Adolescence, from ages 12 to 18, is a difficult transition, especially in a socially complex society with so many opportunities, temptations, and choices, says psychiatrist William Granatir. Hardly anyone gets through it without some anxiety and depression. Even mentally healthy children occasionally act cranky, and “normal” teenagers sometimes slam doors, agonize over rejections, and withdraw from family and friends. Difficulties between parents, arguing, fighting, abuse, as well as separation and divorce, are traumatic and are often the sources of clinical depression. Anxiety and uncertainty about sexual orientation and other aspects of identity formation are also contributors—”Who am I?” is a question all adolescents ask, but for some it is more difficult than others. Sadness, irritability, and even thoughts of mortality/death are normal for teens, especially when we are talking about normal reactions in abnormal situations such as 9/11, sniper attacks, or terrorism.
And, says Lynne Lamberg in an article published in the Journal of the American Medical Association in September, physicians often hesitate to diagnose potentially stigmatizing psychiatric disorders in the young, though we know that early diagnosis and treatment can restore a youngster to health, reduce the lifetime burden of depression, and possibly prevent suicide, now the third leading cause of death in the United States among 15- to 19-year-olds, exceeded only by unintentional injury and homicide.
At the 2002 meeting of the American Psychiatric Association, symposium chair Dr. Bruce Waslick pointed out that children and adolescents rarely seek help on their own, and families and other adults who interact regularly with youngsters usually do not request evaluation until they have noticed persistent changes in a child’s mood or demeanor.
For example, it had been three years since the parents of a 16-year-old first noticed the decline in school performance and the boredom, poor self-esteem, difficulty sleeping, poor concentration, feelings of hopelessness, and passive thoughts of suicide that finally brought them to their primary care physician, in a case vignette reported in the August 29 issue of The New England Journal of Medicine. The young man “presented with a clear picture of major depression,” say Drs. David Brent and Boris Birmaher, and the question then became “How should he be treated?”
Like Dr. Waslick, Brent and Birmaher point out that in children and adolescents, depression is not always characterized by sadness, but instead by irritability, boredom, or an inability to experience pleasure. They describe depression as “a chronic, recurrent, and often familial illness that frequently occurs first in childhood and adolescence.” In the absence of treatment, a major depressive episode lasts an average of eight months, with a high probability of recurrence. Some 20 percent—but not all–of those with such early-onset depressive disorders are at risk for bipolar disorder, in which depressive episodes alternate with periods of mania characterized by decreased need for sleep, increased energy, grandiosity, euphoria, and a propensity for risk-taking behavior. In adolescents, there is often rapid cycling between the two states, over days or even hours.
Using the 16-year-old patient as an example, Drs. Brent and Birmaher offered advice for clinicians who confront symptoms of depression in adolescents. First of all, they said, medical illness should be ruled out. A number of ailments not uncommon in adolescence, including anemia and mononucleosis, cause symptoms that overlap with depression. When medical illness has been ruled out, both the parents and the patient should be encouraged to view the condition as an illness comparable to diabetes or hypertension, that can be managed and controlled.
Two types of clinical interventions for adolescents—medication and psychotherapy–are currently being compared in a large clinical trial funded by the National Institute of Mental Health. What we know so far, the doctors say, is that either approach seems to produce results. Dr. Birmaher, for one, opts for a combination—”It’s impossible to treat children only with medication,” he says. “Psychoeducation and psychosocial interventions, in conjunction with medications, help minimize psychological scars of depression, foster compliance with treatment, and prevent relapses and recurrences.”
Medication and therapy in combination are the general consensus in the mental health field, according to psychologist Olga Acosta.
In pharmacotherapy, the most commonly used treatment for adolescents is selective serotonin reuptake inhibitors (SSRIs). Very little is known about dosage for children, except that the half-lives of some antidepressants are shorter for children and adolescents than for adults, and young patients may need to take these medications twice a day to avoid withdrawal effects. Once the medication brings about remission of symptoms, the treatment should continue at the same dose level for another six to 12 months, to avoid relapse, though Dr. Birmaher points out that “no studies of maintenance treatment have been conducted so far in children and adolescents.”
In psychotherapy, most recent clinical trials have investigated either cognitive behavior therapy (CBT) or interpersonal psychotherapy (IPT), says Laura Mufson, director of psychology at New York State Psychiatric Institute. Cognitive behavior therapy generally teaches patients to monitor and modify negative thoughts and aims to reinforce pleasurable activities and relationships that may buffer against depressed moods. Interpersonal therapy targets conflicts that often precipitate depression; for adolescents, it may focus on separation from parents, budding romantic relationships, experiences with death, or peer pressure.
Death, Divorce, and Sadness
For adolescents, as for adults, life experiences such as the illness and death of a loved person can produce profound feelings of sadness, which should be distinguished from clinical depression, but which health care professionals can help to ameliorate, according to clinicians who discussed adolescent grief in a September issue of the Journal of the American Medical Association. In particular, says Acosta, “unresolved or complicated grief is a pretty significant phenomenon among our youth these days.”
How an adolescent reacts to emotional trauma is related to developmental age, the authors of the JAMA article point out. For early adolescents, 12 to 14 years, the illness of a parent may have created a need for greater assistance from the young person in the home, which clashed with the developmental tasks of withdrawing emotionally from parents, achieving emotional independence, and being accepted by peers. In the terminal stages of a parental illness, parents may see the child’s withdrawal and desire for independence as uncaring and selfish, sometimes leading to spiraling family conflicts.
Middle adolescents, 15 to 17 years, are more constrained in their behavior, more understanding of situational demands, and though they may remain resentful, often exhibit more empathy concerning their parents’ needs than younger adolescents. Their grief at death more closely approximates the grief of adults, because of their increased comprehension of the enduring consequences of the loss.
“Research supports the positive adaptive value of keeping children informed about the parent’s illness and preparing them for the death,” but it is common for an adolescent to be surprised when death finally occurs. It then becomes important to the young person to “get back in the groove” in his personal affairs, but the adolescent may suffer from feeling “different” from peers who have not had his experiences.
Parental divorce is also a traumatic event for children, with research indicating that, compared with their peers with nondivorced parents, adolescents whose parents divorced are more likely to have mental health problems, drop out of school, or become pregnant, according to a report in an October issue of the Journal of the American Medical Association. Seeking to alleviate some of those problems, an intervention conducted in a large metropolitan U.S. city offered two programs, one for custodial mothers and the other for the mothers and their children; both focused on improving coping skills, reducing negative thoughts about divorce stressors, and improving mother-child relationships. Groups met for 11 sessions led by trained master’s-level degree clinicians.
At a six-year follow-up, adolescents who had participated in the programs as children, either with their mothers or through the mothers alone, showed better outcomes in all the risk areas—mental disorders, drug and alcohol use, and numbers of sexual partners—than control subjects.
Research indicates, Olga Acosta points out, that whether there will be long-term negative effects of parental divorce on children depends more on the amount of parental conflict and not necessarily the separation or divorce. If the parents stay together and continue to fight, that may be equally, if not more, detrimental to their children.
Availability of Treatment for Trauma
If multi-faceted treatment does indeed aid depressed and/or traumatized young people, how available is such care in the current medical system?
In response to congressional inquiries, the U.S. General Accounting Office (GAO) in August 2002 examined the ability of one group of children–those who have experienced trauma, including natural disasters, terrorist incidents, and school shootings, as well as family or neighborhood violence—to obtain mental health services through private or public insurers. In an extensive report, the GAO concluded that, although 88 percent of children nationwide have public or private health insurance that, to varying degrees, covers mental health services, children often face barriers in accessing those services.
Employer-sponsored health plans cover nearly two-thirds of children nationwide, or over 50 million. Federal law requires plans that cover more than 50 employees to include mental health benefits to the same extent as other services in terms of annual or lifetime dollar limits. However, the federal law does not preclude employer-sponsored plans from including other features—such as day or visit limits–that are more restrictive for mental health services. In addition, the 4 percent of children, or over 3 million, covered by individual health insurance may face even greater restrictions. For example, insurers in the private market may offer only limited mental health coverage, such as a lifetime limit of $10,000 on mental health benefits, or may exclude specific disorders from coverage, or may offer no mental health coverage at all.
In the public sector, children and adolescents enrolled in Medicaid are not subject to day or visit restrictions with respect to mental health care, and though states differ in the explicit services covered in their Medicaid programs, federal law requires states to provide all children enrolled in Medicaid with any services necessary to treat physical and mental conditions detected through Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings.
EPSDT is not, however, a required component of SCHIP (State Children’s Health Insurance Program), and because states have more discretion in how they structure their SCHIP programs, children enrolled in SCHIP may have more limited access to mental health services. In states such as California and Utah that model their SCHIP programs on private insurance plans rather than on Medicaid, children may face day or visit limits.
But whatever the provisions of either Medicaid or SCHIP, the GAO report pointed out that no one really knows the extent to which children enrolled in those programs receive covered mental health services. “Available evidence suggests enrolled children in some states may not be obtaining services they need,” the report concluded. Currently, the Substance Abuse and Mental Health Services division of HHS is conducting a National Child Traumatic Stress Initiative that is designed to supply some of the missing data about access.
“Adolescent Depression,” David Brent, M.D. and Boris Birmaher, M.D., The New England Journal of Medicine, August 29, 2002.
“Adolescent Grief,” Grace Christ, Karolynn Siegal, Adolf Christ, M.D., Journal of the American Medical Association, September 11, 2002. (Includes recommendations for professionals dealing with children of various age levels during and after a parent’s terminal illness.)
“Multifacted Treatment Aids Depressed Young,” Lynne Lamberg, Journal of the American Medical Association, September 18, 2002.
“Six-Year Follow-up of Preventive Interventions for Children of Divorce,” Wolchik, Sandler, Millsap, Plummer, Greene, Anderson, Dawson-McClure, Hipke, Haine. (Includes a full description of the New Beginnings intervention program.)
“Mental Health Services: Effectiveness of Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma Largely Unknown,” General Accounting Office, GAO Report 02-813, August 2002.
InFocus is grateful to psychologist Olga Acosta and psychiatrist Dr. William Granatir for their review of this paper.