Teen Emotional Problems Go Unnoticed

Clinical Depression, Anxiety Disorders, PTSD Found in Many Adolescents

By Jeanie Lerche Davis

Aug. 4, 2003 -- Nearly one-fifth of the nation's teens are suffering from emotional disorders.
Some have faced violence and abuse in their lives and have enormous difficulty dealing with it. The result: clinical depression,
even posttraumatic stress disorder(PTSD). For others, the trouble is internal -- they battle an inherited anxietydisorder, triggered
by troubling life experiences.
Unfortunately, few adolescents are getting the psychological help they need.
Two studies, appearing this week in two of the country's top psychology journals, address these issues.
The studies should be a wake-up call for parents, school counselors, teachers, and psychologists, says Alan Delamater, PhD,
director of clinical psychology in pediatrics at the University of Miami School of Medicine.
"Don't ever underestimate the emotional difficulties kids may be having," he tells WebMD. "Many people minimize these things,
think they're a phase, think the kids are weak. These problems are real."
Kids React to Violence
Dean Kilpatrick, PhD, director of the National Crime Victims Research and Treatment Center at the Medical University of South
Carolina in Charleston, has studied the issue extensively.
"Shocking numbers" of adult women have been victimized, his studies show. "We found that most traumatic events occurred
when they were children and adolescents -- not when they were adults," he tells WebMD.
In their current study, Kilpatrick and colleagues conducted telephone surveys of 4,023 boys and girls, ages 12 through 17, asking
them carefully worded questions about the major traumatic experiences in their lives to uncover incidents of sexual assault and
physical assault, as well as witnessing violence in person (not in the movies or on TV).
Researchers also asked questions intended to gauge the symptoms of PTSD, clinical depression, and substance abuse or
dependency in the teens.
The findings: "A high percentage of teens -- nearly one-half -- had experienced some traumatic event in their adolescent years,"
he reports. Some 40% had witnessed violence in person.
Other statistics:
Those who witnessed violence were three times more likely to be involved in substance abuse.
Those who had a physical assault were twice as likely to have clinical depression.
Sexual assault victims were 80% more likely to suffer from PTSD than other teens.
In fact, teens very often suffered from more than one emotional disorder, as other studies have discovered. "It seems to be more
the norm than the exception," says Kilpatrick.
"Violence is a problem, and violence-related mental health disorders are also a problem," he tells WebMD. Also, the disorders do
not go away with time, he reports. "This indicates they were not getting effective treatment."
Kilpatrick's study appears in the Journal of Consulting and Clinical Psychology.
Enemy Within: Social Anxiety Disorder
For many kids, social anxiety disorder (SAD) -- it used to be known as shyness -- creates emotional turmoil that can lead to all
sorts of adjustment problems in adulthood.
Social and Emotional Challenges in Adolescence
Most teenagers have concerns about being accepted by their peers, but many teens with ADHD have come to expect some
social rejection due to their difficulties with controlling their behavior and understanding others social signals. Social issues
encountered in childhood can become worse in adolescence, with the intensity of any rejection or bullying increasing during the
teenage years. This rejection can negatively affect both academic performance and emotional healthand can be, in fact, much
more troubling to him than making poor grades in school. He also may appear emotionally immature compared with classmates,
and sometimes hell be more comfortable interacting with younger peers or when spending time with adults who may show
greater acceptance of his immature actions.
As with academic challenges, however, difficulties with social interaction can often be helped by having adolescents learn
specific skills. You learned a number of ways to teach younger children how to interact positively with others, including role
modeling, role-playing, analyzing interaction, and practicing new techniques. Now, in adolescence, your child is likely to
experience new motivation to improve his social life, and advice about social issues is now more often sought from peers than
from parents.
Friendships
Teenagers with ADHD can certainly have the close friendships that are important for their happiness and self-esteem. A
teenagers targeted efforts to increase the accuracy of his social perceptions and monitor his social interactions may make this
easier for him. As he develops friendships, support this by allowing his friends to hang out in your home and help to provide the
kind of supportive environment that facilitates all friendships. Observe how the friends relate to one another, and provide tactful
feedback later if you feel that it will be received in a positive and constructive manner. Teenagers with ADHD need to be
increasingly aware that friendships take organizational skills tooreturning phone calls, arriving at meeting places on time, and
following through on plans.
Conflict Resolution
It is important for your teenager to learn how to resolve conflict without resorting to physical fights, and how to avoid becoming
the target of others aggression. Again, resolving conflict can be a difficult teenage task if his impulsiveness causes him to strike
out when he gets upset. An important step in avoiding this problem is to identify his own anger cues and to brainstorm in
advance about the kinds of positive solutions he can apply to future conflicts.
If this is an issue with your teenager, through discussions with you and peers; post-conflict analysis; and sessions with a
counselor, therapist, or social-skills instructor, he can learn to talk himself down when he finds himself in a frustrating clash of
wills (Im going to take three deep breaths and think about my best choice in this situation before lashing out.). He can also
practice conflict-prevention techniques, such as providing an alternative (How about if we go bowling first and then see a
movie?), adding provisions (OK, you can drive, but then I get to decide on the restaurant.), or changing the subject (Im
starving. You want to get some pizza?).
Once your child has learned a few of these specific techniques, he may be surprised at how effective they are in helping him
avoid the crises that used to disrupt his social life. If you are seeking counseling in this area, the most proven approach is
through cognitive-behavioral therapythis is a type of talk therapy that views behavioral issues as related to the interaction of
thoughts, behaviors, and emotions. In cognitive-behavioral therapy, the therapist and adolescent will work on identifying and
directly changing behaviors that are problematic.
Working on Social Skills
As with other learning processes, your teenager can hone his social skills and interaction by
Developing a list of specific target behaviors to work on
Outlining a step-by-step plan to address each one
Receiving consistent, tactful feedback from you, his peers, and his teachers
Learning such techniques as identifying cues that set off his anger, analysis of others social interaction, social role-playing,
etc
Getting training in anger management or social skills, or treatment in individual or group therapy, when appropriate
Receiving treatment for any coexisting conditions that may affect his social interaction
Getting positive feedback for improvement in targeted social skills
Staying involved in rewarding prosocial activities
That said, it is also true that many people with ADHD continue to have trouble with certain social interactions throughout
adolescence and into adulthood. Whether or not this is the case with your teenager, make it clear that you support him no matter
what. Nothing will be more difficult for him than overcoming social rejection. It will mean a lot to your teenager to know that you
will always be in his corner. Keep in mind that even teenagers who are socially unhappy in high school go on to find rewarding
friendships in college or work situations.
Your Teenagers Emotional Development
It is easy to see how academic, social, and family strains can create a heavy emotional burden for adolescents with ADHD. Low
self-esteem caused by academic failure and social rejection can lead to depression, defensiveness, pessimism about the future,
hostility, and physical aggression. Combined with ADHD-related impulsiveness, it can pave the way for unsafe sexual activity;
alcohol, tobacco, or drug abuse; and other high-risk behavior.
Take a moment to consider your teenagers emotional state. Does he spend nearly all of his time alone in his room? Does he
seem sad nearly all the time, or irritable? Is his anger starting to get out of hand? Has he been suspended from school more than
once this year, or are you receiving reports of inappropriate behavior? If so, discuss these issues with your adolescent and bring
them up at follow-up sessions with his pediatrician. Anxiety and depressive disorders should be thought of any time an
adolescents social, academic, or behavioral functioning starts to deteriorate without an obvious explanation.
In teenage years depression and anxiety increase significantly in individuals with ADHD. Whereas in childhood the number of
boys and girls who experience depression are about equal, in adolescence the number of girls outnumber boys by 2 to 1. The
sooner an adolescents depression, anxiety, anger, substance use, etc, is recognized, the greater the chances that the situation
can be resolved before worse problems develop.
Risk Taking
Adolescence is a time when all teenagers are prone to testing limits and engaging in risk taking. Adolescents with ADHD and an
impulsive style are especially prone to taking risks. Surveys have shown that teenagers with ADHD can have an earlier age of
first intercourse, more partners, less use of birth control, and more sexually transmitted infections and teenage pregnancy than
their peers. Education about these issues in the preteen years and continuing guidance now can really pay off.
Driving can be a particular area of concern as well. Teenage drivers with ADHD have been reported to be 8 times more likely to
lose their license, 4 times more likely to be involved in a collision, 3 times more likely to sustain a serious injury, and 2 to 4 times
more likely to receive a moving violation. As a parent, you may want to consider this area carefully, make sure that your
adolescent is at a maturity level appropriate for driving, and set appropriate limits if necessary. Some parents restrict the time of
day when their adolescent with ADHD can drive and make driving contingent on responsible driving behavior.
It is a known fact that teenage driving accidents go up progressively with the number of people in the car. Parents may put limits
on how many teenagers can travel in the car when your teenager is behind the wheel, particularly in the first year or two of
driving. Discuss safe driving at home. Where medication is found helpful in cutting down on impulsivity, it makes sense to have a
rule that teenagers who respond well to medication make sure that their medication schedule includes driving times.
Finally, as with any teenager it makes ultimate sense to have a parent taxi understanding. Even if use of alcohol or drugs is
never condoned by parents, develop an understanding that it is always safe for your teenager to call you and ask you to pick
them up if they are even minimally impaired from these substances.

Facts:
T.V. influences behavior. If it didn't, Nike, Budweiser, Pepsi, etc. would not invest billions of dollars in
advertisements.
Violence on T.V. occurs in most programs and even more so, in cartoons.
By age 12, the average child has witnessed tens of thousands of acts of violence on T.V. and games. The
gaming acts of violence are even more damaging, because the player is actively seeking to kill or wound
fellow players. Multiplayer online games have real people taking the part of avatars, which means that fights
are going on in real psychological space.
Thousands of studies have shown that violence on T.V. can influences behavior and attitudes among
children who watch it.
While not all researchers agree, the Surgeon General reports that T.V. violence is linked to aggressive
behavior in children who view violent shows. Similarly, American Medical Association, American
Psychological Association, UNESCO, and US Attorney General, have all reached the conclusion is that T.V.
violence is linked to the proliferation of violence in our culture.
In some violent video games, players act as killers as the sole purpose of the game. This can include a
disturbingly realistic "target" over other figures in the game.
The proliferation of violence and pornography on the Internet has become a significant factor in
desensitizing children to violence and sexual crimes against women, children and vulnerable minorities.
Cyberbullying is violence against victims over the Internet and cell phone technologies. This is an
unfortunate natural offshoot of participatory digital culture, and must be addressed with the same
seriousness of violence in T.V. shows and games.

In summary:
Violence in the media, whether it is reflected in music, games, cartoons, T.V. shows or movies, desensitizes children
to the effects of violence, legitimizes and glorifies violence and can increase aggressive behavior or, at the least,
increases tolerance and acceptance of violent and abusive behavior. After seeing violence on T.V., cartoons, and
playing violent games, violence offline seems "normal."

What You Can Do:
A child's bedroom should be free of T.V. and video game consoles, so you have control over the amount of
time they spend on games and passive activity.
Monitor the amount of exposure children have to violent movies, T.V. and video games.
Don't expose children under the age of 10 to ANY violent content in entertainment (this includes games).
Watch age-appropriate shows together, as a family.
Don't turn on the T.V. before school and turn it off well before bedtime.
Check www.movierports.org for information on violence and sexual content in movies.
Do not provide free and unmonitored access to the Internet for your child. Children need supervision and
training to use the Internet safely. As they grow up, you can supervise them less.
Keep the conversation active in your family about Internet safety, including cyberbullying, sexting, gaming
and violence online.
Discuss how the content of media your family encounters does or does not reflect the values of your family.
Teach your children age-appropriate critical thinking skills.