John Hill was a typical teenager in many ways: He started smoking when he was in high school, which upset his mother, and he spent a lot of time in his room alone, staying up until 5 in the morning playing video games. He went to school but often signed himself out sick after a couple of hours, and his grades plummeted.
When his mother asked what was wrong, he told her to leave him alone.
John’s mother Barbara, of Homedale, Idaho, was worried. But, she said, “He had always been the kid who never got in trouble … I kind of assumed it was just adolescent behavior kicking in.”
Teenagers are, by definition, difficult. Like the stereotype, they can be moody, reckless and emotionally volatile, crying in the shower, screaming at their parents, slamming their bedroom doors behind them.
It’s not a new phenomenon: the psychologist G. Stanley Hall dubbed the teen years a time of “storm and stress” more than 100 years ago. But experts now know these years are a critical period of development when serious mental illnesses can emerge and progress undetected and untreated, in part because they are perceived as typical teen behavior and may manifest with symptoms different from those in adults.
By the time they are college age, nearly one in five young American adults has a personality disorder that interferes with everyday life, found an extensive study released Monday by Columbia University and the New York State Psychiatric Institute.
While half of all serious adult psychiatric illnesses start before the age of 14, evidence suggests that parents may be the last to know. One study found that parents were unaware of 90 percent of suicide attempts made by teenagers. Another report from a screening program found that the vast majority of parents of kids identified as having psychiatric symptoms thought their child was all right.
“The tendency of parents is to think ‘This is normal,’ ‘They’ll outgrow this,’ ‘Not to worry,’” said Alec Miller, a doctor of psychology and chief of child and adolescent psychology at Montefiore Medical Center and Albert Einstein College of Medicine in New York City. “As a parent you can really lose your compass about what’s normal and typical when you have a range of behaviors coming at you.”
“Parents tend to believe the myth that it’s just a phase,” agreed Dr. Harold S. Koplewicz, founder and director of the New York University Child Study Center and author of “More Than Moody: Recognizing and Treating Adolescent Depression.” And, he added, “The worst thing a parent can do is wait.”
Many parents baffled by changes in their children’s behavior seek out counseling on their own. One third of the queries to TeenTalk, which offers free phone and online counseling for teens are from parents, said officials with the project, run by the Ruth Rales Jewish Family Services of South Florida.
Barbara Hill watched as her son became more and more withdrawn, even from his friends. When she tried to broach the subject he was, by his own account, gruff and dismissive.
“Every time she tried to sit down and talk with me, I’d blow her off, or be real rude,” said John, now 20.
But while he appeared angry, John was actually terrified. He was hearing voices calling his name when no one was around — experiencing what he later learned were the first symptoms of schizophrenia — and was too frightened to confide in anyone, even his mother.
“I thought she was going to kick me out of the house but I finally broke down and told her,” said John, who was surprised at how supportive his mother was. He now takes medication to control his symptoms and has become an outspoken advocate for other young people with mental illness.
While schizophrenia is relatively rare, affecting only about 1 percent of the population and usually developing during the college years, depression is common among younger teens. According to a nationwide report by the Substance Abuse and Mental Health Services Administration, 8.5 percent of teens aged 12 to 17 — or one in 12 — experience depression in any given year, with almost half saying they were so down that they couldn’t perform their daily activities.
The report, based on the responses of 67,706 youngsters surveyed between 2004 and 2006, found girls much more susceptible to depression than boys, with 12.7 percent of females and 4.6 percent of males reporting a depressive episode.
One of the SAMHSA report’s surprising findings was that only 30 percent of those who had experienced a depressive episode had gotten treatment. The number is even lower for college age adults struggling with personality disorders, according to the Columbia study. Fewer than 25 percent of them receive treatment, researchers found.
Last year, public health officials reported the first increase in teen suicides following a 13-year decline, an 8 percent increase in suicides among young people aged 10 to 24 in the year 2004, with the biggest percentage jump among girls aged 10 to 14.
Irritable and angry
One one reason parents may not recognize depression in their teenagers is because depression expresses itself so differently in teens, experts say. Changes in sleeping and eating habits are a red flag, as with adults. But while depressed adults are sad and melancholy, depressed teens are angry and irritable. Adults may say they don’t enjoy things anymore; teens may still enjoy activities but not look forward to them. They often say they’re bored, and can be indecisive, giving a lot of “I don’t know” answers.
Sharon Fawcett, a mother of two teenagers in New Brunswick, Canada, had struggled with depression herself for almost a decade, so she was always on the lookout for signs of the illness in her daughters. But, she said, she completely missed the disease in her younger daughter.
“Jenna started telling me she was depressed when she was 14, but to me, she was just laying around and being lazy, and using this as an excuse,” Fawcett said. “I thought: she’s not depressed, she’s angry and she’s moody. I just thought it was the stereotypical adolescent moodiness and negativity.
“The thing that confused me about my kids — and I’ve heard other parents say this — is how they can be so happy when they’re out with their friends, and as soon as they come home they’re depressed and angry and not speaking with us. I’ve learned since then that kids reserve their anger for the people they know they’re safe with.”
For a while, Fawcett attributed her daughter’s dressing in black, listening to heavy metal music and hiding her face behind long bangs and a hooded sweatshirt to teen fashion and old-fashioned rebelliousness. But by the time Jenna was 16, she had developed acute social anxiety, had difficulty concentrating and was refusing to go to school. She missed 100 days of school one year and failed most of her courses.
The dramatic change in performance for the girl who had been an honor student finally convinced Fawcett her daughter needed help. She consulted the family pediatrician, who referred her to a psychiatrist for a combination of talk therapy and medications, which have been very effective.
“The school failure was the most obvious identifying symptom,” Fawcett said.
A clear red flag
Experts agree that irritability and moodiness that keep a teenager from functioning normally for more than two weeks should be clear red flags. Ditto for withdrawal from activities and social isolation from friends. Other warning signs parents should look for are substance abuse, which is often a form of self-medication, and cutting, or self-injury, which can be a precursor to suicide.
“Parents will often let this go at least two weeks or more because they’re convinced it’s just a phase, even though if their child had a rash, they wouldn’t ignore it,” said Koplewicz.
The good news, he said, is that teenagers respond to targeted treatment, such as psychotherapy either with or without medication.
“The nice part is that we see dramatic turnarounds with kids, often in four to eight weeks. We believe wholeheartedly that we can change the trajectory for these kids if we nip it early.”
Roni Caryn Rabin is a health writer who lives in New York City. She has written for The New York Times, The Washington Post, Newsday and Real Simple magazine, among other publications, and is author of the book, "Six Parts Love: A Family's Battle with Lou Gehrig's Disease." She teaches journalism at the Columbia University Graduate School of Journalism.