Pediatrician Nerissa Bauer still remembers vividly the first time a patient answered “yes” when she asked about feeling down, depressed, hopeless or having thoughts of self-harm.
While not looking directly at Bauer, the teen anxiously waited to hear what she was going to say next.
“We must ask, and we must be ready to respond,” said Bauer, who is part of the American Academy of Pediatrics steering group to create guidelines for pediatricians to screen children 12 and older for mental illnesses during annual visits. “You can’t just look at a teenager and know he is depressed because boys especially can hide it well.”
As many as one in every five teens experience depression at some point during adolescence, and about half are undiagnosed and untreated, according to the American Academy of Pediatrics. With boys, there are additional factors at play: Teenage boys tend to communicate less, commit suicide more often and will turn to alcohol or other substance abuse when depressed.
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Even as pediatricians step in to help, for parents of teenage boys, differentiating between normal growing pains and more serious depression can be difficult. Doing so, though, is becoming increasingly important. The National Institute of Mental Health estimates that 3 million adolescents ages 12 to 17 have had at least one major depressive episode in the past year and more dangerous behaviors, like self-harm, are increasing.
“What they found is the brain is still developing, so we see high levels of impulsivity during this time,” said Ana Ojeda, Psy.D., a board-certified clinical psychologist with Miami’s Nicklaus Children’s Hospital Department of Psychiatry.
During the teenage years, boys often communicate less, and answer parents’ questions with grunts — if at all.
“When asked about what they are feeling, often they can’t tell you what their emotions are because they don’t have the vocabulary and they are not in tune with why they feel certain things,” explained Dr. Rachel Rohaidy, a psychiatrist with Baptist Health Medical Group.
The sheer numbers illustrate how untreated mental illness can be fatal: Suicide is the third-leading cause of death of young people ages 10 to 24, and 90 percent who died by suicide have an underlying mental illness. Parents of teenagers who have died by suicide often express regret for not getting help sooner and have said their teenager’s problem with depression was worse than they had suspected.
Bauer, an associate professor of pediatrics at Indiana University School of Medicine, believes parents, teachers, coaches — and pediatricians — need to know the warning signs for depression.
For pediatricians, “asking patients about psychosocial health, and making them feel comfortable enough to discuss it, is just as important as taking vitals,” Bauer said. “It becomes more important with problems like cyberbullying on the rise and gun violence repeatedly spilling into teens’ world at school, concerts, movie theaters and even places like church.”
Some of the warning signs for teen depression and mental illness are obvious, and some are subtle:
Disengagement and withdrawal. While many teenagers have bad breakups or failed tests that lead to sadness, depression occurs for an extended time, usually longer than two weeks.
“Teen depression is a different than feeling sad and anxious, which is normal for a teenager,” Ojeda said. “When you are depressed, being sad and anxious lasts a long time, and interferes with daily functioning.”
Heightened aggression. It is common for most teens to fight with parents and siblings, but aggressive behavior may indicate a bigger problem. Depressed teens often exhibit irritability, big reactions to small things and feelings of intense frustration or anger.
A large Canadian study of child development released earlier this year found a link between high irritability and teenage suicide attempts. Rohaidy cautions that irritable, aggressive behavior may not only surface in person, but also on social media. She advises parents to keep close tabs on their teenager’s accounts.
“Maybe their posts are getting more serious. … Look behind what they post for additional meaning.”
Isolation or change in behavior. Another warning sign of depression is a desire to be alone. If your son previously had joined the family for dinner or spent time with friends and now doesn’t come out of his room, that’s something to look for, Rohaidy said.
While adults tend to isolate themselves when depressed, teenagers may keep up at least some friendships.
At Joe DiMaggio Children’s Hospital in Hollywood, Dr. David Rube often treats teenagers with severe depression. Rube, a specialist in child and adolescent psychiatry, said one teenage boy he treated for depression had been considering suicide for 2½ years before he attempted it.
“Boys often don’t have the social network to say, ‘I’m really depressed.’ Girls say it to other girls all the time,” Rube said. “There also is that stigma that boys should know how to handle it, and the result is there are a lot of unidentified boys out there with depression.”
Drop in grades. Depression can deplete a teenager’s energy and create concentration difficulties. At school, this may lead to poor attendance, a drop in grades, or frustration with schoolwork.
“Don’t be afraid to call the school and find out what’s going on,” Rube advises parents. “A change in grade performance could be depression, drugs, or something else,” he said, “but it does give an indication that something is off.”
Crying, sleeping and eating issues. Unexplained crying, loss of appetite and sleeplessness or too much sleep are also signs that a teen is troubled or potentially depressed. A 2014 University of Texas Health Science Center study found depressed teens were four times as likely to lose sleep.
Substance abuse. Substance abuse often accompanies depression, particularly in boys. Because addiction and depression both originate in the brain, people who have mental health issues are more prone to addictive behaviors.
“In general, for boys, numbing their feelings with alcohol or drugs tends to be a way of dealing with intense emotion,” Rube said
Thoughts of suicide. Teen depression often makes problems seem overwhelming and the associated emotional pain unbearable. Most teens who feel suicidal will usually tell someone before they kill themselves, or attempt to kill themselves. With this in mind, anyone who has thoughts or feelings about hurting themselves or feeling hopeless should be taken seriously, Ojeda said.
When parents recognize warning signs, Bauer recommends they make an extra effort to keep the lines of communication open, even if their teen tries to withdraw. And, rather than telling a teen what to do, listen closely to get to the deeper issues causing the problems.
To get help, Bauer advises parents to take their teenager to the pediatrician, a mental health professional or the emergency room if violence or self-harm is a concern.
South Florida experts say a parent who is unsure if a teen is depressed or just a moody teenager should consider how long the symptoms have been going on, how severe they are and how different the teen has been acting from his prior self.
Hormones and stress can explain some teen angst, but not long-term, unrelenting sadness or irritability. Most often, depression is treated with a combination of therapy and medication.
“Treatment works if you stick with it,” Rube said. “Unfortunately, there is still a stigma that holds people back from getting mental health treatment.”
Teen Depression and Violence
Some depressed teens — usually boys who are the victims of bullying — want to hurt others rather than themselves. While it’s important to note that not every depressed teenager is going to be a school shooter, extra caution needs to be considered when there is a preoccupation with violence, mental health professionals say.
For the most part, the violence is preceded by warning signs. A recent FBI study analyzing the pre-attack behavior of 63 active shooters who killed multiple people between 2000 and 2013 — all male and white — found more than half had communicated to someone online or in person that they intended to harm someone. And more than 75 percent spent a week or longer planning their attack.
The exact correlation between depression and violence is unclear. A New York Times analysis of mass shooters found about a quarter displayed signs of depression and psychopathy and in many cases never sought professional help. And while shooters are often paranoid, resentful or narcissistic, it is not always to the extent that they had been found to have a mental disorder.
Often the mass killer believes he has been wronged. There is always a personal grievance, history of loss, or trauma, that will start a person on a pathway to mass murder, researchers found.
“With teenager mass shooters, we don’t know why they got to this point, but what we do know is there are warning signs,” Ojeda said. “They have some level of sociopathic, anti-social traits, in addition to being depressed.”
Meanwhile, law and medical professionals are still probing for more understanding of mental health and violence among young white males, but say it is critical for parents who suspect their teen boy is troubled to make a safety plan that includes removing weapons.
“The warning signs are not uniform,” Ojeda said. “They may predict risk, but not the likelihood these teens will act on that risk.”