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JUNE 29, 2010

Mental Illness Often Starts in Adolescence. Telling Typical Angst From Serious Problems

Everyone warns parents about the drama of the teen years—the self-righteous tears, slamming doors, inexplicable fashion choices, appalling romances.
But what happens when typical teen angst starts to look like something much darker and more troubling? How can parents tell if a moody teenager is simply normal—or is spinning out of control? This may be one of the most difficult dilemmas parents will ever face.

Signs of Depression
Physicians often use the mnemonic "SIGECAPS" for the checklist of symptoms, says Mark Goldstein, chief of adolescent and young adult medicine at Massachusetts General Hospital in Boston. He cautions that parents should not try to diagnose their children, but bring the child to a pediatrician. A teen may have a problem if four or more of these signs persist for two weeks or longer.

Is your teen's sleep impaired? Is he or she sleeping too much? Not enough? Trouble falling asleep or staying asleep?

Has your teen lost interest in once-enjoyable activities? These could include school, sports or extracurriculars, friends, even eating.

Does your teen have excessive guilt? Or, is the child feeling worthless or devalued?

Does your teen feel a loss of energy? Is he or she unusually tired or exhausted?

Does your teen have a diminished ability to think and concentrate? An increased indecisiveness?

Has your teen's appetite changed? Either decreased or increased? Some teens lose weight with depression. Others gain it.

Psychomotor Skills
Are your teen's physical movements speeding up or slowing down? This one may be hard for parents to determine. But look for sluggishness—or, alternately, restlessness or the jitters.

Is your teen thinking about death? Doctors ask teens: Have you had thoughts about death repeatedly? Have you thought about suicide? Do you have a plan?

Studies show that about 20% of teenagers have a psychiatric illness with depression, anxiety and attention-deficit hyperactivity disorder being among the most prevalent. Yet parents of teens are often blind-sided by a child's mental illness. Some are unaware that mental illnesses typically appear for the first time during adolescence. Or they may confuse the symptoms of an actual disorder with more normal teen moodiness or anxiety.

Eric Beasley, a 49-year-old project manager for a software company in Cary, N.C., has been there. He says that his daughter always seemed like a typical child. She was a good student and a great soccer player with many friends. But three years ago, when she turned 14, she began to throw temper tantrums when her team lost—stomping her feet and yelling at her teammates. She even asked her dad for help managing her anger, and he talked to her about ways to cope.

"I thought it was typical teen behavior," says Mr. Beasley, who also has two sons. "We'd never had girls before. And I'd heard they were very moody and emotional."

But his daughter's behavior declined. She snuck out of the house one evening to meet her boyfriend and stayed out all night. When they confronted her about some of her actions, she became alarmingly depressed, weeping in bed for days and refusing to eat. She took a handful of her father's heart medicine and was committed to a psychiatric hospital for 10 days.

Mr. Beasley says he expected his daughter's problems to be solved by the hospital stay. "We had no idea that was only the beginning," he says.

His daughter did feel better for about a week, he says. But even with therapy and medication, she sank further into depression, throwing tantrums over little things, "like whether she was given a fork instead of a spoon at the dinner table," Mr. Beasley says. She started swearing, lying and leaving the house in anger.

Her parents took away her cellphone, monitored her email accounts and put an alarm system on the house to keep her from sneaking out. After she told her parents that she was running away to live with a boyfriend, Mr. Beasley had her hospitalized again for six days. Several months later, she tried to overdose using her own medication.

Experts say that many parents fail to recognize the signs of a child's mental illness. Some don't know what to look for. Others don't want to admit that there is a problem. After all, everyone wants a perfect child: 10 fingers and 10 toes, looks, brains, charm—and hopefully a Harvard degree.

A mental illness can threaten to derail much of that. And a psychiatric disorder—unlike, say, cancer—can come with a stigma attached, which can fuel a parent's feeling of denial.

Making matters worse: It can be genuinely difficult for parents to tell the difference between early signs of a mental illness and typical teen behavior.

But the risks of missing the more serious problems are huge. Untreated depression and other mental disorders can derail a child's developmental progress or, in the worse-case scenario, lead to suicide. For this reason, experts say, parents must be vigilant.

"All we want parents to do is notice there is a problem and to bring their child to the doctor," says Mark Goldstein, chief of adolescent and young adult medicine at Massachusetts General Hospital.

He recommends parents first take their concerns to a pediatrician as that doctor has the longest relationship with the family and will be easier to get an appointment with than a psychiatrist.

The American Academy of Pediatrics has been making a push in the past few years to better train its members in how to identify and manage mental illnesses in children and teens. This month, they issued a 160-page guide to help doctors screen early, intervene and determine when to refer to a mental-health specialist. And today the group is publishing a new CD-Rom for doctors that includes tools to help pediatricians screen and assess for psychiatric disorders, develop care plans and educate parents.

"It's one of those things, an ounce of prevention kind of deal," says Evelyn Gerber, 37, a chemist in Salt Lake City. She says she has become "hyper vigilant" about watching for signs of troubling behavior in her 16-year-old son, who was diagnosed with attention-deficit hyperactivity disorder in second grade.

Ms. Gerber says her son was an emotional child who sometimes got pushed around by bullies on the school bus and once stabbed a kid with a pencil in an attempt to fight back. After that incident, in 4th grade, she got counseling for him.

These days, he functions well in school and has good friends. But he also sometimes pouts or cries in frustration after he has a fight with his dad and locks himself in his room. Other times, he turns red-faced or yells when he doesn't get his way or he is frustrated with the computer.

But Ms. Gerber says she never lets him brood in his room for more than a few minutes before going in to talk to him. And she uses the 15-minute drive to school each day to chat with him about everything from peer pressure to drugs and alcohol. "If you can see the problems coming and ward them off, your child won't sink so deep," she says.

Parents who are worried that their teen is showing signs of mental illness should first put their child's behavior into perspective, experts say. Occasional outbursts of anger, irritability or crying are normal for teens. So is dressing weird, rebelling against rules and even experimenting with drugs and alcohol.

Periodic tension is typical, too. "It's when the conflict rises to the level of hostility and real animosity, and doesn't recover easily, that I become concerned," says Guy Diamond, a psychologist and director of the Center for Family Intervention Science at the Children's Hospital of Philadelphia.

Dr. Diamond says sulks or doldrums that persist for two or more weeks could be a sign of depression and should be taken seriously.

The Next Step: Treatment
A family therapy designed for teens with elevated depression and suicidal thoughts is showing good results. Attachment-Based Family Therapy, or ABFT, was developed by researchers at the Children's Hospital of Philadelphia. A study reported last February in the Journal of the American Academy of Child and Adolescent Psychiatry included 66 children, ages 12 to 17. Patients with severe suicidal thinking were at least four times more likely to have no suicidal thinking at the end of the treatment—three months later than patients who had other treatments.

Some hallmarks of the therapy:
Family involvement. Most treatment models mainly work with the adolescents alone, says study leader Guy Diamond, director of the Center for Family Intervention Science at Children's Hospital of Philadelphia. Yet a family's influence is very important to teens, he says. "We try to help parents understand the challenges that these kids are struggling with and give them the parenting tools that allow them to reach out and support a depressed and suicidal adolescent."

A specific time frame. Unlike many other forms of therapy, ABFT is a rapid process, lasting just six to 12 weeks. Therapists first meet with the teen to identify the issues that are causing the child to be distant from his or her family and discuss the importance of addressing these problems directly. Then they meet separately with the parents to help them understand what is going on with their child, discuss ways to improve trust and work on emotional-based parenting skills.

A no-blame atmosphere. "We are not interested in blaming the parents," says Dr. Diamond. "We say, 'If the kid could get some of this off his chest, it could open up communication.'" In the final stage, the therapists meet with the teen and parents together, to facilitate the dialogue between them.

Source: Children's Hospital of Philadelphia

“ I have lost count of my daughters' doctors and psychologists. Not many of these truly know how to help teens. You have to keep fighting for help, just as you would if your child had cancer. Mental illness is NOT their fault. In many cases it is genetic. ”
—John Goold

Parents should pay attention to how a teen is functioning in school, sports, favorite activities, a job and with friends. A temperamental child who throws a fit, even for a few days, but continues to get good grades, enjoy friends and participate in sports is likely OK. But one whose grades fall, who shuns friends or refuses to participate in a team or activity he or she once loved may have a more serious problem.

Other signs to watch out for, experts say: Teens who are excessively angry, abuse alcohol or drugs, or run into trouble with the law may be depressed. Also, changes in eating habits—eating more or less—or sleeping (ditto) may signal a problem.

"The most important thing parents can do is stay connected to their kids and keep open communication," says Dr. Diamond. "Let them know that they can talk to you about anything serious and know that you will listen and hear them." He often encourages parents to consult a therapist on how to talk to their children about these difficult issues.

A 48-year-old writer from Asheville, N.C., says she spends much of her time these days trying to monitor and help her teenage son. A handsome, outgoing kid who excels at golf, he was diagnosed with obsessive-compulsive disorder when he was in middle school, after teachers suggested she have him evaluated by a doctor because he was getting up from his desk every few minutes during class to sharpen his pencil.

Then, after she divorced his father two years ago, the boy became increasingly angry. He started yelling at his mother if he didn't get his way. Then he began throwing things: rocks and apples at cars and eggs at houses.

Last year, he watched as his friends stripped his mom's Christmas tree and threw all the ornaments in the road. Then he got arrested twice—first for using a paintball gun to disfigure all the mailboxes in an entire neighborhood and then for possessing marijuana at school.

His mother has taken him to five different psychologists—he often refuses to go back—who gave him an additional diagnosis of ADHD.

"If your eyes aren't open, if you're in denial, the problems escalate," she says.

Mr. Beasley believes that his daughter's life was saved by a company called Behavioral Link that provides peer support, intensive in-home counseling and therapists who are available around the clock for parents and children to call in a crisis. Now she has a psychologist she likes and takes her medication. Her grades are getting better, Mr. Beasley says, and her depression appears to be in check.

"We were naïve," says Mr. Beasley in retrospect. "Someone needed to sit us down and say, 'Here are things you should be looking for.' "

Write to Elizabeth Bernstein at This email address is being protected from spambots. You need JavaScript enabled to view it. and follow her column at www.Facebook.com/EBernsteinWSJ .

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