At-Risk Children

We've all seen media stereotypes of the misunderstood teenager stereotype we either laugh at or glorify from the safe distance of our living room couch. But when the rebel is in our living room, the story may not feel so funny or have a happy ending, even though teenage rebellion is a normal developmental stage often expressed relatively harmlessly.

How can a parent tell if a teenager's rebellious or destructive behavior is indicative of a more serious problem?

A common root of rebellion that often goes undetected in teenagers - and in adults - is depression. Depression is believed to occur in approximately one in seven children. More than 70 percent of these children or teens do not receive the necessary diagnosis and treatment. It is important to identify and treat youths who are depressed since depression affects growth and development, academic performance, and relationships. Signs of depression in children and adolescents include impaired attention, loss of interest in activities, excessive or inadequate sleep, poor self-esteem, irritability or hostility, poor concentration, and recklessness.

Does this sound like someone you know and love?

Of course, just because a teenager is demonstrating these behaviors, doesn't always have to mean he's depressed. But the scary fact is, the risks of missing a diagnosis of depression can be fatal. A recent report exploring youth risk behaviors from the Centers for Disease Control revealed these statistics: 28.5 percent of all teenagers nationwide felt so sad or hopeless almost daily for more than two weeks they stopped their daily routine; 16.9 percent seriously considered suicide; 13 percent made a suicide plan; and 8.4 percent had actually attempted suicide within the 12 months preceding the survey.

Our children are also engaging in other types of high-risk behaviors, like driving when they have been drinking (9.9 percent), riding in a car when the driver had been drinking (28.5 percent), or just driving recklessly. It's no coincidence that 71 percent of all deaths among 10- to 24-year-olds are the result of motor vehicle accidents, unintentional injuries, homicide, and suicide.

How do some teens handle depression or anxiety that goes undiagnosed? Like some adults, they might self-medicate. They often turn to drugs or alcohol to "numb their pain." The CDC report provides disturbing statistics on drug and alcohol use among our young people: 43.3 percent of all high school students had had at least one drink in the last 30 days (prior to the survey), and 25 percent had engaged in episodic heavy drinking. Furthermore, from 2 to 8.5 percent of high school students had admitted experimenting with drugs and had tried one of the following drugs at least once: cocaine, injected drugs, inhalants, hallucinogens, heroin, methamphetamine, and ecstasy.

Not all of these young people are depressed, obviously, but the tendency to self-medicate while depressed is very dangerous - especially for young people who may be tempted to experiment with drugs that can produce devastating and life-altering consequences. Because of their developing brains, fluctuating hormones, and limited access to financial, emotional and medical resources, children are even less equipped than adults to cope with depression. A teen's method of coping with depression, in addition to reckless behavior and self-medication with drugs and alcohol, may be to withdraw, become angry and resentful, or to become destructive to self or others. As mentioned earlier, reckless driving is common and can even be a form of suicidal behavior. Eating disorders may also be seen in depressed teens: The CDC reports that 6.3 percent of youths take diet pills and 4.3 percent vomit or take laxatives. Teens may also turn to self-mutilation like cutting or burning as a way to control the pain in their lives.

Some teens, like adults, cope with depression by working. Instead of withdrawing into their bedrooms, video games or televisions, they may become overachievers in school or athletics. Just like alcoholism, workaholism is a method of avoiding despair and sadness.

Unfortunately, adolescents are likely to be even less informed than adults about depression. Teens are even more vulnerable to falling between the cracks when it comes to diagnosis and treatment. It is the parents' primary responsibility to try to identify the warning signs, find help, and facilitate recovery. Depression is believed to have both genetic and environmental causes, and the few studies available suggest that effective treatment must address both sides of this equation.

Once a diagnosis of major depression is made, it is important to determine the severity of the depression and to look for co-existing problems like substance abuse, anxiety, or attention deficit disorder. These conditions often require referral of the patient and family to health professionals with experience treating adolescents and children. The good news is, a sizeable percentage of patients with mild depression respond to supportive therapy and don't require referral beyond a motivated primary care physician.

The key is a commitment by the physician, family, and patient to a very high level of involvement and communication during this supportive care phase. If for any reason this cannot be provided by the physician and the family, a referral to a mental health provider would be indicated. In this case or in more acute depression, a combination of medication and psychological counseling provides the best outcome for patients. Patients feel better faster, the improvement is longer lasting, and they have lower rates of recurrent depression than those treated with medication alone. Some data indicates that patients who are also in therapy tolerate their medications with fewer side effects. Getting the correct diagnosis, getting the right combination of medication and counseling started, and achieving remission of symptoms are critical.

As parents, our role is to help our adolescents maintain good communication with their health care providers, to look for opportunities to reduce the stresses they face, to help watch for signs of recurrent depression during and following treatment, and to be their best advocates at home and in the health care system.

Susanna Wu-Pong, Ph.D., and David Wu-Pong, M.D.
All About Kids Magazine, June 2008