Podcast: Recognizing and Addressing Mental Health Disorders in Teens

Jeff talks to Dr. Guvenek-Cokol about the challenges that children and teens face in today’s world and the impact they can have on their mental health. They discuss the warning signs that parents can look out for that can differentiate “normal” teenage troubles from more worrying concerns and how to go about asking for help.

Perihan Esra Guvenek-Cokol, MD, is a double board certified child, adolescent, and adult psychiatrist. Specializing in emerging mental illness in teens and young adults. She is the medical director for McLean’s Child and Adolescent OCD Institute and STAR, an outpatient program for teens and young adults.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there, and welcome. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to thank you for joining us for this episode of our educational webinar series. Our focus today, mental health disorders in teens.

And our goal is to provide some guidance for spotting the onset of adolescent mental health conditions. It can be tough at times to distinguish between so-called typical teen behavior and signs of emerging mental health conditions, but understanding these distinctions can be critical when it comes to guiding teens to effective mental health care.

Our guest today is an expert in this area, Dr. Perihan Esra Guvenek-Cokol, is a double board-certified child, adolescent, and adult psychiatrist. She specializes in emerging mental illness in teens and young adults, and serves as the medical director for McLean’s Child and Adolescent OCD Institute, as well as an outpatient program for teens and young adults.

Esra, thanks so much for loaning us your expertise today.

Esra: Thank you, Jeff. Happy to be here.

Jeff: Well, we’re thrilled to have you with us. And before we dive into mental health disorders that can impact teens, I want to start by asking you to help us understand the typical everyday challenges that they have to navigate. It’s not easy to be a teen today.

Esra: It’s not, it’s not. I mean, adolescents, teenagers, it’s a period of immense change, right? For teenagers, life is happening really fast and, you know, their bodies change, their brains change, their emotions change very rapidly.

So, it’s a really fast-paced period and a lot happens. They learn so much and they all try to navigate these fast-paced changes, and their environments change a lot, and their parents try to figure the process along with them.

Jeff: You mentioned the brain. This is sort of a critical period for brain development, is it not?

Esra: It is, it is. So, what happens during the adolescent period is our brains, you know, our brains make a lot of connections growing up. The baby brain is small, and as babies grow the brain creates a lot of connections, like synapses and there’s something happening during the adolescent period, what we call pruning.

The brain becomes practical. So, what the brain does is really consolidate the parts of the brain that are working, the connections that are important. They like, amplify, and or like, expand on these connections and also get rid of the parts that are not working, the connections that are not important or not used, kind of clean that.

It’s a bit of a cleaning consolidation process, what we call pruning. And because it’s so important, that pruning is so important, usually problems around brain connectivity can come up during that phase.

So, a lot of mental illnesses can emerge during the adolescent period, and something like maybe 50% of mental health disorders have their, like, early signs are shown by age 14. So, a lot of times, and some mental health disorders come up later in life, but a lot of them have their early signs and symptoms come up and emerge during the adolescent period.

Jeff: And I want to talk about some of those signs in just a minute here. But first I want to continue sort of talking about the challenges that teens face every day. We’ve got behavioral development and identity development happening at the same period as well.

Esra: Yes. So, what happens during the adolescent period is, you know, think about, you know, these children, school-aged kids, they are sort of at home a lot with parents, and parents are very active in their life.

And then during the adolescent period, teens start to kind of start separating from their parents. So, they notice their body change. Like, think about middle school, right? You know, it’s a full chaos. The friendships, the relationships become very complicated.

The emotions of the teenagers are like, naturally really up and down. Like a lot of, like, teens start feeling strong emotions, puberty hits, you know, physically, they notice the changes in their body.

So, it’s a very chaotic kind of naturally, normally chaotic case. And then they sort of go through this transformation period during adolescence and then emergence of becoming young adults. I think, oh, sorry, go.

Jeff: I’m sorry. Please continue.

Esra: Oh, I was going to say, you know, it is like a transformation phase, and I think for teenagers, you know, they try to figure this out and they start to figure out who they are, you know, what kind of person I am, what are my values, what are the things I care about in life?

What does the society want from me? And as they figure this out, you know, the parents, you know, try to support them and obviously, you know, that’s a process. Like it doesn’t happen in a day, and it is painful naturally, normally painful for many families.

Jeff: What about some of the social challenges that teens have to navigate as well? Peer pressure, bullying, dating days, and so forth?

Esra: Yeah, yeah. So, I think, you know, I think first it’s like important to kind of understand why these are so challenging for teenagers because, you know, they are in the phase of learning. It’s a very active learning process, being a teenager, you know.

They, first of all, they try to recognize their own feelings. Like all of a sudden, they start, the emotions start feeling really big, the anger, the happiness, you know, emotionally up and down, like emotional, like swinging in their emotions.

That is all kind of, they try to figure out, they also try to figure out their body, you know, body changes, you know, sexuality, being interested in, you know, romantically in peers, and then the whole value system, right?

As a teenager becoming a little bit like late middle to late teens, they start to really experiment and understand and, you know, kind of figure out what their personality value system, how they want to present themselves into the world.

And of course, like the impact of like, you know, you know, the community, media, like, social media, friendships, peers, this is, again, it’s a vulnerable period. So, any impact, positive or negative is going to affect how the teen will develop.

Jeff: I can’t help thinking that the world is moving a lot more quickly these days than it was when I was a teenager. And that’s got to present some challenges as well.

Esra: Yeah, yeah. So, I think the way I think about it is, you know, adolescence is a period of mistakes, right? Like every teenager pushes boundaries, limits, because that’s their growing pain to become independent.

And they will, you know, they will make some, you know, they’ll make decisions that are not very wise. And there’s a biological reason for that. Like, our brains develop from the bottom to the top and the part of the brain, what we call the prefrontal cortex right here, is a part of the brain that helps us to make good decisions.

So that’s the part of the brain, you know, that handles the impulsivity, you know, it helps us to kind of raise pros and cons of the decisions being made. And that part of the brain develops the last. Like, it develops until like in the late twenties and maybe thirties for some people.

So, I think that is sort of a, normally naturally teens don’t have a fully developed brain that makes, helps them to make good choices. So, they will make some wrong choices.

And the parent’s job is, I think, society’s job too, to make sure those mistakes are not too big and non-reversible, you know? But you know, in today’s world, especially with the social media, like the problem is like when they make mistakes, it’s sort of more visible and amplified.

And that, it’s a burden itself on teenagers, because they’re like, they have like real life presentation and there’s a whole online presentation and things on the internet tend to stay. So that is really hard to kind of like, regrets or like taking back is really hard for them.

Jeff: Before I forget to circle back to this, I have to ask you about the ways that the pandemic created additional challenges. I’m thinking about isolation for some teens for example.

Esra: So, one of the things that really helps teens, like any person, like I mean adults and kids, but social connectedness is really important, especially when teenagers try to figure themselves out and try to make sense of what’s happening to their body, their emotions, their social circle. Having, you know, good solid, helpful adults and friends, is really important.

What the pandemic did to all of us and more so for teenagers it sort of really impacted the connectedness, right? We all felt a bit more isolated than disconnected and that has a huge impact on teens.

And, you know, schools, like, not having steady school access, and school can be a challenge for some teens, but like having their social circle, friends, like good adults at school, certain teachers, you know, school counselors, you know, not having access to that has been very hard.

And we also see this in, you know, kind of clinically, right? There’s a significant increase in, you know, anxiety and depression with the pandemic.

There is something like a 30% increase in emergency room visits for teenagers coming with emotional, you know, some sort of psychiatric emergencies. So, there’s like an impact that we can actually measure by seeing how many more kids are seeking care.

Jeff: This is a long list that we’re running through right now in terms of challenges that teens face every day, even with good mental health and well-being.

Let’s talk now about where the transition is to actual clinical diagnosed mental health disorders for teens. When is that line crossed?

Esra: So, I think, you know, someday, you know, it’s normal to expect teenagers to have big emotions, right? You know, big emotions, feeling confused about emotions, having conflicts with, you know, friends and parents.

Like this is all kind of growing pains of becoming an independent adult, but then problems are not solvable. Like then, you know, it affects the way they function, right?

Then, like for example, it’s normal to have anxiety about like, if first I’m dating, I’d be anxious, you know, but then anxiety, or depression, or like emotions become so strong that the teens cannot function in the world.

They are too anxious to go to school, they’re too anxious to hang out with friends, or they’re too depressed, or too sad to do the things they really care about. Then we become concerned and that is really important to kind of seek help and reach out and, you know, try to sort of get the help as early as possible.

We also know that, you know, with mental health disorders, the earlier we intervene, the better the outcome’s going to be. The longer something is sort of built up without being addressed, it’s going to be harder to treat it.

So that’s really important. Sort of recognize early and then get the help early on, so it doesn’t kind of accumulate and becomes harder to treat.

Jeff: You’ll help us with some perspective here. Any statistics or just general guidance in terms of the population size of teens with diagnosable mental health challenges?

Esra: Yeah, so I mean when we look at anxiety and depression, something like 10 to 15% of teenagers have anxiety and depression is similarly, I mean, and the numbers are sort of getting a little bit higher with the pandemic impact I feel, but something like 8 to 10% of adolescents sort of report depressive symptoms.

You know, there are other, you know, cannabis use, substance use is common, you know, teens especially girls struggle with body image and can have early signs of eating disorders. Something like, you know, like, 0.5% of girls, like, teenagers sort of struggle with some sort of body image problem.

So, this is sort of often what we see in teens is sort of these early signs of the emerging illness and the key is really sort of teasing out what feels kind of normal, what feels kind of like growing pains of an adolescent, and what feels concerning.

And the line is hard to really know and it’s not just parents’ job to figure it out. And I always recommend, you know, when your gut feeling as a parent sort of says something is a little off and you worry about it, like reach out.

And I feel like pediatricians are a wonderful resource when it comes to that initial contact. Because a pediatrician knows the kids, you know, from like being babies into kind of becoming a teenager, kind of talking to a pediatrician could be an excellent first step to sort of tease out this what is normal and what feels like a little off.

Jeff: Talk a little bit if you would, about some of the more common mental illnesses that impact teenagers.

Esra: Yeah, sure. So I think, you know, the most common, and I see this a lot, the anxiety disorders are very common and they’re so common and like, a lot of times when I work with an anxious teen, they feel like they’re the only one who is very worried about things.

And anxiety disorders are one of the like, the most common mental health conditions in the entire population. And the treatment, you know, really works, and helps and it is really, so, um, not so complicated in a sense if we intervene early.

Often with anxious teenagers, we sort of guide them and coach them to sort of start facing some of their fears. But I see a lot, you know, of anxiety disorders, that’s so common in adolescents.

Mood disorder’s another one, like especially depression and we really try to help teens to, when they feel down and depressed, we practice some opposite action, you know, pushing back on depression and try to sort of like, what we call behavioral activation.

Like when the depression tells the teen to not get out of the bed, or not go to school, we really try to coach and help them to get out of that if possible. Sometimes we use medications to support, but most commonly I see depression and anxiety in teenagers.

And there are other, you know, substance use is sort of very common, especially cannabis is very common, and we always worry about that, like exposure to cannabis in a developing young brain, you know.

Disordered eating and body image is another one. Self-harm is common, especially with depression. And often you see these early signs and symptoms, you know, like middle school age, or early high school age.

Jeff: Can you help us with some of the more typical signs that there might be a problem? And I realize that will vary from anxiety disorders to eating disorders, to mood disorders, and so forth, but any guidance you can provide in terms of what to look for, too much sleep, lethargy, whatever the case might be.

Esra: Yeah, yeah, I think it might be helpful to kind of break down this, like, different disorders, for example, depression can come as sadness, but depression can come also as irritability, right? You know, and every teenager is a little bit moody and irritable and that’s kind of normal.

But if a teenager is persistently sad, or irritable to the point that they don’t enjoy life anymore, I think the differentiation is also part of like functionality. We look at what the functioning is.

If their mood is so strongly different than their usual self and then they can’t function in the world the way they want to, that’s a reason to seek help and the help doesn’t have to be medication for everybody, right?

I think one of the concerns and kind of stigma of seeking help is, this sort of concern that like, you know, if I have a mental health disorder, it has to be like some sort of like, I need to be in the hospital.

Sometimes, having a counselor where the teen can talk about things and learn some good skills to cope with strong emotions or anxieties can, may, be the only thing they need.

So, I think that’s also important. Not every problem needs a very heavy intervention. Like, sometimes having one therapist, the teen meets regularly and learns some skills to cope with big emotions, maybe that’s the only thing they need.

Jeff: How about anxiety disorders? Some signs to watch for.

Esra: So, with anxiety disorders, a lot of times they may show early signs even like as a young child. And what we see is that as the demands increase in adolescence, so for young children, for example, parents do a lot of the social piece like, so like setting up play dates or you know, connecting the kids with other kids.

And I think these dynamics rapidly change in the adolescent period and teens have to kind of navigate all these complex relationships by themselves. And anxiety can show as, you know, a teenager who’s really struggling to connect with friends, avoid social interactions.

Sometimes specific phobias can come up, sometimes obsessions can come up like, you know, teens doing a lot of rituals to overcome those fears or anxieties and I think then, you know, again when the parents notice that their teen is, they’re not, you know, functioning the way they should.

When they’re not hanging out with friends, they’re not attending school the way they should, or their life is really consumed with these, you know, like intrusive anxious thoughts and they’re constantly worrying and constantly seeking reassurance from parents, that’s the time it’s really important to seek help.

And often what’s special for anxiety disorders, you know, like as a parent when you see your child struggle, all you want is to make them feel better, right?

Like you want to reassure them, you want to say that the world is not as scary as you think, but specific to anxiety disorders, we actually try to help teens, kids, teenagers to sort of, like, stay away from that reassurance.

And we teach parents, you know, do not reassure, I know you want to, that feels like the right thing to do, but part of the anxiety treatment is sort of being in the world and then actually experiencing it’s not as scary as you think. So, it’s sort of some of our natural parenting tendencies may not align with valid anxiety treatment.

Jeff: Kind of speaks to the importance of involving parents in that treatment process as well, which we’ll circle back to, as we continue to look at these different disorders though on some of the early warning signs. What about eating disorders? What can parents be watching for?

Esra: Yeah, and again, I think there’s a societal component, right? Especially girls and the influence of, you know, social media, you know, what is normal has shifted so much over time. What is new, what is normal, has shifted so much over time.

I think, and eating disorders kids hide it, so like it is hard to recognize for parents. I mean the kids who, for example, kids who restrict and lose a lot of weight, tend to wear, like, very big clothing like these saggy, like big sweatshirts to hide how thin they are.

I think you know, like pediatricians like these annual visits, regular visits with pediatrician, they’re a great resource to recognize disordered eating.

And I think for parents, if they notice their kids like there’s a big change in their eating habits, or there’s a lot of conversation about their body image, like how big they are, or how much they need to lose weight and like these concerns are active in conversations, I think it’s important to sort of seek pediatrician support to see if something is off.

And I think, you know, unfortunately that’s a so common problem and it’s also like a, it’s very hard for teens not to be impacted by all the conversation about, like what is the ideal body should look like.

And I think there are a lot of efforts to change that. I think even in, you know, in the media and social media there are more awareness, the negative impact of eating disorders and how we should watch our language, and how we should view a normal and beautiful differently.

But again, like I think for the parents, I really see pediatricians as a wonderful first line of support.

Jeff: Do you see personality disorders developing in teenagers?

Esra: So, I think today, if you look at the personality disorders, and I think maybe it’s important to think about personality in general, right? We all have our personalities, and we have our personality traits, and for teenagers, as they grow up as a teen, they figure that process out.

They sort of start to understand their personality, what kind of person they are, and what kind of things they like and don’t like. We tend not to diagnose personality disorders as much as we can in the adolescent period, because their personality is evolving and changing.

So usually that process needs to go through in order to really consolidate the personality. So there’s a sort of a consolidation process of who you are as a person that happens during the adolescent period then we’re very mindful not to overly diagnose personality disorders in teens.

But certain personality disorders for example, borderline personality disorder comes with, you know, really big emotions and interpersonal skill deficits and you know, they can have early signs in the adolescent period, and treatment like dialectical behavioral, therapy is wonderful to intervene.

So even if we don’t always diagnose personality disorders in teens, when we see these early signs, concerning an emerging personality disorder, we seek help. Like, I mean I recommend seeking help, good therapy, evidence-based therapy, and they can really change the course of the person, right?

It doesn’t, we don’t have to wait until the personality disorder fully emerges, when we see early signs, we seek the right therapy to sort of intervene as the personality develops. So, it develops in a way that is not a problem, not a mental illness.

Jeff: One of our goals is to weave in some questions from viewers today, Esra, and because you just touched on this, let me go ahead and weave this one in right now.

For teens showing emerging traits of BPD borderline personality disorder, is there an advantage to getting them formally diagnosed before the age of 18? I think you just touched on this.

Esra: That’s a very good question. I think it really depends on person to person. So, for some teenagers and families, having a name for what they’re going through is very helpful. It can really give them some sort of like, a closure, or like, make sense of things. So, it can be very helpful.

Some of the families and some of the teenagers really like the idea of calling it something, so we know there’s a treatment for it that we can seek. For other people, for some of the teenagers, having a name attached to what they’re going through can feel labeling, can feel overly diagnosing and for them, it’s not a good thing.

So, I really see this as a case-by-case thing, and it really depends on the need of the person. I mean I don’t think, there’s nothing wrong to call if a clinician sees a set of problems as borderline personality disorder in a 15 or 16-year-old, I don’t see the problem to call it what it is, but I’m always mindful what the diagnoses are for, because they’re not always helpful.

They’re not for every person. Like if someone needs a diagnosis that helps them to sort of make sense, great. If it is something that feels more of a label and not so helpful, we do not need to call it something.

Jeff: Just to round out this section as we look at some of the teen disorders that are more common, mental health disorders, substance use disorders, you’ve mentioned them as well. What should parents and other adults be watching for in teens?

Esra: Yeah, I think you know, it is especially cannabis I, you know, it’s so common and it comes up a lot in our clinical practice and we use the words cannabis has evolved over time too, like as if it’s not that dangerous. Honestly cannabis is really dangerous for a teenager.

It’s not, it’s okay for, I mean I don’t want to okay anything, but it’s very different to be exposed to cannabis as a teenager versus, you know, using cannabis as adults.

In a developing emerging brain, exposure to cannabis can impact motivation, can impact mood, actually lowers this is like, there’s a very nice study came out of about this that it can lower IQ points, especially younger exposure.

The younger we expose brains to cannabis and persistent exposure, like I’m not talking about smoking once in a while, but being repeatedly, persistently exposed to heavy doses of cannabis in a young brain has all sorts of negative impacts from cognition, memory, IQ, and motivation. And mood, like irritability, you know, low frustration tolerance and all that.

So, when we see teenagers repeatedly smoking cannabis, we really try to understand what that is for and there’s usually a reason, right? And try to support the teen in ways to sort of either cut down on, like reduce how much they smoke, or limit how much they smoke even if they’re not ready to quit yet.

Jeff: You’ve referenced a couple of times the value of reaching out for professional help. How does a parent or another adult go about doing that? What’s the starting point? Where do you turn?

Esra: Yeah, I think that it is a challenge for parents. I mean there’s so much need to find professional and good mental health treatment, and there’s so much need, and the capacity doesn’t always match with the need.

I do advise starting with the pediatrician, because that’s usually the first clinician who knows the family and the kids, and then pediatricians have certain resources they can help families connect with a therapist.

I think starting with therapists, especially for young kids is important if things feel more complicated, or not as straightforward, or the pediatrician needs more support, I think getting a consultation with a child psychiatrist is really important.

But I do see pediatricians as a first point of contact and finding a child therapist is a first point of contact and depends on, you know, the assessment and what kind of need the teen needs.

And they can make the decision whether further treatment, more intensive treatment, involving child psychiatry, or involving more intensive services is needed, or not. They can help parents figure that out.

Jeff: It can be intimidating at times for a parent or an adult to reach out to a professional in terms of not knowing whether this individual is the right person to be working with their child.

Do you have some screening questions for lack of a better way of putting that, that parents might use?

Esra: Yeah, yeah, I think that’s hard. I think one of the other, I mean I’m also thinking, you know, it is hard to kind of seek sometimes help, because the parents may worry about, maybe they did something wrong or it’s their fault.

Like there could be a lot of feelings when it comes to seeking mental health support. I really feel like for mental health care, I mean the person’s credentials, I mean training is important, but also like how they feel in the room with the person, whether it is a good match or not.

So, therapy is a matching process. Like a good therapist may not be the best match for certain, this sort of going for an initial meeting, going for a consultation, you know, spending some time and then seeing how the kid responds to it.

Like how the teenager responded, whether the teen wants to sort of continue connecting with the person or not. Sometimes you also see that teenagers are not ready to seek help, but parents want them to seek help. So, there could be another conflict with that.

I always advise parents to seek parent coaching if their child is not ready to be in therapy.

So, if the child is not interested in seeing counselors, parents can get parent coaching support and that would be a really wonderful way to start, you know, mental health treatment with the parents, learning specific tools that are unique to their child’s needs, and then that can really help the child to get into treatment as well.

Jeff: We’re going to talk more specifically about treatment processes that are available for teenagers and how that looks for a family dynamic. Right now, though I want to weave in a couple more questions about societal pressures.

You touched on this but let’s talk a little bit more about the relationship between lifestyle advertising and social media and teen mental health.

Esra: Yeah, yeah, it’s a complicated topic because, you know, in some ways for some teenagers, especially those who are so disenfranchised and they’re not feeling connected with the, like world around them.

Sometimes certain connections in social media, online connections, can feel very validating, especially for teens who have an environment that’s not validating for them. So I can see the, sometimes, benefits of having an online community.

But there’s so much more to social media and I think, it is an unfiltered wild community out there and it can be, like negatively impactful for a lot of teens. And sometimes we see teens spend too much time online, you know, like being really, having a very inner rich world online but their real life is neglected.

So, all these kinds of components are important to keep in mind. I mean again, I’m not saying, you know, social media is a source of evil or anything like that.

but I think there’s real concern about how much time in a virtual world, teens and adults and all of us are spending, and how much we are missing in the real world, real connections and I think that’s a great problem of the modern world we live in.

And when you put a developing, very vulnerable brain in that environment, like I can understand how parents will be very concerned about, protect that developing brain from the influence of things out there that it’s very hard to control, or filter, or navigate.

Jeff: We had a related question come in about teen comparisons with others in a peer group and what parents can do to help their teens navigate that inevitable tension that can develop in terms of being compared to others in their peer groups.

Esra: Yeah, yeah, I think you know again, so these interpersonal dynamics, like teens learn this by experience, like, you know, how to navigate conflict, what to do when they feel excluded. I mean bullying is not always physical bullying, like it could be emotional bullying, like relational bullying.

Sometimes kids bully other kids by just excluding them from social connections and they can be very brutal and might hurt more than the physical aggressive, like physical aggression. So, these are the things, you know, kids navigate, especially in middle school like.

Especially, as they’re not little kids anymore, they’re in this sort of big chaotic middle school, it’s so intense, the friendships are intense, and expectations are different. So, it can be really, really hard.

I do recommend, so with the parents, I think having like maintaining a line of communication with the kid, like, for the kid to be able to reach out to their parent and for the kid to, like, not feel judged, or not feel told what to do by the parents. So that really helps that line of communication open.

Sometimes it could be the parents, but if the parents are struggling to maintain that connection, and, it’s not the parents’ fault.

I just want to say that sometimes it’s really hard to maintain that line of communication with the teens, bringing a therapist, using school guidance, you know, reaching out to pediatricians, having a stable adult who gets things and the kids’ life is really important to navigate those conflicts and the kids need to learn these skills.

Like, what do you do if a friend is so unfair to you? Like, how do you sort of grow out of that? How do you navigate that conflict? These are the processes that the kids learn as they grow, as they develop.

Jeff: Let’s talk a little bit more about how parents can have those difficult conversations with their teens. You sent me an article to read, which I found very interesting about motivational interviewing. Can you talk about how that plays into this whole process?

Esra: Sure, I mean motivational interviewing is a clinical technique we use, and we work with clients who have ambivalence, and ambivalence is sort of being unsure about things, right? And that’s the core of being a teenager.

Teens are naturally ambivalent, they want parents to help them, and they don’t want parents to help. It’s hard to win in arguments with teenagers and some clinicians sort of adapt to some of these motivational interviewing techniques into parenthood.

And sort of I think, just to kind of summarize a little bit like, how it is hard to talk to teens, it’s hard to intervene in teens’ problems, it’s very easy to have a conflict with teens, and how can parents talk to them in a more productive way.

It’s a good sort of concept to think about. I think, you know, first of all for parents, sort of hold a couple pieces of information in mind. One is teenagers need to feel in control. The world is so out of control for them, and they want to be in charge, they want to practice being in charge, they want to be understood and they want to feel confident about the decisions they make.

So that is sort of starting the conversation by empowering the teen, even if their decisions are not what we would decide. And empowering, showing that understanding, showing that value is a really good place to start.

There’s you know, usually when our kids come to us with problems, or friends, or anyone, like there’s this urge to fix, right? Like someone comes to you, I have this, and this, and this is not working. And as a parent, like parents would just want to just fix the problem, right?

Like that’s what parents do, they fix problems for their kids. I think that’s an important urge to withhold, because when we problem solve, the teens, they do not want that. They don’t want us to come up with solutions, they want to come to the solutions by themselves.

I think sort of giving up that fixing, urgently fixing problems and just being in that listening mode is really important and listening is hard. I mean I think sometimes the parents come to me and say, you know, I listen but my child doesn’t think that I’m listening. There’s something called reflective listening.

We practice a lot clinically, they can be very helpful for parents. So, for example, their teen is telling them something happened, sort of kind of repeating what they heard, what the parent heard sort of, I heard you said something, is that the case, that sort of gives the child a feeling that, okay my mom, my dad, is really listening to me.

It also gives them an opportunity to sort of reflect about what they said, right? Like for the teen to like, “Oh, this is what I said, my mom is reflecting this on me. Okay, this is what I said.” So, it kind of creates the space of reflections, really helpful for a teen to think about what they actually said, what they talked about.

They also feel very understood and heard. Then they hear their parent kind of paraphrasing, repeating what they just said. The other important thing while listening to teenagers, is just sort of being curious, sometimes we miss the curiosity, because as a parent you just want to come in and fix things and you kind of assume that you know what’s going on.

Sort of like bumping those assumptions and approaching the problem with curiosity, like asking these open-ended questions like, you know, “Help me understand, tell me more.” “What did you like or dislike about this?”

Sort of creating this space for teens to say more, talk more. And then parents approaching this curiosity, like I want to learn from you, like you know what happened and I don’t. So, I want to learn from you.

There’s one other point I want to make is, you know, as a parent, like especially with if you have young kids, you like to praise them like, “Great job! You did this and you did so well.” So, the praise has to change for adolescents.

So, what we call more like affirmations. And what I mean by that is for parents to rather than just say “Yay, good job!” Like that’s for little kids, but teenagers look for things that you can admire.

Look for things that show their strength and their values, and then sort of comment on that. “I see that you did this X, Y, and Z, like, that’s amazing.” “I’m so impressed by this, and you did this so well.”

So, it is not a “Yay, good job,” it is more like “I’m recognizing how wonderful a person, how wonderful you’re doing these things and I’m admiring you for that,” and that is much more, it’s so valuable.

So, attempting for the teens and they really appreciate that. And you know, I think you know the other piece is, then there are problems, and the parents sort of really holding that urge to fix. One way of approaching this is asking the teen, how they would like to handle it, right?

Rather than just jumping into solutions, you hear a problem and a teen has like, you can ask, okay, what would you like to do about it? How are you planning to handle this? And the teenager can come up with a solution, that makes no sense, right?

Like, let’s remember this again, teenagers don’t have the part of the brain that makes good judgment. That part hasn’t fully developed yet.

So, their solutions may not be what we would choose, and then help them understand it by just asking, right? “Okay, you know, I hear that’s what you would like to do. What are the pros and cons? Like, how is that like, help me understand how that is going to play out?”

Like have them see the pros and cons, have them sort of assess like create space for the teen to really understand decisions they make, and sort of like help them to kind of see the next steps with those decisions.

And then when you put all these efforts in the time to listen, reflect, be curious, ask all sorts of good questions, open questions, and then if you want to make a suggestion, ask for permission. That’s what we do in motivational interviewing technique.

Like would it be okay if I share what I think? Can I suggest something? And then if you get permission, by all means, give your opinion. If you don’t have permission to share, hold your opinion.

Because if you give your opinion without being asked, they’re not going to listen to it, no matter how good your opinion is. So, I think it’s really important to sort of create that space and then give your solutions if you’re asked to.

And then the other, I think one final point about this is sort of, we’re not expecting parents, or even like clinicians to do this perfectly. Like they’ll be making like errors, like parents are humans and they’ll be upset. And I think one important thing is to have a sense of, kind of, like, holding that responsibility a little bit and not be shy from apologizing if things go wrong.

Like if the teen feels misunderstood, apologize, just say I’m very sorry, that’s how, like I didn’t mean to do this, but I understand that’s, you know, how that impacted you. I’m very sorry about that.

So having this sort of like shifting power dynamics a little bit, equalizing that, and doing it without, you know, I’m not saying parents should allow also like, you know, parents hold the responsibility for the child, and they need to keep their teenagers safe.

But when it comes to creating space for less heated conversation, and more process-oriented conversation, these could be really helpful techniques for parents to try.

Jeff: Makes sense all the way around. And many of those are very small things but I can see how they can make a big difference.

Esra, let’s pivot and talk a little bit about formal treatment right now, because there are many different ways that can go and obviously treatment for an anxiety disorder is different than that for a personality disorder and so forth.

But generally speaking, what are some of the considerations, inpatient versus outpatient, when to involve the family and when not to involve the family, taking kids out of school. Talk to us about some of those considerations that parents have to weigh.

Esra: Yeah, yeah absolutely. I think so involving families, we would love to involve families. I think, you know, child psychiatry, family psychiatry, because, you know, what parents, like parents can have a parenting style, that can work very well for one child, and if they have a child with different needs, their parenting style may not be the best fit.

And that’s nothing wrong with the parenting, right? Like they just need certain tips, and tools, and skills, to navigate parenting for the particular child. So, I think involving parents and helping parents to navigate that challenge is really important.

That’s why I always recommend parent coaching, you know, parent coaching doesn’t mean that you’re not, you don’t know how to parent, you know how to parent, but you may need certain tips and tricks and tools, that would meet the needs of this, your particular child who needs certain needs and vulnerabilities.

From, you know, like inpatient, I think for typically a lot of kids start treatment as an outpatient. Inpatient is much like that’s the highest intensive care we provide and that’s usually saved for teens, kids, who are not safe. Like if we worry about safety, suicidality, then we do recommend doing treatment in a safe environment, which is inpatient.

Sometimes kids who are so non-functional and struggling to meet their basic needs, like eating or taking care of their body, sometimes those kids need to be in the hospital care more, may need those intensive services.

That’s usually the, like, safety and meeting basic needs. If we have concerns about those then we usually recommend hospital-based care, what we call inpatient level of care.

The outpatient services can range from, you know, once a week therapy to, three times a week therapy, to five days programs, day treatment programs. So, it kind of varies based on the need of the child and the family.

And it’s usually decided by, like, a discussion between the child, and the parent, and the clinical team, right? Because the clinical team can have an idea, but if the kid is not ready for that intensive level of care, it may not be the best to push a child to more treatment.

Like there’s also like preparing to be ready. Respecting what the kid is willing to do, sometimes they can’t if you’re worried about safety.

But for the most part, you know, motivating the kid to seek treatment and not like have them feel forced is an important concept. So, I think the intensity of outpatient is sort of a discussion between the clinical, the child, and the parents.

Jeff: What about the broader team of support? You’ve got educators on the school campuses, you’ve got clinicians, you’ve got pediatricians for example, involved the mix as well. Can you talk a little bit about how you can approach this from a team approach?

Esra: Yeah, yeah. I think this is sort of a, like it’s a large team, right? This sort of connected network and a lot of times, you know, families seek, like, may not end up ever seeing a child psychiatrist.

A lot of things can be handled or can be treated, without needing every inpatient level of care. So often pediatricians are the first point of contact and pediatricians have their own resources, right? Sometimes they have a therapist in their clinical practice, sometimes they have access to consultation with psychiatrists.

So, they have, like, for many, they have some, not all of them, but many have some sort of resources that they navigate when the kids and families come for help, the schools are another source of support. Like a lot of schools, they have a guidance counselor, then you know, depends on the school.

These supports can vary. It’s not the same in every school system, but school guidance counselors are another wonderful first step to reach out. And sometimes they have the bandwidth to support and if not, they help kids to connect with other therapists.

And I think, you know, parents are key in the support system, right? It’s sort of like the way we think about broader treatment, is sort of a network of good adults in the kids’ life that supports the kids. Could be the school, could be the teachers, right? Like teachers can be a wonderful, wonderful resource.

Could be the pediatrician, could be a therapist, could be a psychiatrist. So, it’s sort of a network of adults who are there to support the teen and depends on the intensity of the struggle, that changes the number of adults, or what context they operate in.

Jeff: Let me walk in a few more audience questions. One is this, is the increase in gun violence impacting more teenagers?

Esra: So yeah, I mean, you know, what we know, I mean this is sort of broader than the adolescent mental health, but access to guns, access of these to hurt yourself increases the chances of hurting yourself.

So, when we do suicide screening, that’s one of the questions we ask, is there any guns in the house? And is the gun locked? So, the reducing access to lethal ways could be guns, could be, you know, pills, could be sharps like, you know, and certain means like guns are much more mortal than others, right?

But yes, I mean the short answer is, you know, it is bad, and it impacts everyone and, you know, it’s not good for teens to have any access to weapons like that. And it’s usually impulsive decisions, like suicide is a very complex phenomenon.

But a lot of times it is special for teenagers because they’re impulsive by nature. Like teens, again, I’m sort of kind of repeating this a little bit too much, but the teen brain is an impulsive brain.

They make decisions in a snap second, and they regret them later on. So, keeping them safe from these impulsive decisions and removing all sorts of lethal ways is one way of it, is really important to keep them safe.

Jeff: Let’s, as we look at the clock and see our time winding down a little bit, let’s talk about some important resources for parents. Are there books that you would recommend, organizations we could point people to, crisis hotlines? What should we know?

Esra: Yeah, I mean there are many hotlines. There are hotlines, I mean there’s a new hotline 988, like, you know, the greater resource, it’s kind of relatively new, but there are hotlines that teens themselves can call and the families can call.

There are also organizations, you know, National Alliance on Mental Illness is another one. Often, they run family groups. I think it’s sort of the way I kind of see the sort of support system, right?

There’s a local support, pediatrician, school, a step like a local therapist, psychiatrist, and then there’s sort of more organizational level, there’s crisis management and there is, sort of supporting like kids and families in a like, you know, kind of feeling that you’re not the only one, right?

Like anxiety, depression, self-harm, suicidality, these are so common. And being around other people who kind of go through similar things and who navigated what you’re trying to navigate now, can be a very powerful tool to not feel isolated.

I think some of the organizations, like the National Alliance on Mental Illness serves this function really well to kind of connect families together, so they don’t feel that they’re the only ones going through it, and when it comes to specific resources, I mean I think there are organizations for every sort of subgroup of treatment providers.

So, for example, I work with a lot of kids, kids with OCD and anxiety and there’s a wonderful website from International OCD Foundation and many resources in there, including finding a therapist.

So, I think looking for resources specific to what the teen is going through is one thing, but also kind of larger communities to support kids and teens are also very important.

Jeff: A viewer wants to ask you about resources for parents and families, which I think is very important as well. That self-care element for a parent who’s trying to navigate these challenges with their teen, that can take a lot out of a person. So, what would you suggest on that front?

Esra: Yeah, I think it’s just sort of like this, again, I’m always thinking about stigma, because sometimes parents feel bad about seeking help and as if they didn’t do a good job as a parent, which is really not the case.

And it’s very important to sort of put that feeling aside and be open to seeking guidance and help. With challenging parenting experiences, it is a really good thing to seek parent coaching. Like, you’re actually doing the right thing by seeking parent coaching.

I think for parents who struggle themselves with mental illness, like anxiety, depression, or just like being a parent of a teen can be very challenging. Seeking their own support and therapy is important, because kids, I mean teens, or young kids, they’re like really pick up whatever they see in the environment, right?

If the kids struggle, and see their parents struggling, they model that. Like we all model growing up. We model what we see in our environment and the most influential environment is the home environment.

So, I think for parents to be prioritizing their own mental health and seeking help if they’re struggling, it’s very helpful for their children, or especially for their teenagers.

Jeff: You mentioned stigma and that reminded me that I want to circle back to that topic and ask you about campaigns that are trying to increase awareness around teens and mental health challenges, and athletes speaking out and other influencers, if you will, speaking out about their mental health challenges. Is that making a difference?

Esra: Yeah, I think those are the kind of like, I see the good impact of social media. Like, you know, when we see these like TikToks or Instagram posts of influential figures, really talking about their own struggle and how they come and manage their own anxiety, depression, eating disorder, or self-harm, like, or borderline personality disorder.

That can be a really normalizing experience for a lot of kids and families who feel so isolated, because it’s not spoken out loud as much. There’s whole stigma and mental illness as if, like you can talk about and get a lot of support if you have a medical illness, but when psychiatric it feels much more isolating.

So, I think it’s really good to see all these, you know, influential figures being out there and talking about their own experience and normalizing it. That has such a positive message. And I really, really value it a lot.

And I think, you know, that’s sort of a first step and it is a step towards normalizing mental illness, normalizing seeking help for psychiatric illness.

And I think that is sort of, I think the new generation and the kids are in a different wavelength in a good way when it comes to normalizing mental illness and seeking help.

Jeff: Let me squeeze in just a couple more questions before we let you go. Systemically, what’s missing from the equation, or what needs more attention?

Esra: Ah, that’s a big question. I don’t know if, I probably need another, you know, hour for this. There are so many pieces, but I think, you know, one of the pieces is really having a better system to reduce the time in between wanting help, or getting help, like that usually takes a while from asking for help and getting help.

And I think some of the new initiatives like Massachusetts, you know, as a state tries really hard to reduce the time for like, and there’s emergency crisis services, but I think that’s one of the important pieces, like expanding mental health workforce, so we can all meet the needs of the community and the teenagers, and also like access to good evidence-based treatment.

Like, you know, counseling might be enough for one patient, but you know, for a kid with OCD for example, we need an exposure and response prevention therapist.

So certain problems need the evidence-based, specific evidence-based treatments and expanding on those are really important.

And on a community level, I mean, you know, access to, for example, inpatient beds is a huge, huge problem nationwide.

Like when a kid is in crisis, and they need to be in a hospital to be safe, they can wait for days in emergency rooms waiting for a bed. So, all these things are kind of systemic issues that need systemic solutions and it’s not a matter of a child or a clinician, it’s sort of a broader problem.

And I think, you know, in Massachusetts, in our state, there are a lot of conversations and efforts towards addressing these. But again, you know, these are big systemic problems, that need really big solutions.

And the core is reducing the time between seeking help, needing help, and accessing, getting the help. So, we want to really narrow that gap. Because the longer we don’t treat a problem, bigger and harder it becomes, and it’s harder to treat it.

Jeff: And as we’re finally, I like to wind up our webinar series segments with a hopeful note. And I’d like to ask you to speak to a parent, or an adult right now who’s helping a teen navigate their challenges and feeling a little overwhelmed by the whole process.

You’ve seen so many lives turned around through the work that you and others are doing. Speak to that if you would.

Esra: Yeah, yeah. Thank you, Jeff. This is a really nice way of kind of wrapping up. I think I want to really point out how resilient kids are. Kids are amazingly resilient and, you know, they bounce back much better than adults.

Like, the kids can struggle immensely to the point that they stay in the hospital for long period of time, sometimes months, and then they can bounce back from it.

I think it’s kind of important, like it’s a wonderful thing. Seeking support, and getting services, as intensive as it sounds, could be staying in the hospital. Those are the hardest, most crisis moments that kids and their parents feel.

But really holding the hope that kids are wonderfully resilient and by the right treatment, good treatment, early treatment, they can bounce back, and they can be wonderful functioning adults who know how to manage this, right?

I think that’s why we really emphasize on adolescent mental health. Let’s give the tools to kids early on, so they can sort of learn how to navigate all these challenges. And then when they become, like adults, they can enter the world with a really much better understanding of how to navigate all these complexities and mental health disorders.

But also, kind of like coming out of adversity with these resilient skills. I really believe in the resilience of the kids. And it’s not just my belief, it’s also research proving that over and over again, kids bounce back from adversity really wonderfully and holding that hope, not being shy from seeking treatment, and not defining a kid’s life by a moment of crisis.

So that’s also another important point like, when a kid is in a hospital, really struggling, cannot function. That’s not how their life is defined. It’s just a hard moment in their life and they will bounce back from it with the good support, right support they get.

Jeff: I love your passion for your work, Esra. Thank you for sharing that passion and all your expertise with us. This hour has just flown by. We’re going to have to have you back on for more. But thank you so much for joining us today.

Esra: Thank you so much for having me.

Jeff: And for all of you who have joined us on the webinar today, thank you so much for your time. We very much appreciate it. On behalf of McLean Hospital, I’d like to wish you a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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