When It Hurts to Be a Teenager

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Principal Leadership Magazine, Vol. 4, Number 2, October 2003

Counseling 101 Column

When It Hurts to Be a Teenager

Depression in students is more than mere teenage angst and requires more than patience and understanding to cure.

By Ralph E. Cash, NCSP

Ralph E. Cash is a school psychologist in Orlando, FL, and a cochair of the National Association of School Psychologists' Government and Professional Relations Committee and Health Care Initiative.

"There is a tide in the affairs of men which, taken at the flood, leads on to fortune. Omitted, all the voyage of their lives is bound in sorrow and in misery. On such a full sea are we now afloat, and we must take the current when it serves or lose our ventures." -William Shakespeare

Depression, particularly in teenagers, is often described as the invisible illness. Its symptoms can easily masquerade as part of the normal tumult of adolescence, a time not noted for level moods or stable behavior. Rapid changes in hormonal balance, physical and cognitive development, response to peer pressure, and perceptions of the world, combined with conflicting desires to be independent but free of responsibilities, make adolescence a time of emotional turmoil and behavioral extremes.

Most middle level and high school students experience brief, sometimes intense episodes of the blues, irritability, or rebellion. Even common adolescent behavior-slavish adherence to fads, body piercing, erratic sleep habits, and cyber socializing-can seem pathological to adults. How, then, can parents and educators differentiate between adolescent characteristics that, no matter how outrageous, are "just being a teenager" and those that suggest serious clinical depression?

What is the responsibility of schools to do so?

The answers to these questions are not just academic. Depression is the most common mental illness among adolescents. Statistically, in a school of 1,000 students, as many as 100 may be experiencing depression or mood swings severe enough to warrant a psychiatric diagnosis. Approximately 13 of those students will attempt suicide in a single year, making suicide the third leading cause of death among teens. Fortunately, most will not succeed, but 15 of the 100 are likely to die by their own hands eventually.

Approximately 90% of those who commit suicide have a treatable mental disorder at the time they die. Depression is at the top of this list, but about 70 of those 100 depressed teens will never see a mental health professional. Of the 30 who do, 20 or so will only have that contact in school. If the school has a higher than average proportion of students living in poverty, the picture will be even worse.

Schools are an essential first line of defense in combating mental health problems, such as depression, because adolescents spend much of their time in school with skilled and caring professionals who have the opportunity to observe and intervene when a student exhibits signs of a problem. Principals can work with staff members to strengthen protective factors in the school and to educate students, staff members, and parents about depression and the hope offered by effective treatment. Schools can also provide early identification, intervention, and referral services. Failure to do so has serious consequences besides suicide-depression's most tragic and irreversible outcome. Without treatment, depressed teens are at increased risk for school failure, social isolation, unsafe sexual behavior, drug and alcohol abuse, and long-term life problems. Conversely, virtually everyone who receives proper, timely intervention can be helped, but early diagnosis and treatment are necessary.

What is Depression?

Depression is not a personal weakness, a character flaw, or the result of poor parenting. It is a mental illness that affects the entire person, changing the way he or she feels, thinks, and acts. A depressive disorder, sometimes referred to as clinical depression, is generally defined as a persistent sad or irritable mood as well as "anhedonia," a loss of the ability to experience pleasure in nearly all activities. It is more than just feeling down or having a bad day, and it is different from normal, healthy feelings of grief that usually follow a significant loss, such as a divorce, a break up with a boyfriend or girlfriend, or the death of a loved one.

How Does It Differ From Moodiness?

Depressed teens can experience a range of symptoms including change in appetite, disrupted sleep patterns, increased or diminished activity level, impaired concentration, and decreased feelings of self-worth. Adolescents are often more defiant and oppositional than depressed adults. Symptoms can manifest themselves in school as behavior problems, lack of attention in class, an unexplained drop in grades, cutting class, dropping out of activities, or fights with or withdrawal from friends.

These behaviors are distinguished from normal teenage behavior by their duration, intensity, and the degree of dysfunction they cause. Symptoms or behaviors that last longer than two weeks, are markedly out of proportion to an event or situation, and impair a student's academic or social performance are cause for professional evaluation. Although episodes of clinical depression are sometimes self-limiting (meaning that a student may appear to get better), depressed teens cannot just "snap out of it" on their own and are likely to experience further episodes in the future.

What Characterizes Depression and Other Mood Disorders?

Depression, like adolescents themselves, comes in all shapes and sizes. Teens can suffer from a variety of depressive disorders, sometimes called mood disorders. These can include:

Adjustment disorder-an extremely intense reaction to life stressors that is in excess of what would ordinarily be expected and can be dangerous, but usually does not become chronic; dysthymic disorder or mild, chronic depression-a few or milder symptoms occurring either continuously or most of the time for a year or more, but with relatively good functioning
Major depressive disorder-a severe, serious condition characterized by extreme depressive symptoms including hopelessness, lethargy, feelings of worthlessness or unrealistic guilt, and recurrent thoughts of death suicidal plans or suicidal attempts
Bipolar disorder-severe moods swings from depressive depths to unrealistic and uncharacteristic elation, grandiosity, behavioral excesses, verbosity, or belligerence.

Teens who exhibit symptoms of a depressive disorder should be referred for a mental health evaluation. They should not be left alone if they are suspected of being suicidal. Depression in teens may also be masked by other problems or behaviors, such as anxiety disorder, frustration over learning problems, sexual promiscuity, and substance abuse. Depressed adolescents often self-medicate or seek thrills to alleviate their pain. Some seek relief through self-injury, such as cutting or extreme physical risk-taking. Students who are identified as engaging in these behaviors should be referred for depression screening at once.

What Are the Risk Factors?

Depression does not discriminate, but there are certain risk factors that predispose adolescents to depressive disorders. Clinical depression usually has a genetic component, and those who have a family history of depression, particularly among close relatives, are more vulnerable. More than half the teens who are diagnosed with a depressive disorder have one or more coexisting mental disorders, so those who already have emotional or behavior problems are at greater risk. Other risk factors include poverty; being female; low self-esteem; uncertainty about sexual orientation; poor academic functioning; poor physical health; ineffective coping skills; substance abuse; and frequent conflicts with family, friends, and teachers. In addition, students who have experienced significant trauma or abuse, are bullied, or do not feel welcome or accepted at school are much more susceptible to depression.

How Can Schools Help?

The best intervention is prevention and early intervention. Schools can provide a number of supports to help decrease the occurrence of severe depressive reactions and prompt appropriate early treatment.

Destigmatize and shed light on the illness. Perhaps the most important thing schools can do to combat depression is to make the illness easier to identify. Principals can work with their school psychologists and other mental health staff members to educate students, staff members, and parents on the realities, risks, and signs of depression. This should include helping students recognize the difference between their normal feelings of sadness, confusion, or disconnnection and depression. Students should be encouraged to talk openly about the illness and other mental health problems with friends and trusted adults.

Train staff members, students, and parents in appropriate interventions. Schools that have effective training programs for teachers and other staff members (e.g., bus drivers, school safety officers, coaches, and office workers), parents, and students are much better at intervening early and appropriately on behalf of depressed teens. This should include developing a protocol for reaching out and responding to students who may be depressed and providing appropriate ways to observe and to refer students to mental health services. However, teachers are not trained mental health professionals and should not "counsel" depressed students. Students should be included in the training programs so they can begin not only to recognize signs of depression in themselves but also to help break the code of silence that often prevents teenagers from telling responsible adults when they or their friends are depressed and contemplating suicide or violence.

Create a caring, supportive school environment. An impersonal, alienating school culture can contribute to students' risk of depression. Effective interventions must involve collaboration among schools, parents, and communities to counter conditions that produce the frustration, apathy, alienation, and hopelessness experienced by many of our youth. All students and parents should feel welcome in the building. Central to this is to build trust between school personnel and students and to ensure that each student has at least one adult at school who takes a special interest in him or her. Knowing individual students personally is particularly important in recognizing significant changes in behavior, which is one of the key indicators of depression. Bullying prevention is also necessary.

Develop a suicide prevention and intervention plan. Depression and suicide prevention programs are intertwined. It is important to educate the school community about the warning signs of suicide and to have a clear intervention plan in place that includes a trained crisis intervention team. All staff members should know what to do if they think a student is suicidal. Students must be partners in suicide prevention efforts because they are most likely to be aware of classmates' plans to hurt themselves or others. In the vast majority of cases, students who attempt suicide or perpetrate violent acts have warned someone beforehand, and that person is usually another student who keeps the information to him- or herself. Emphasize that all students and staff members have a responsibility to report any threat of suicide or violence. Have a well-defined, confidential procedure established for doing so.

Be mindful of at-risk students. These students should be monitored, particularly during periods of high stress, either on an individual level or in the school community. Examples of high-stress situations can include exams, the death of a family member, the suicide of another student, or a major event such as September 11, 2001.

Use school mental health professionals. School psychologists, social workers, and counselors are excellent resources for designing and implementing training programs for all groups. They can also be invaluable in developing suicide prevention and violence prevention programs as well as in providing direct intervention and ongoing counseling to students. Intervention plans must include mechanisms for connecting students and parents with appropriate and affordable community resources for treatment and monitoring.

Provide students with appropriate supports. These should be recommended by your school psychologist or the student's private clinician, but they may include individual or group counseling, continued observation, academic accommodations, opportunities for creative expression, medication, and self-monitoring strategies and steps for seeking help. It may also be appropriate-if given permission-to reach out to the student's social network to generate social support. It should be made very clear, however, that students should not take on responsibility for managing or fixing a friend's depression and should seek adult help if a friend seems to be deteriorating.

Encourage cooperation with parents. Educate parents and open up lines of communication. Some parents of depressed teens will want significant help from the school; others who can afford to do so will prefer to keep their child's illness and treatment separate from school. In such cases, the school should make every effort to establish some coordination with the student's private clinician either directly or through the parents. This will make it easier to provide appropriate supports in school and to be aware of the student's progress. However, be sensitive to parents' concerns for privacy and what information may or may not go into their child's school record.

Take the Current When It Serves

In Shakespeare's words, we are "on such a full sea" of knowledge about depression, from identification to treatment, that there is no excuse for depression to remain invisible or untreated. There are tremendous volumes of research and numerous successful programs designed for schools. Schools that destigmatize depression, educate and engage stakeholders, and provide appropriate interventions can help ensure that students are not "bound in sorrow and in misery" but "lead on to fortune." PL

Facts About Depression

Depression is a treatable medical illness, not just a bad mood or an inevitable part of life's ups and downs.
Depression affects 8-10% of adolescents and is the most common cause of disability in the United States.
Depression in teens differs from depression in young children or adults. Teens are more affected by their social environment, more irritable than sad, and more chronically depressed.
Depression affects people of all ages and backgrounds. However, postpubescent girls are twice as likely to suffer from serious depression than boys, and certain populations, such as gay and bisexual youths and American Indians, suffer higher rates of depression.
Untreated depression is the leading risk for suicide among adolescents.
Suicide is the third leading cause of death among adolescents ages 15-24 and the fourth leading cause of death among children ages 10-14. Nearly 2,000 young people die of suicide every year; nearly 400,000 attempt suicide; nearly 2 million make a suicide plan.
Girls are twice as likely to attempt suicide but boys are 10 times more likely to succeed because they tend to choose more lethal methods of attempting suicide (e.g. guns).
Depression can be linked to poor academic performance, poor social relationships, school absenteeism, dropping out, disruptive behavior, and school violence.
Depressive episodes can resolve themselves but, if ignored, are likely to reoccur within a year.
Talking to friends or family is an important source of support but on its own is not enough to treat depression.
Nearly 70% of children and youth with serious mental health problems do not get treatment.
Eighty percent of people treated for depression respond to treatment, which usually includes a combination of medication, psychotherapy, and support groups.

Identifying Depression

Distinguishing depression from adolescents' normal mood swings can be difficult. School staff members should contact a mental health professional if a student exhibits symptoms that:

Are new or changed in intensity, frequency, or manifestation
Continue for a two or more weeks
Interfere with the student's social and academic function
Cause disruptive or uncontrolled behavior
Reflect thoughts of hurting oneself or others

Warning Signs of Depression in Adolescents

Sadness, depressed mood, or irritability
Agitation, defiance, or sullenness
Lack of pleasure in daily activities
Withdrawal or crying
Unexplained physical complaints
Lethargy or chronic boredom
Poor concentration or inability to make decisions
Poor academic performance
Negative thoughts about self, the world, and the future
Self-blame, guilt, and failure to recognize one's success
Change in appetite or weight gain or loss
Excessive sleeping
Increased-risk behaviors (e.g., sexual risk-taking or abuse of drugs and alcohol)
Suicide ideation or attempts

Risk Factors for Depression

Existing or history of mental health problems
Poor academic functioning
Poor physical health
Poor coping skills or social skills
Low self-esteem
Behavior problems
Problems with friends or family
Poor school and family connectedness
Major life stressors
Substance abuse
Family history of depression or suicide

Warning Signs of Suicide Risk

Untreated depression is the leading risk for suicide in adolescents. Four out of five youths who attempt suicide give clear indications of their intentions. Warning signs include:

Suicide notes, threats, and references either verbal or expressed in writing or creative work
Previous attempts
Obsession with death
Depression or other disturbed mood or behavior
Risk-taking behaviors, such as aggression, reckless driving, gunplay, and alcohol or substance abuse
Efforts to hurt oneself (e.g., cutting oneself or jumping from heights)
Inability to concentrate or think rationally
Changes in physical habits (e.g., sleeping or eating) and appearance (e.g., hygiene and dress)
Sudden changes in personality (e.g., sadness or irritability), friends (e.g., withdrawal or isolation), or behaviors (e.g., loss of interest, absenteeism, or drop in grades)
Making final arrangements (e.g., a will) or giving away belongings
Suicide plan (i.e., specific talk or allusions to timing and method) and access to method (e.g., guns or prescription drugs)

Reaching Out to Students

Students who are depressed may not ask for help because they believe no one cares or that nothing can be done.
Students may not want to be labeled as having a problem, particularly if they already believe they are to blame for being unpopular, unworthy, or a failure.
It is never wrong to ask a student who seems troubled if she or he is OK, but a depressed student may dismiss overtures of concern as misplaced or intrusive. Depending on the severity of the student's symptoms and behavior, staff members can respect this type of response but should continue to observe the student and confer with other staff members.
Positive connection between an at-risk student and a trusted adult is important. However, teachers are not trained mental health professionals and should not take on responsibility for treating a student.
Staff members should never promise to keep a student's feelings a secret but should assure the student that they will only share their concerns with other appropriate adults (including parents) who can and will help.
Contact parents and the school psychologist or other mental health professional immediately.
Do not leave the student alone at any time if they are suspected of being suicidal.

Schools Can Help

Create a caring, supportive school environment that promotes connectedness and prevents alienation.
Educate students, staff members, and parents on the realities and signs of depression. Help distinguish between depression and normal adolescent emotions (being upset by a bad grade or a fight with a friend). Destigmatize attitudes and openness about the illness.
Build trust between school personnel and students. Ensure that each student has at least one adult in the building who takes a special interest in him or her.
Develop and disseminate a protocol for reaching out and responding to students who may be depressed. Train staff members and parents in appropriate ways to observe students and to increase their comfort level and ability to intervene and refer students.
Know the signs of suicide and have a suicide prevention and intervention plan in place. Emphasize the responsibility of all students and staff members to report any threat of suicide or violence.
Use school mental health professionals (e.g., school psychologists and social workers) to develop prevention and intervention plans, provide intervention, and train others. Be familiar with community mental health resources.