Answers to common questions about identifying and compassionately addressing issues of anxiety and depression in adolescents.
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Health risks in adolescence are undergoing a major shift. Three decades ago, the biggest health threats to teenagers were binge drinking, drunken driving, teenage pregnancy, cigarettes and illicit drugs. Today, they are anxiety, depression, suicide, self-harm and other serious mental health disorders.
From 2001 to 2019, the suicide rate for American youngsters from ages 10 to 19 jumped 40 percent, and emergency room visits for self-harm rose 88 percent.
Managing a mental health crisis can be challenging for teenagers and their parents. It is often unchartered territory that needs to be navigated with the utmost sensitivity. The guidance below may help.
Anxiety and depression are different but can share some indicators. First, look for some key changes in a youth’s behavior, such as disinterest in eating or participating in social activities previously enjoyed, altered sleep patterns or withdrawal from other aspects of life. It’s tricky; these behaviors can sometimes be normal teenage angst. However, a teenager in distress may express excessive worry, hopelessness or profound sadness, particularly for long periods of time.
Whether a teenager is dealing with angst or a clinical problem “is the 64 jillion dollar question,” said Stephen Hinshaw, an expert in teenage mental health issues at the University of California, Berkeley. The question is about “persistence, interference with thriving, sheer suffering (on her or his part and yours) that can help to make this difficult differentiation.”
If the lines become too blurry to tell the difference, it can help to visit a pediatrician to explore whether there is a clinical problem.
The counsel from experts is resounding: Be clear and direct and don’t shy from hard questions, but also approach these issues with compassion and not blame. Challenging as it may seem to talk about these issues, young people often are desperate to be heard. At the same time, talking to a parent can feel hard.
“Be gentle, be curious, and, over time, be persistent but not insistent,” Dr. Hinshaw explained. “Shame and stigma are a huge part of the equation here, and if you are outraged and judgmental, be prepared for a shutdown.”
“A good number” of teenagers “are practically begging you — without telling you so directly — to stay concerned and loving and to keep open a dialogue,” Dr. Hinshaw said.
For teenagers having trouble opening up, try working together on a shared hobby or activity without bringing up their mental health. Put them at ease, and eventually they may be more willing to share.
These issues are “typically very hard for a teen to talk about with their parent or guardian,” said Nicole Nadell, an assistant professor in pediatrics and psychiatry at Mount Sinai. “Be a patient and active listener at first, reflect back to the teen what they are saying, thinking and feeling.”
If you are having thoughts of suicide or are concerned that someone you know may be having those thoughts, in the United States call or text 988 to reach the National Suicide Prevention Lifeline, or call 911, go to the emergency room, get help from an adult, or go to SpeakingOfSuicide.com/resources for a list of additional resources. Go here for resources outside the United States.
It is a sign of strength, not weakness, to seek help.
Research shows that the suicidal impulse will pass if it can be put off. Then the underlying problems can be addressed. Researchers call suicide “a permanent solution to a temporary problem.” It takes help to get through this period of excruciating pain that leads to suicidal ideation. Get that help.
Self-harm can include cutting, hitting oneself, burning or other forms of mutilation. These behaviors may appear to induce pain, but they are actually intended to redirect or make emotional pain go away, experts said.
Nonsuicidal self-injury is “predominately used to re-regulate,” said Emily Pluhar, a child and adolescent psychologist at Harvard Medical School. The behavior, she explained, can actually release a pain analgesic, a natural painkiller that may provide a feeling of relief. “It helps people re-regulate and feel calmer.”
The trouble is that such behavior ultimately doesn’t work to eliminate the underlying problem and then can intensify.
Cutting often happens on the wrists, ankles or thighs. “Self-harm is often hidden from parents and peers by long sleeves and secrecy. If you see evidence, try to engage in discussion — even though your teen is likely to try to minimize or hide it, out of shame,” Dr. Hinshaw said.
If you see wounds that appear to put a teenager at imminent risk, call 911 or go straight to the emergency room.
When cutting is discovered, it is vital that a parent or caregiver reacts with concern and compassionate curiosity, not alarm (unless danger is imminent). “First, be curious rather than alarmist. The best way to get your teen never to talk with you about any key problem is to be outraged or moral or judgmental,” Dr. Hinshaw said.
Some recommended tactics for starting and stoking conversation about mental health issues in general include making sure you are genuine and authentic — admit if the subject makes you nervous — and creating silence and space for a youth to express. And try a “change of settings,” some experts recommend, like a car ride or an activity, that can make conversation feel natural with less eye contact.
Then: “Validate, validate, validate,” says Dr. Pluhar, from Harvard. “You don’t have to agree with their perspective but you have to validate that their perspective matters and that you understand it.”
The ultimate goal is to help an adolescent find the root cause of the emotional pain leading to self-harm. Once your child is ready, a pediatrician or another health expert can help you find an appropriate counseling path. Evidence supports various forms of cognitive behavioral therapy, including dialectical behavioral therapy to help teach coping skills. These skills help people recognize their thinking patterns and reframe issues in healthier ways.
It is important to understand that self-harm is not the same as a suicidal ideation, which is a much broader overriding of the biological instinct to survive. That said, self-harm that goes on for a long time and that becomes more severe can be a predictor of suicidal behavior.
It may be worthwhile to suggest healthy alternatives to self-harm that your child could try. Research shows that the urge can be put off by removing from the home the object or tool used to harm, and by using simple methods like exercise. Dr. Nadell from Mount Sinai suggests a few:
