Speaking to the issue of violence among youth, Donna E. Shalala, Secretary of Health and Human Services said:
"Today, violence is the second leading cause of death for Americans between the ages of 15 and 24 -- and the leading cause for African Americans in this same age group ... According to recent statistics, the death rate from homicide for teens 15 through 19 doubled between 1970 and 1994 to 20 per 100,000. It has also doubled for children 10 through 14. For African American males, the homicide rate was 136 per 100,000 - nine times that of white males the same age.... Suicide is also a leading cause of death for young people. In 1995, about 24 percent of children in grades 9 through 12 -- almost one in four -- reported that they seriously considered taking their own lives in the previous year. And almost 10 percent reported actually attempting suicide."
(Julius Richmond Lecture, Harvard University, Boston, Massachusetts, November 21, 1997, italics added)
Depression, according to the National Institutes of Health, occurs with greater frequency among teenagers today than in the past. Because many adolescents' behaviors are attributed to "normal adjustments", they are often not identified as troubled and do not get the help they need. Many teens who believe their problems to be unsolvable, become so despairing that they attempt suicide... and many succeed.
Although other causes of teen suicide and violence exist, depression is a major factor. Adolescents often "act out", obscuring depression with aggression, elopement, or antisocial acts. Manic-depressive disorder also begins in post puberty and may be manifested by impulsive episodes, irritability and loss of control alternating with periods of withdrawal and excessive sleeping. If these behavioral signs are considered by parents and professionals as natural to adolescence, the disorders go unrecognized and untreated.
Late 18th-century, German romantic literature was influenced by the conception of Sturm und Drang (i.e., storm and stress), the theme involving a struggle of a highly emotional individual against conventional society. Possibly a metaphor for youth, adolescent antagonism was represented during the 19th Century largely as rebellion and arguing against parental expectations. By the 1950's, fistfights between peers escalated to chains, pipes, and knives, with zip guns appearing infrequently. After four decades, we have witnessed a significantly increased frequency of firearm-related homicides and suicides by youth.
Recently, the nation was stunned by methodically planned murders in a middle class Denver suburb in April, 1999, taking the lives of 15 (including the young killers) and wounding 28. Barely a month later, a 15-year-old wounded 6 classmates before surrendering. In 1998, a 14 year old opened fire in a school hallway, wounding a teacher and volunteer, a 15-year-old killed 2 students in the school cafeteria, wounding 18 more, this after his parents were found dead in their home. An 18-year-old honor student fatally shot a classmate who was dating his ex-girlfriend. Six more fatalities occurred in 1997 in 2 separate shootings involving a 14 and 18 year old. (Knapp, 1999; The Washington Post, 1999).
Whether homicide or suicide, violence among adolescents has forcibly brought these problems to the forefront of our attention, while other, less sensational yet far more frequent adolescent dramas occur among our youth on a daily basis. These appear intimately interrelated to a broader problem in our lack of identification, understanding, and treatment of adolescent disorders in the home, the school and the clinic.
Recently, I have dealt with "Ronny", a close relative who is 15 years old, a gifted student, athlete and musician. Over two-years, he showed increased moodiness, agitated depression, withdrawal and frustration over peer relationships. These traits, along with the appearance of secondary sex characteristics, were assumed typical and expected in a "normal kid".
Starting Fall, 1998, he accepted weekly psychotherapy with a School/Clinical Psychologist. Nevertheless, his mood deteriorated and, never having administered testing, the therapist requested a psychiatric consult. Medication was prescribed, although -- to date -- neither psychologist nor psychiatrist offered a diagnosis.
A January peer encounter exacerbated the fulminating depression (unaffected by the medication), worsening his sleep, making Ronny unable to attend school regularly for fear of uncontrollably falling asleep in class. After being awakened for school one morning, he dissociated, revealing a level of psychopathology never before suspected by either the psychologist or psychiatrist. It exposed internalized rage, quasi-hallucinatory experiences and paranoid ideations.
By January's end, Ronny-when he spoke at all--complained that nothing helped his moods, showed agitated despair and hopelessness, admitted to suicidal ideations, began self-mutilative behaviors (picking at his forearms) and had evening rage reactions. After resisting attempts to voluntarily admit him as an inpatient, an involuntarily commitment for emergency services and treatment became necessary (Section 7302 of the Mental Health Procedures Act of 1976; see Knapp, VandeCreek, & Tepper, 1998). Due to his geographical location, however, rather than being transported to a hospital adolescent unit, Ronny was taken to a generic, County emergency services facility. The staff was caring and skilled, but the surroundings were reminiscent of the "snake pit" atmosphere found years earlier in State mental hospitals.
Committed by law for up to 5 days, this acutely depressed, non-drug-addicted teen was placed in a population of primarily adult, some acutely psychotic, some self-mutilative, some drug-addicted and dual-diagnosed adults, many of whom had been committed numerous times before.
After a "303 hearing" (Section 7303 for review of extended involuntary emergency treatment), he was transferred to a hospital young persons unit. With Ronny's agreement, in preparation for his eventual discharge, another outpatient psychotherapist and psychiatrist were found, each having excellent records of accomplishment with adolescents. During this search, however, I became acutely aware of the scarcity of appropriate inpatient and outpatient adolescent practitioners and resources.
Following release from inpatient and partial care, Ronny's recovery was slow. By chance, I spoke with a psychiatric colleague who suggested a medication change. Ronny's psychiatrist agreed and, within a month, he responded to the new antidepressant and was weaned from the antipsychotic that had been prescribed earlier (Note: a Rorschach I requested while at the hospital indicated depression and no psychosis). His mood brightened at times and his sense of humor reappeared.
About the same time, he spent three weeks in another partial hospital program. In combination with the new medication, this provided a positive start towards recovery. However, despite the gains, just as his social needs were being addressed and positive changes started to take hold, partial treatment was abruptly terminated by the insurer as he was "no longer acute". He is now continuing with his outpatient therapist and psychiatrist, supported by a proactive school counselor and teaching staff, receiving homebound instruction. The episodic rages are gone as are the feelings of hopelessness. However, although wraparound services are available, his functioning is too high for partial hospitalization and other forms of supervised, therapeutic adolescent social activities -- including group psychotherapy -- are rare or unavailable.
Curiosity prompted a search of APA's Psychinfo Online for the period from 1980-1999 for 5 keywords: hormone, adolescent, adult, male and female. The results demonstrate a 2:1 relationship between adult and adolescent studies (not accounting for animal studies).
Murray Rosenthal, M.D., Director of Behavioral & Medical Research in California, reports "While the advances in the opportunities for treatment have clearly expanded, making accurate diagnosis remains for the most part an enigma, The reason for this enigma is manifold, not the least of which is the time required to make a proper diagnosis... Often the individuals to perform these tests and the tests themselves are unavailable in routine clinical practice... As such, many children end up with what have become popular diagnoses such as ADHD. In research facilities, children who have previously been diagnosed with ADHD and go through a full diagnostic panel are often reclassified into such illnesses as generalized anxiety disorder, agitated depression, and incipient bipolar illness." (personal communication, June 17, 1999, italics added).
The primary focus is less on the adolescent than on the challenges that dealing with the adolescent presents to parents and adults in general in this society, according to Michael Silver, M.D. Director of the Adolescent Unit at Friends Hospital. "The first challenge is that dealing with an adolescent offspring offers us the opportunity (if we're willing to seize and confront it) to assess where we are with our lives, and to review our own satisfactions, accomplishments, disappointments, and losses as manifested and reflected in the hopes and fears we have for our child. The second is that adolescents behaviors continually give us opportunities to deal with our own issues regarding interpersonal power and control. It's a wonderful (and terrifying) arena in which to struggle with the limits of our ability to influence our children, and by extension, to influence our own lives and the world at large." (personal communication, June 15, 1999).
In a excellent review of adolescence literature, Arnett (1999) identifies three major areas of difficulty in adolescence: (1) conflict with parents, (2) mood disruptions, and (3) risk behavior. He asserts that, although current evidence indicates that biological changes contribute to adolescent problems, far too little is known about these factors to make definitive statements about their role. He refers to delayed phase preference, adolescents' preference for staying up late and sleeping late (recall Ronny's sleep phase change), as one sign of a biological effect. This leads to the hypothesis that an adolescent's adjustment to school scheduling demands may contribute towards sleep deprivation that feeds into mood disrup tions and more parental conflicts.
From a cultural perspective, Arnett says that pubertal changes do not make the stormy aspects of adolescence inevitable. He reports a recent study in which most traditional cultures experience less adolescent stress when compared with the West, although such stress is not completely unknown. Differences are noted among tradi tional cultures, with those that exclude adolescent boys from the activities of men as being more likely to have prob lems with their adolescent boys than cultures in which boys take part daily in men's activities.
Arnett concludes that anticipating adolescent stresses may instigate parents and other adults to plan how best to approach possible adolescent problems and be pleasantly surprised if none appear.
Adolescents are exemplified by quickly changing moods and behaviors. It follows that careful scrutiny is necessary to identify differences between depressive and normal behaviors. The vital aspect in recognizing depressive disorders is that the behavioral change lasts for weeks or longer. Adolescents showing 4 or more symptoms of depression for longer than a few weeks, who do poorly in school, who seem withdrawn, overly impulsive, and uninterested in activities once enjoyed, should be checked for possible depression through screening with qualified professionals.
For a diagnosis of depression based on the DSM-IV (1994), the following signs would be observed over a 1-year period in adolescents:
- Chronically depressed mood occurring for most of the day, more days than not.
- Showing or describing their mood as sad.
- This may be shown as irritability rather than depression
- Poor appetite or overeating.
- Insomnia or hypersomnia.
- Low energy or fatigue.
- Low self-esteem.
- Poor concentration or difficulty making decisions.
- Feelings of hopelessness.
- Low interest .
- Self-criticism, with the self-concepts of being uninteresting, incapable, or
APA and MTV worked jointly to provide youth with information about identifying warning signs of violence and what to do to obtain assistance if they recognized such signs in themselves or peers.
- History of violent or aggressive behavior.
- Serious drug or alcohol use.
- Gang membership or strong desire to be in a gang.
- Access to or fascination with weapons, especially guns.
- Threatening others regularly.
- Trouble controlling feelings like anger.
- Withdrawal from friends and usual activities.
- Feeling rejected or alone.
- Having been a victim of bullying.
- Poor school performance.
- History of discipline problems or frequent run-ins with authority.
- Feeling constantly disrespected.
- Failing to acknowledge the feelings or rights of others.
Through my involvement with Ronny I encountered many serious deficits within the mental health system including:
Professionals lacking skill and understanding of the developmental milestones of typical adolescents and the ability to discriminate between youngsters needing counseling, intensive psychotherapy, and/or medication
The use of minimal or no psychodiagnostics -- this is of particular significance as adolescents may show psychotic-like behaviors, which can be verified psychometrically.
Inappropriate facilities/environments for adolescents in acute distress.
The impact of managed care and time-limited treatment on chronically disturbed adolescents.
Overworked staff and understaffed mental health facilities.
Adolescents without sufficiently involved parents or relatives who fall through the sizeable cracks in our mental health or juvenile justice systems.
Minimal or non-existent social services where this critical support area is desperately needed.
Lack of cohesive case management and coordination, resulting in fragmented, inconsistent treatment.
Dr. Rosenthal predicts that the next decade will bring "exciting changes in the recognition and treatment of psychiatric disorders in children and adolescents. Parents and physicians alike are now beginning to accept that such disorders as phobias, panic attacks, depression, generalized anxiety and bipolar illnesses as well as schizophrenia do not magically appear at age 18, but often have antecedents in childhood. As teachers, pediatricians and other individuals with frontline contacts with children become more in tune with these diagnoses, the interventions for children will become more plentiful, the proper diagnosis and treatment will be made earlier, and children will be less likely to be labeled as 'bad kids' and more likely to be helped with our growing body of knowledge."
Arnett, J. J. (1999). Adolescent Storm and Stress, Reconsidered. American Psychologist, 54, 5, 317 326. Diagnostic and Statistical Manual IV (1994). Washington, DC: American Psychiatric Association.
Diagnostic and Statistical Manual IV (1994). Washington, DC: American Psychiatric Association.
Knapp, S., VandeCreek, L., & Tepper, A. (1998). Pennsylvania law and psychology (3rd ed.) Harrisburg, PA: Pennsylvania Psychological Association.
Knapp, S. (1999, June). Three rules for addressing school violence. The Pennsylvania Psychologist, 1, 7.
National Institutes of Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663.