Clinical Services
Dr. Steven Schlozman, M.D., Associate Director,
Child and Adolescent Psychiatry Residency, Massachusetts General Hospital/McLean Hospital Program in Child Psychiatry
Staff Child Psychiatrist, Massachusetts General Hospital
“A joint project of the School Psychiatry Program and the Mood & Anxiety Disorders Institute (MADI) Resource Center, both of the Department of Psychiatry at Massachusetts General Hospital…schoolpsychiatry.org is committed to enhancing the education and mental health of every student in every school.”
Dr. Ingrid Raab, Psy.D., Clinical Psychologist
572 Washington St.
Applies a variety of behavioral approaches, including Cognitive Behavioral Therapy, Hypnosis, Relaxation/Meditation, Integrative Psychotherapy, and Biofeedback Therapy.
Dr. Lyn Styczynski, Ph.D., Clinical Psychologist