Introduction
The term “teenager” refers to a person from around the age of thirteen to nineteen. The teenage years are marked by cognitive advancement, increased social interactions, behavioral and emotional independence, abstract thought, idealism, and physical and sexual maturation. The multifaceted context of development can hinder as well as nurture the well-being of teenagers. For some teenagers, mental health (psychological resiliency and well-being) diminishes at a time when the framework of adulthood is to be constructed.
In the early twentieth century, G. Stanley Hall
became one of the first scientists to consider an interlude in human development between the immaturity of childhood and the maturity of adulthood; he called this period adolescence. To Hall, adolescence was a recapitulation of the evolutionary transition from proto-humans to modern humans and therefore was characterized by struggle, confusion, and stress (storm and stress). Although Hall’s evolutionary explanation of adolescence was later discredited, his theme of adolescent storm and stress persisted for much of the twentieth century. For many teenagers, the transitions to and pathways through middle and high school are the main source of stressors. Some experts consider adolescence to be a time when the key goal is endurance within a developmental context of negativity.
The “Real” Teenager
The reality, however, does not back up such negative views of adolescence as those of Hall. Most teenagers lead happy, satisfying lives and sustain positive outlooks even when faced with innumerable challenges. The life of a teenager consists of a wide assortment of biological, psychological, and sociocultural factors that combine to form myriad opportunities and adjustments. Teenagers also face pressure as they formulate their academic and career goals and encounter familial expectations regarding performance and social expectations regarding conformity. However, teenagers effectively face these many challenges and adjustments with advancing developmental capacities that they bring to bear in their lives. Teenagers are not embroiled in Hall’s storm and stress but rather enjoy lives filled by stimulating adventures and challenges. Adults should focus on making sure teenagers have the psychological and social resources they need to confront their challenges and grow from them.
Mental Health
A teenager’s mental health status can be defined as the degree to which an individual exhibits resiliency and effective coping across life circumstances. Mental health is a mediating factor in how well teenagers deal with stress, make decisions, and operate interpersonally. Teenagers’ mental health is a reservoir from which they draw a number of important resources such as confidence, self-esteem, and hopefulness. These elements make up a general sense of well-being and fuel teenagers’ psychological endurance when they confront difficult challenges.
Teenagers have near-adult capacities of reasoning, self-regulation, behavioral autonomy, and intellectual achievement, but only a narrow repertoire of skills to guide those capacities and few experiences to inform them. When teenagers experience mental problems, there is an associated disruption in normative development and an increased likelihood of persistence of the disorder into adulthood. When mental illness accompanies development, it can initiate a vicious cycle in which a disorder compromises development, then the compromised development makes a disorder more intractable, leading to further compromised development and a worsening of the disorder. Teenagers’ mental health problems involve real pain and suffering and have severe acute and long-term consequences if left untreated.
According to the National Institute of Mental Health (NIMH), a person may have a mental health problem if the individual exhibits the following behaviors:
•Consistently experiences anger or worry
•Feels grief or sadness longer than typically expected after a loss or death
•Believes his or her mind is too controlled or out of control
•Uses alcohol or drugs
•Exercises or diets excessively, overeats, or thinks obsessively about exercise and diet
•Act in ways that harm others or damage property
•Acts impulsively or in reckless ways that expose the self or others to harm
Resiliency
Resiliency is the sum whole of protective factors in teenagers’ lives that serve to buffer against risk and harm. Teenagers’ ability to endure and even respond positively to adversity is a product of resiliency and predicts the maintenance of mental health. Resiliency is not a prewired competence but is constructed with internal and external protective factors available to teenagers.
The list of potential protective factors is long but generally incorporates factors from the individual (for example, intelligence), family (for example, nurturing parents), and environment (for example, a supportive and invested teacher). For example, a resilient teenager may have a stable and nurturing family, have access to health care and nutrition, live in a safe neighborhood, have good communication and interpersonal skills, and have access to social supports and mentors outside the family. No single factor is necessarily more protective, although some may more consistently have a positive impact.
Risk Factors
Risk factors are those internal and external aspects of teenagers’ developmental context that weaken their capacity to effectively cope with challenges and stress. Risk factors, like protective ones, exist within individuals, their families, and their environments. For example, dyslexia, a learning disorder involving difficulties in recognizing and comprehending written language, is a common risk factor for school-age children and teenagers. Dyslexia can disrupt learning, academic performance, and participation in extracurricular activities. Such disruptions can erode basic developmental resources such as self-efficacy and self-esteem, creating further disruption across other domains of development. Fortunately, any given risk factor does not represent an inevitable erosive force on development, although some, more consistently than others, exert a negative effect. Risk factors have a compounding effect; as challenges to development accumulate, so does the likelihood of maladjustment.
Although some teenagers are predisposed to certain psychiatric disorders such as major depression (often because of genetic makeup), whether they develop these disorders is largely a function of resiliency. No teenager is destined to suffer mental health problems; adequate resiliency minimizes the risks and maximizes the effectiveness of a teenager’s response if he or she develops the disorder. Overall, the degree of teenagers’ resiliency is determined by the number of positive protective factors relative to the total negative impact of risk factors.
Depression
Discussions of teenagers’ mental health generally focus on major depression. No other psychiatric disorder identified among teenagers is as widely intermixed with accompanying disorders and psychological and social problems. Some 40 to 70 percent of teenagers with major depression are diagnosed with a co-occurring disorder such as an anxiety disorder, conduct disorder, eating disorder, oppositional defiant disorder, or substance abuse.
The prevalence of major depression increases with age from 1 to 2 percent among school-aged children to 5 percent among teenagers (about 1.5 million people). An additional 10 to 15 percent of teenagers may experience depressive symptoms that do not meet the clinical criteria for major depression but still generate serious distress and are at risk of intensifying and crossing the threshold into clinical severity. Although up to 25 percent of teenagers will experience major depression by their nineteenth birthday, major depression is not a normal part of teenage life and development. In fact, it involves significant psychological and biological distress that results in serious pain and potentially life-threatening risk.
Challenges of Recognition
Two primary factors—limited parental scrutiny and the wide variability of symptoms according to age—create challenges for recognizing major depression among teenagers. First, the normative social and emotional context of adolescence generally involves teenagers spending less time with their parents. Teenagers have schedules (school, extracurricular, and personal) that create a rather autonomous social context and minimize the extent to which parents can monitor their psychological and medical health. In addition, many of the symptoms of major depression are not obvious but rather are largely internalized.
Second, the symptoms of major depression vary widely across age groups. Depressed younger adolescents (eleven through twelve years old) may exhibit symptoms such as somatic complaints (including aches, pains, or illness) instead of psychological negativity, and irritability instead of a depressed mood. In contrast, depressed teenagers (thirteen years old and older) are more likely to show persistent inability to experience happiness or pleasure (anhedonia), debilitating reduction in movement (psychomotor retardation), delusions, and a pervasive sense of hopelessness. Some symptoms are consistent across all age groups (including adults), such as thoughts of suicide, disruption of sleep, and poor concentration.
Alcohol Use
A particularly important aspect of teenage depression—and mental health in general—is the high incidence of
alcohol use and abuse among teenagers. A 2004 study funded by the National Institute on Drug Abuse found that almost 40 percent of American eighth graders, 66 percent of tenth graders, and 75 percent of twelfth graders had used alcohol. Some 25 percent of tenth through twelfth graders had engaged in binge drinking (five or more drinks within a short time period) within the previous two weeks. Teenage alcohol use (abuse) complicates the risk for depression because it can both mask and protract the symptoms of depression, acting as an inappropriate coping strategy that sustains an insidious disruption of normative development. Indeed, depressed teenagers are more likely to have co-occurring substance use behaviors that may call for a further diagnosis of substance abuse or dependence.
Impact of Depression
In teenagers, depression typically starts as a single episode that averages about nine months in duration and has a 40 percent cumulative chance of recurring within two years. This reflects the disruption that major depression has on the lives of young people. Depression, like most other disorders, is not a fast-resolving condition and may well last an entire school year. As school is an exceptionally important context of teenage development, depressed teenagers experience disruption to some degree across a wide range of social, psychological, and emotional domains. For example, depression among teenagers is associated with interpersonal difficulties, poor academic performance, and weak self-esteem. These and other difficulties often create a vicious cycle of developmental disturbance that can progressively increase vulnerability to further bouts with depression or another disorder over time.
Many of these age-related differences in symptom expression are due to developmental changes. For example, younger adolescents are more likely to interpret their distress in concrete ways that are constrained by their experience. That concrete thinking translates to an interpretation of their pain and distress as a physical injury or illness (for example, gastrointestinal pain). Younger adolescents (and children) are essentially prone to experience depression and other psychiatric distress as a function of physical illness and only rarely as connected to psychological states.
Teenagers develop severe physical symptoms of depression, but the disorder expands deep into their thoughts, self-concept, and future orientation. Depressed teenagers, like depressed adults, have more advanced cognitive abilities (for example, abstraction, idealism, and hypothetical thought), but these are often compromised by thoughts and reflections infiltrated and dominated by negativity. Depressed teenagers commonly operate within an external locus of control in which they view positive events as being outside of their control and interpret negative events as being completely their own fault. They convince themselves that they are worthless and acquire a pessimistic orientation toward the future that gives rise to seemingly intractable hopelessness. These exaggerations are amplified by the idealistic adolescent mind-set, which they bring to the context of the disorder.
Signs and Symptoms of Depression
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed., 2013), the clinical criteria threshold for a major depressive episode is at least five (of a possible nine) symptoms exhibited by the teenager for at least two weeks and that represent a change from previous functioning. At least one of two primary symptoms—either depressed mood or loss of interest or pleasure—must be present. The remaining seven symptoms are abnormal weight gain or loss (including a failure to make expected weight gains), almost daily insomnia or hypersomnia, almost daily observable psychomotor agitation or retardation, almost daily fatigue or lack of energy, consistent feelings of worthlessness or exaggerated or inappropriate guilt, consistent diminished ability to think or apply focus, and persistent thoughts of death, suicide without a specific plan, suicide attempt, or specific suicidal plan.
These symptoms must produce a disruption in functioning within social or academic domains. However, additional criteria appropriately frame the existence of the depressive disorder. Depressive symptoms cannot be due to a teenager’s substance use (alcohol or other drugs), nor can they be due to a general medical condition. Further, it would be inappropriate to seek a diagnosis within eight weeks of the loss of a loved one, with exceptions made for extreme functional impairment, morbid obsession with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Teenage depression at any level of severity is not an inevitable or normative aspect of development. Many people erroneously assume that teenagers are “normally” emotionally irregular, and this can prevent them from recognizing potentially serious mood disorders in teenagers. Although teenagers confront stressors that can precipitate emotional reactivity, healthy (resilient) teenagers remain emotionally stable and adaptable. Deviations from normally happy day-to-day lives lasting upward of two weeks should be cause for concern and action.
Suicide Risk
Teenage suicide is a critical danger that accompanies major depression and subclinical depressive symptoms. It is the third leading cause of death among teenagers (thirteen to nineteen years old), after unintentional injury and homicide. Although life stressors and other disorders are associated with teenage suicide, depression is the most prominent risk factor. Other risk factors include a history of physical, emotional, or sexual abuse; alcohol or drug abuse; any mood disorder, especially depression or bipolar disorder; feelings of hopelessness; disruptive behavior; deficits in interpersonal skills; a family history of suicide or a prior suicide; a suicide within the child’s peer group; stress; and permissive or neglectful parenting. It may be that teenagers’ developmental advancements, which are not yet mature, act synergistically with the persistent negative thoughts and feelings of depression to amplify the risk of extreme behaviors such as suicide.
Seeking Help and Information
Seeking help for teenagers’ mental health problems can be an intimidating prospect. Teenagers themselves, despite their distress, may not understand or acknowledge the extent to which they need help. Parents or family members, despite their good intentions, may not have enough information to feel confident that they have identified a real problem. However, indecision should not prevent parents from taking action on issues relating to teenagers’ mental health. Consulting with professionals (whether in person or through hotlines) is always a prudent and safe choice.
Communities may not always have as many options for referral and treatment of mental health as they should, but people and programs are available to assist teenagers and their parents in securing proper information, referrals, or diagnostic evaluations and treatment. Sometimes getting the best information and help requires some effort, but it is crucial that teenagers receive the assistance they need. Teenagers and their parents should seek out those people or programs that are most likely to have experience with mental health questions and should remember that serious problems require specialized professional help. Some sources of help are community medical or mental health clinics; family assistance programs; religious leaders or counselors; family doctors or nurse practitioners; hospital psychiatry departments; outpatient clinics; mental health specialists (psychiatrists, psychologists, social workers, or counselors); school counselors, nurses, or principals; social service agencies; state hospital outpatient clinics; and local college- or university-affiliated programs.
Teenagers and their families must seek out multiple sources of information to ensure that all aspects of a mental health problem are understood. For instance, the Internet can hold a wealth of information about disorders and symptoms but cannot substitute for in-person assessment, diagnosis, and treatment by a trained professional. Knowledge is empowering, and discomfort is no excuse for not asking questions about diagnoses and treatment services. Teenagers and their families should seek out other families in their communities that share similar mental health challenges to tap into an empathetic source of support and information. In addition, family networks provide extensive sources of support, information, and advocacy.
Bibliography
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Johnston, L. D., P. M. O’Malley, J. G. Bachman, and J. E. Schulenberg. Monitoring the Future, National Results on Adolescent Drug Use: Overview of Key Findings, 2004. NIH Publication No. 05-5726. Bethesda: Natl. Inst. on Drug Abuse, 2005. Print.
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