A mother finds a drawing of a tombstone among her son’s schoolwork. “Rest in Peace,” the caption reads. “Maybe I’d be better off dead.”
The boy is 10 years old.
In terror, she turns to marriage and family therapist Laurie Singer. That a child so young struggles with mental health is no surprise to Singer — or to teachers, other mental health experts, physicians or a troubling share of parents who see the cauldron of anxiety and depression boiling in America.
The crisis has bubbled for decades, and by 2019, one-third of high school students — half of females — reported feeling persistent sadness or hopelessness, a huge increase from 2009. The pandemic dumped grief and fear into the pot.
The mental health of millions of American youths has become so fragile that U.S. Surgeon General Dr. Vivek H. Murthy issued an urgent public health advisory in December.
“The pandemic era’s unfathomable number of deaths, pervasive sense of fear, economic instability, and forced physical distancing from loved ones, friends, and communities have exacerbated the unprecedented stresses young people already faced,” Murthy wrote. Amid the COVID-19 pandemic, cases of depression and anxiety doubled among young people. Emergency room visits for suspected suicide attempts were 51% higher for adolescent girls and 4% higher for adolescent boys compared to early 2019.
Then, just when some kids got a little used to doing school and life while cocooned at home, the doors flew open and they were ordered back into a world that doesn’t really seem any safer.
America’s mental health crisis isn’t ageist. At her practice in Camarillo, California, Singer treats patients as young as 5 and as old as 80 who have anxiety, depression or both. But teens have been especially hard hit.
Sam Goldstein, psychologist and adjunct professor of psychiatry at the University of Utah, specializes in treating youths with multiple, complicated mental health issues. He’s watched the numbers swell.
In 2020, the National Survey on Drug Use and Health found that 21% of 16-17 year olds experienced a major depressive episode. Anxiety, depression, somatic disorders and teen suicide are known as “internalizing disorders” — conditions that are often nearly invisible to others, but cause great pain to those tormented by them.
One of the harshest challenges that these disorders entail is that they tend to come back, warned Goldstein, author of “Tenacity in Children.” “Once your body kindles that kind of an extreme response, under stress the body regresses to that again. So about 50% to 70% of teens who have a depressive episode before 18 will have another one before 18.
“And if you have two, then you’re in the club. You may not always be in the building, but you have a membership card. You’re going to cycle in and out of depressive episodes,” he said.
Why the increase in severe mental health problems among the young? Perhaps there is less stigma today, so more are seeking help. Or maybe mental health really is getting much worse.
Undisputed, experts say, is that young America faces grave mental health challenges, growing up in a crucible of digital media, academic pressure, financial uncertainty, racism, gun violence, societal inequality and fear that the planet itself will die.
Nor is the pain portioned equitably. Rural kids, LGBTQ kids, immigrants and those in poverty are among those facing the hardest path. Girls are more likely to be diagnosed with anxiety, depression or an eating disorder, while boys may show up with behavior problems and are more apt to die by suicide.
COVID-19 has decidedly ramped up stress and that impact isn’t theoretical, said Goldstein. Levels of cortisol — the main hormone produced by stress — have measurably increased as children and adults struggle to make sense of what they see, feel and hear. Cortisol spikes can cause depression and harm physical health, too.
When Presidents Donald Trump and later Joe Biden assembled advisers for their pandemic responses, Goldstein wishes they’d taken a more holistic approach, incorporating educators and experts in dealing with substance abuse and family violence. The virus has exacerbated those issues as surely as it’s filled hospitals and clinics. “We may have dramatically increased the numbers and the vulnerability in multiple other areas downstream,” he said.
Goldstein thinks America needs to drastically alter its approach to mental illness. “In light of increased vulnerability we all have — not just being unhappy, but unhappiness that causes impairment — maybe we need to think about systemwide intervention like we’re doing in physical health,” he told Deseret.
Just as kindergartners are screened for school preparedness, children need to be screened for mental health, Goldstein says. He offers the example of a school district in Austin, Texas, where all students were screened as part of a study 30 years ago. Students who answered yes to a question were further screened. Of three questions, one — “Are you worried about school?” — was especially correlated with mental health problems, usually depression.
The next logical step is teaching children about depression and how to spot it in themselves, with increased information and resources depending on the degree of identified risk. “I’m not trying to pathologize and I’m certainly not trying to create business, because right now there aren’t enough professionals to go around,” he adds.
Parents can do some screening, too, by considering if their child seems worried more about their capabilities than is warranted. Do they see the world in mud-colored glasses? Kids could ponder that, too. Self-diagnosis is fine as long as it’s not where people stop.
Goldstein breaks action into big things and little things. Being proactive is big. The threshold leading to action should be low. If you’re concerned, do something about it, he said.
Pediatricians and family doctors offer a place to start, experts say. Many insurance carriers have access to an Employee Assistance Program with mental health professionals who can help people to get care. Groups like the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and mental health-focused nonprofits are among groups with reputable screening tools online.
Health systems and academic institutions are also pitching in. In New York, for example, the Montefiore Health System’s Pediatric Behavioral Health Integration Program uses telehealth technology to convene group therapy for teens with anxiety and depression. Psychologists and psychiatrists are based in primary care offices and refer children if mental health screening reveals cause for concern, said psychologist Teresa Hsu-Walklet, assistant director of the program. The program is focused on helping young people to understand mental disorders and learn coping strategies, in part by telling each other what worked for them.
Telehealth is a growing resource for mental health treatment that is likely to persist beyond the pandemic, though capacity is limited, and requires good Wi-Fi, Hsu-Walklet said. But the technology enables critical help when two people can’t be in the same place.
Harvard Medical School and Boston Children’s Hospital created “Mightier” in 2016, an emotional health program for kids 6 to 12 that pairs video games with evidence-based strategies to help kids learn to regulate their emotions and build coping skills at home. Available by subscription at Mightier.com, it combines biofeedback with curated video games that kids already play. When biofeedback shows the player is getting anxious or frustrated, the player must self-calm or the game gets even harder. Emotional regulation becomes instinctive over time, and the kids learn that they can work through stress.
Jason Kahn, a behavioral health researcher and Mightier’s chief scientific officer, said kids are asked to be resilient, often without tools to do it. “That’s a really big ask and we have to prioritize building the types of skills that will help them.”
Singer, the therapist and author of “You’re Not Crazy: Living With Anxiety, Obsessions and Fetishes,” combines cognitive behavioral therapy with behavior modification to help children temper depression and anxiety using color-coded “signaling” strategies and other tools. Though communities often lack enough professionals to meet local need, she said families mustn’t give up. Doctors, teachers and friends may know someone who can help.
Walls aren’t high enough nor locks strong enough to keep the world away from children, so Goldstein tells parents to have frank, age-appropriate discussions about whatever might confuse them, like why schools and businesses open and close and what’s risky and what isn’t. “If adults are confused, imagine how confused kids are,” he said.
Murthy’s suggestions are more prosaic: He said it’s important to ask for help, work on having healthy relationships, find ways to serve others, manage stress, get sleep, nurture body and mind and be “intentional” when using social media and technology.
He points out that news is never all bad. Some kids have thrived during the pandemic: more sleep, more quality time with family, less academic stress, less bullying, a more flexible schedule. But the call to action on mental health is clearly urgent. Communities must guarantee access to good mental health care that’s affordable and culturally competent, he said. “It would be a tragedy if we beat back one public health crisis only to allow another to grow in its place.”