Kids' Wellness Matters Podcast Ep. 2: Supporting Teen Mental Health

November 2, 2023

The COVID-19 pandemic shed light on a growing mental health crisis in the United States, impacting a record number of teens and many younger children, too. In this episode, Lurie Children’s pediatric psychiatrist, Aron Janssen, MD, shares ways parents, communities and healthcare providers can give kids the support they need. Dr. Janssen is the Vice Chair of Clinical Affairs in the Pritzker Department of Psychiatry and Behavioral Health here at Lurie Children's. He sees patients and conducts research on pediatric mental health and behavioral health.

“We might not be able to change the fact that you are in an environment that is stressful, but we can teach you how to manage through it a little bit more effectively and learn to seek out help where help exists, and make it through to the next day, and then the next, and then the next, and eventually get yourself to a position where you've built a life that is more validating and affirming and effective.”

-Aron Janssen, MD

Show Notes

[00:04:02] One in five kids will be diagnosed with a mental illness by the time they graduate high school. During 2020, mental health-related emergency department visits among teens increased by over 30% compared to 2019, as the pandemic eliminated the safety net of friends, family, and community to support these kids.
[00:06:32] Since 2009, there has been a 40% increase in persistent feelings of sadness and hopelessness in high school students. It’s speculated that lack of access to care, increased stressors and social media play significant roles.
[00:08:16] It’s crucial to teach children how to use technology (phones, social media, etc.) within appropriate limits, especially since their developmental skills–executive functioning, for example–are still forming.
[00:12:19] Parents should be on the lookout for changes in sleep patterns, appetite changes, or even just a gut feeling that something is “off” if they’re concerned about their child’s mental health.
[00:14:17] Parents are vital in shaping kids' resilience to manage stressors. Parents can help children and teens build resilience by learning to identify their emotions and possible causes for those emotions through open conversation.
[00:16:48] Janssen emphasizes the importance of shared goals between a medical professional and parents when addressing a child's challenges. He suggests understanding the family's concerns and aligning interventions based on evidence and the family's values.
[00:19:08] For teenagers, suicide is the second leading cause of death, and about 10% of teens in the most recent large national survey identified having attempted suicide over the past year.
[00:21:14] Direct and clear communication is important when discussing potential suicidal thoughts with someone, especially children. He suggests practicing such conversations with trusted people in one's life before approaching a child.
[00:24:18] When teens grapple with identity issues or face rejection based on appearance, gender identity, sexuality, or race, coupled with stressful peer relationships, it's crucial to ensure they understand that they can learn coping strategies to help them navigate.

Episode Transcript

[00:00:00] Rob Sanchez, MD: Today's episode is going to focus on depression and the rise of suicide ideation in teens. I want to mention at the front, that if you or someone you know is experiencing suicidal thoughts, call or text 988 for immediate help.

[00:00:12] Nina Alfieri, MD: Welcome to Kids’ Wellness Matters. I'm Dr. Nina Alfieri.

[00:00:18] Rob Sanchez, MD: And I'm Dr. Rob Sanchez. We are both parents and pediatricians at the world-renowned Ann & Robert H. Lurie Children's Hospital of Chicago.

[00:00:26] Nina Alfieri, MD: On this show, we'll chat with a wide range of experts about caring for children from newborns to young adults. Because kids' wellness matters.

[00:00:40] Rob Sanchez, MD: So Nina, I know one of the things we have in common is our commute times. We both have pretty long commutes.

[00:00:44] Nina Alfieri, MD: Always a good time.

[00:00:45] Rob Sanchez, MD: I don't know about you, but one of the things that I like to do is I use it as an opportunity to call my nieces and nephews. I have like 5, 6, 7 nieces and nephews they're getting older, they're going into eighth grade, seventh grade. But when you're family members, you know, it's a little tough to have the conversation going and find what they're engaged in.

[00:01:01] Nina Alfieri, MD: Their shells can be a little tough to crack sometimes, but there's always gold in there. I think it's a great thing to spend our commute time on. What better than investing in your family? And I think everyone needs an Uncle Rob, honestly.

[00:01:13] Rob Sanchez, MD: I find myself driving down Lake Shore Drive, you know, I'm literally driving past Lurie Children's and find myself talking about Percy Jackson books or, you know, latest movies that my niece is going to with her friends, or my nephew is really into Pokemon Go. I'm trying to get better at it 'cause I know that it's important, they're getting older and a thought that's in a lot of our minds is how are they doing? Like, how are they really doing? Because there's more and more concern about the mental health and well-being of adolescents and teenagers.

[00:01:45] Nina Alfieri, MD: When I said everyone needs an Uncle Rob, I was serious about it. A quick phone call to check in with your nieces and nephew might be bigger than you think it is. There are a lot of things we can do as parents, as mentors to youth to support them, especially given all the new research that's coming out about mental health and the concerns that we all have about it.

[00:02:00] Rob Sanchez, MD: And Dr. Aaron Janssen is a leader in the area of psychiatry at Lurie Children's, and I'm really looking forward to talking with him. And what we're really hoping to do is shed some light on the problem itself, this issue of mental health in young adults and teenagers and how it's grown, how it's changed, and of course talk about what we can do as parents, as Uncle Robs. It's something that our listeners are really gonna wanna know what to look out for and how they can be that person for someone in their life.

[00:02:28] Nina Alfieri, MD: Just a plug out there too, we care about parents as well. We care about adults even though we're very kid-focused. Your mental health matters too.

So I'm hoping we can all use this as an opportunity to check in with ourselves and to all get help if we need it. It's out there.

[00:02:42] Rob Sanchez, MD: The Covid 19 Pandemic shed light on a growing mental health crisis in the United States impacting a record number of teens and many younger children too. Today we want to understand why so many more teens and children are suffering from depression, anxiety, or thoughts of suicide, and explore ways to get them the help they need. We're bringing in our expert, Dr. Aaron Janssen, for the latest on this topic. He's the Vice Chair of Clinical Affairs in the Pritzker Department of Psychiatry and Behavioral Health here at Lurie Children's. He sees patients and conducts research on pediatric mental health and behavioral health. Dr. Janssen, thank you so much for your time today

[00:03:23] Aron Janssen, MD: Thank you so much for having me. It's great to be here and it's great to be able to talk about mental health in kids. For too long there's been a stigma about talking about this topic, so I really appreciate the opportunity to break down some of those barriers and preconceived notions about what psychiatric care is.

[00:03:39] Rob Sanchez, MD: So Dr. Janssen, could you please start out by sharing how you interact with patients and families?

Aron Janssen, MD: We see over 30,000 patient visits a year just in our outpatient psychiatry department alone. I help to oversee our clinical programming and ensure that all of the incredible clinicians that I have the privilege of working with have what they need in order for their kids to get better and for the families to get the care that they need.

Rob Sanchez, MD: During 2020, mental health-related emergency department visits among teens increased by over 30% compared to 2019. Now, at the time, this was surprising data to many when the news broke, but not to you. Explain how the pandemic exposed and worsened this problem.

Aron Janssen, MD: Yeah, we have a number of different factors that are in play. One is prevalence. We know that about one in five kids is gonna have a diagnosable mental illness by the time they graduate high school. There are nowhere near as many providers as we need to serve those one in five kids, but they're struggling and they put themselves together through a combination of support from friends, and family, from school, from online spaces, from activities, from churches, whatever it may be. The kids who are struggling but don't have access to care are often buoyed by the community connections that they have. What we have seen is prior to the pandemic, increased rates of depression, increased rates of isolation, and increased rates of suicidal thinking and suicide attempts, and what the pandemic did was it eliminated that safety net. It eliminated the capacity for teens, especially to have access to the community networks, support, and friends, that are vital to their developmental health. And so what we saw was the bottom dropout for a lot of kids, and we saw exposure to mental health issues that were already present, but just needed a push. It was the proverbial straw that broke the camel's back.

[00:05:28] Rob Sanchez, MD: Would it make sense to say that without those resources in the community or that access, you're seeing more of that care, that need, being funneled to a location like the emergency department if individuals or resources or families don't know where else to turn?

[00:05:40] Aron Janssen, MD: it's probably fair to say that the number one provider of mental health support, in most states, are kids' schools. Whether that's a school social worker, whether that's a teacher or a lay provider who's listening and providing support and validation. And when that was gone kids didn't have access to that kind of care. And so the only opportunity that folks had was to go to the emergency room, and so we did see a significant spike in levels of referrals to the emergency room for mental health issues.

[00:06:09] Rob Sanchez, MD: We know that more than one in three high school students have said that they experienced persistent feelings of sadness, of hopelessness in the past year that they couldn't participate in their regular activities and that's a 40% increase since 2009. We know that the pandemic plays a part in that, but what are some of the other contributors that are facing young people today? As we think about the broader aspect of this mental health crisis?

[00:06:32] Aron Janssen, MD: We know that the rates are increasing, but we don't have as much information that's reliable about the why. And so we have a lot of theories and certainly there are, some qualitative studies that have looked at why teens today are reporting more thoughts of hopelessness and suicide. And we're learning a lot from all of the kids who are coming in to seek care. What are the challenges that are leading you to think in this way and one is increased rates of depression and stress. But I wanna make sure that it's clear that not all children who attempt suicide or have suicidal thoughts are depressed. Some are anxious, some are overwhelmed by social or relational challenges or stressors. Some have been traumatized. We have to understand what is driving kids to experience this hopelessness in order to most effectively treat it. There are a number of factors, including lack of access to care, and increased stressors. I think social media has a complicated role in this department that the jury is still out on. It's a tool like any other, but I do think that the comparisons that folks have with one another and the sense of missing out, can be a real big challenge in this developmental age.

[00:07:43] Rob Sanchez, MD: A lot of folks do think about social media. I'd like to focus on that a little bit more closely. Just this past May, the Surgeon General issued an advisory about the effects of social media use on youth and their mental health, and some of the advice that it brought up was how parents can watch and make plans in terms of social media use. How to establish tech-free zones and better foster in-person relationships. And touches on how to optimize the benefits of the good aspects of social media. Is that something that you take to mind in the work that you do and think is contributing to the mental health of youth today?

[00:08:16] Aron Janssen, MD: It's a really important piece and I think social media, like many things in this technological age that we are in, is something that most of us who are listening to this podcast were exposed to as adults, and we had fully developed adult brains when we began to engage in these products and these tools. And we forget that our kids have different developmental skills than we had when we started using social media. And all we have to do is look at our own phones and see how much time we are spending. Am I fully utilized? Am I fully engaged in my life, when I'm engaging with social media? And then know that for kids.That sense of executive functioning, the ability to say, I need to plan out my day, or How could this potentially be impacting steps two, three, and four of the things that I need to get done today? That part of the brain just hasn't developed yet. And so it's a tool like anything else, and we need to teach kids how to properly use the tool and have appropriate limits and expectations about when they're using it. That is very easy to say. It's very hard to do. Just as an example, my oldest daughter just finished kindergarten, and she has an iPad through her school that she has to use to access the school curriculum. At six she already knows how to get around all of the controls to get access to YouTube, but she's not allowed to watch on her own without supervision, but she does because it's not possible for any child to be supervised 24/7. And so we have to recognize that the reality of the world that we live in is that kids are gonna be exposed. So how do we help teach them the skills to know this is what's appropriate to use? This is who I talk to when I see something that's confusing or concerning to me, and this is the time to turn it off and step away and engage in more healthy activities.

[00:10:02] Rob Sanchez, MD: The teenage population or even the preteen population engaging with social media, what do you think are some of the important topics to bring up in conversation about what we should watch out for?

[00:10:12] Aron Janssen, MD: One thing that's important to know is that most kids have positive experiences on social media, and find that there's value and benefit to it. And if we come in as parents or as providers or caregivers or teachers and say, everything is doom and gloom and this thing is gonna ruin your life, and it's the worst thing that's ever existed. You have no credibility because it's not the experience that most youth have, right? Most youth have the experience that there are positive aspects to it, but then there are also negative aspects to it. And just like a car, you can drive safely or you can get into accidents. And we're not gonna give kids a car as soon as they turn 16 without going through the proper education and training on how to use it. And so with social media, it's how do we learn about the content? How do we question the content that we're seeing? How do we recognize the feeling that we have when we're engaging in this content? If I'm on Instagram and I see all my friends posting about this amazing party that they're at, and they all look great and look like they're having a good time, it makes me feel really crappy about myself. Let's notice that and comment on it, and let's talk about, whether is it worth it for you to be engaging in this if this is how it makes you feel. The flip side, of course, is that people find social media as a useful tool to connect to other kids who are struggling. For a lot of minoritized youth, LGBTQ, youth, racial minorities, ethnic minorities. These folks often find communities in online spaces that they otherwise don't have access to in their day-to-day lives. So again, it's about how we use a tool. It's not that the tool is good or bad, it's making sure that there are appropriate guardrails and appropriate expectations. And one comment that I would say, which would apply to everything that we're gonna talk about today is that it's never too early to start those conversations. Right? If you haven't had this conversation by the time the kid is in middle school, it's almost too late, right? It's never too late. You always have the opportunity to talk about it, but before you're introducing the tool, is time you wanna start talking about the tool that you're introducing.

[00:12:13] Rob Sanchez, MD: For families in the home, what might be some of the things that they would wanna be aware of and look out for?

[00:12:19] Aron Janssen, MD: I would almost flip that on its head and say that, even when kids are doing well, we should be talking more about how they're feeling and helping kids to identify some of their strengths and resilience. Be like, you seem like you're in a really great mood today. Like what happened today? Let's understand what it was about today that made you feel so great, and build some of that so that when you are struggling and your kids are starting to withdraw if they're starting to have personality changes. If they're particularly having in psychiatry we use a fancy word to describe things that are very naturalistic, anhedonia. Which is the sense of numbness, right? When you notice that things that normally make your kid happy are just not doing that at all. That's a time to really start thinking about what is happening and how can I understand what is going on for my kid. Sleep, when sleep becomes disturbed, when you start to notice appetite changes, these are all things to look out for. But you know, most parents know, that there's something, and it's okay even if you can't articulate what that sense of offness is. If you have a gut feeling that something is off, ask the question. And particularly when we're talking about suicide. I think what I find is that many people are afraid to ask questions because they don't know how, or they're afraid they're gonna say the wrong thing. There's no possibility, and this has been well substantiated in the research literature, that asking about suicide makes people think about suicide or makes people act on suicidal thoughts. It helps people feel validated. And often there's an intense amount of shame for having suicidal thoughts and having a caregiver or a loved one say, I'm worried about you. Are you having thoughts about suicide? Is enough for them to feel open, engaged, and validated to be able to talk about what they do need.

[00:14:05] Rob Sanchez, MD: What are some of the things that you like to see or like to promote in families and in conversations of ways that they might be able to talk to their young ones at whatever age that can help lead to more productive conversations when things do get more challenging?

[00:14:17] Aron Janssen, MD: There's a lot of ways you can approach it. So one way is to model, right? We all have bad days. I come home, it's a stressful day at work and I'm grumpier than normal, or I'm shorter than normal. Rather than pretend like that's not the reality, you name it, you're like, gosh, I'm noticing I'm a lot more grumpy than I normally am when I come home. I think that's because I've had a really stressful day. I'm wondering what I can do to help myself feel better in this situation. So one is to model what that's like for kids. The other is to observe and comment in positive ways. That same level of logic you apply to your kid, be like, wow, I noticed that you're a little bit more withdrawn. I know that sometimes it can happen when you're tired, when you're hungry, when you're feeling sad or something happened. Tell me, what do you think it is for you? Sometimes, in some families, that's not the culture, right? Some families are not talkers and this isn't gonna work for every single family. But having a base of being able to talk about what you're feeling and experiencing really does make a significant positive change for most kids' lives. And the other piece is that kids are resilient. They can do really well and most kids face stressors and just have to remember that this terrible feeling that you're having is not gonna last. It's really tough right now, but it's not always gonna be tough. Sometimes we just need to hold on and wait, and not do anything until the feeling starts to pass and kids start to feel better.

[00:15:42] Rob Sanchez, MD: Do you find that, especially knowing that symptoms of anxiety, depression, these diagnoses, they can run in families, do you find that finding ways to support parents, to manage their own feelings, to help support them, is that something that is also beneficial?

[00:15:56] Aron Janssen, MD: Parents are vital in shaping kids' resilience to manage stressors. Kids don't have the skills to do it on their own, and they need external folks to help build that resilience for them to contain some of these really overwhelming, really intense emotions. When your cup is full as a parent and your kid is presenting you with a challenge, you might not be able to handle it in the way that you would otherwise have done if you were feeling better. And so it's not just modeling getting help when you need help, but being able to be present for your child is a really important part of parenting and it's okay not to be okay. We never expect that parents are gonna be on or perfect all of the time. It's just about how you model seeking care. How do you model making sure you're identifying when you're not in that space to help? And recruiting others when that's possible.

[00:16:48] Rob Sanchez, MD: With families, I often share that with them. In my own personal life, I've benefited from things like therapy. But it's not something that was talked about very much, welcomed in, my upbringing. But I do think it's important to share that. Can you speak to the benefits of things like talk therapy and medications that you like to share with families?

[00:17:06] Aron Janssen, MD: My typical approach is to have shared goals with the parents that you're working with. Like, what do you see as the challenge for your child? What are you naming this problem and how is this problem impacting your kids' functioning? And what is the number one thing that you want to see improve? And almost everybody can get on board with the same set of shared goals, right? I want my kid to be happy. I want my kid to start doing better in school again. I want my kid to be able to make friends. Okay, great, let's start by talking about what are the areas or what are aspects that are making your child have difficulty in those pieces. And then what are the evidence-based interventions that we know impact in a positive way, and what is causing the dysfunction? So if your child is depressed, let's talk about what are the studies on depression. What is the role of medication? What is the role of therapy? And what is the role of the combined? And let's talk about what are your thoughts about it. What do you understand about it? And let's just engage in a dialogue about where you are what you think and what your values are, and ensure that we are making decisions collaboratively that are based upon the values of the family. And sometimes that means it's gonna align and we're gonna be able to make recommendations that we know have the best chance of success. And sometimes it doesn't. But you build on that relationship over time by validating and reinforcing a family's own value system. And eventually, you can get a lot of folks to acknowledge that, you know, maybe we are gonna try exercise first to target depression. Great. When it doesn't work, you want people to be able to come back to you and say, gosh, thank you so much for letting me try this. Maybe let's try therapy next.

[00:18:45] Rob Sanchez, MD: I would love to hear if you have any particular success stories. Ways that you've seen your influence felt and where you felt like you really had some strong impacts on families.

[00:18:55] Aron Janssen, MD: Sure, let me give two different examples. First being a patient of mine who is now a young adult who just emailed me out of the blue after five years Just to say, I know I was tough and I was in a rough spot but you listened and you helped and I'm thriving now. And I just wanted you to know about having that space in my life. We are so lucky to be able to get some of these experiences where just connecting patients to care that treats depression, that treats anxiety can really turn a patient's life around and allow them to access all of their potential and all of their opportunities. And there's no better feeling than seeing patients succeed and learn to live a life that they value. The second example would be the importance of not making assumptions. So one of the projects that I work on is suicide screening in the hospital. And our policy is that we screen everybody.

Why? Because for teenagers, suicide is the second leading cause of death, and about 10% of teens in the most recent large national survey identified having attempted suicide over the past year. So this is a public health crisis and we often don't know, many, many kids are suffering in silence. And so we've had multiple occasions of kids who, nobody had any sense that they were suffering who came in for just a random, whether that's a bone fracture or a cold, who were having very serious suicidal thoughts. And it was only because we asked, even though nobody suspected, that those were able to be identified and we were able to connect those kids to care.

[00:20:33] Rob Sanchez, MD: it speaks truly to, if you don't start that conversation, there could be things that, that aren't brought up and that could be a, a missed opportunity to engage You mentioned earlier oftentimes that either through assumption or just the fear of not knowing what to say next, that might lead to parents maybe not bringing up the conversation or having that conversation. What are some of the tips and advice that you like to offer to parents or offer broadly? Questions about understanding how people are thinking about suicide are most effective when they're direct, they're clear, and the person asking the question doesn't seem anxious or worried or minimizing about the response. Right? So how do we do this?

[00:21:14] Aron Janssen, MD: One, you can learn how to ask. There's a lot of tools online. There are a lot of tools you can learn from your healthcare providers. But really it's about finding your own language that's as clear and direct as possible. Have you ever wanted to go to sleep and not wake up? Have you had thoughts about being dead? It can be just as simple and direct as that. I would practice doing it with people in your life who are not your kid first so that the language feels more comfortable to you. So call your parents, call a friend. If you have a partner, talk to your partner and just test it. Go through and say, you know, I'm really worried about you. And I'm wondering, have you been thinking at all about being dead? It doesn't have to be any more complicated than that. And what happens if somebody says yes? Well, thankfully we have a lot of resources. As you mentioned at the beginning of the podcast, 988 is a brand-new resource available for mental health crises. There are a lot of other resources available online to match people with folks who can talk them through these thoughts. But we want to see those kids get connected to care. If you're having thoughts of suicide, we want to help understand what is leading to those thoughts and teach kids and families how to build up the strengths and tools to reduce the likelihood of acting on those thoughts and work with families to ensure that your home is safe and that kids' thoughts and plans aren't gonna be able to be enacted. If you do have a kid who is struggling with suicidal thoughts, the first and foremost is the reduction of access to what we call lethal means. So how you would commit suicide? You wanna understand what kinds of thoughts your child might be having, and that's a tough conversation to have. But it means locking away medications in a locked box so that they don't have access to it. Ensuring that if you have firearms in the home, they're locked and stored safely and properly. If you live on a high floor, your doors are locked and you have the capacity to ensure that folks don't have access to it. That there are sharps, perhaps knives in the home that are locked away. A lot of these specific safety interventions are gonna be determined based upon your individual child's thoughts and feelings, but that's gonna be something that you're gonna wanna work through and have a clear understanding of how to do if you seek care.

[00:23:28] Rob Sanchez, MD: Dr. Jansen, I know this is part of my work, through screening, through visits that we have, we'll get some information and we'll bring families in to, provide whatever support we can to do some of that safety planning to reduce some of those risks. One of the things I wanted to make sure I touched on as well because we did get to talk a little bit about things like social media is affecting it, but there are other areas that are impacting youth that can really affect their mental health. I wanna talk about other stressors that are realities for some of these young individuals. So a teen has a bunch of jobs, right? One of those jobs is to figure out who you are and individuate yourself from your family. Who am I that's different from my parents? And your peer relationships take on an increasingly important value in your life, both as a way of defining that identity, and also providing support outside of the family.

[00:24:18] Aron Janssen, MD: So when those two aren't going well when you're struggling to understand your identity or who you are is being rejected, whether that's kind of your appearance or your gender identity, or your sexuality or your race or ethnicity. And you also have a friend group that maybe there's an increasing amount of stress or conflict or rejection. That can be a real challenge that we wanna make sure that we're understanding. Those are unique aspects of teen development that we want to make sure that we are screening for when we're talking to our kids. How are your peer relationships? How are you understanding your sense of self? Where do you fit in the world? But the other piece is, just to make sure that they're understanding that distress does not last forever. You can feel the worst you've ever felt, but it's going to go away at some point and we might not be able to change the fact that you are in an environment that is stressful. But we can teach you how to manage through it a little bit more effectively and learn to seek out help where help exists and make it through to the next day, and then the next, and then the next, and eventually get yourself to a position where you've built a life that is more validating and affirming and effective for you.

[00:25:28] Rob Sanchez, MD: Dr. Janssen, thank you so much for your time today and for taking part in this valuable discussion. We greatly appreciate it.

[00:25:34] Aron Janssen, MD: Thank you for having me and for shedding light on this important topic.

[00:25:37] Rob Sanchez, MD: Thanks for listening to Kids' Wellness Matters.

[00:25:42] Nina Alfieri, MD: For more information on this episode and all things kids' health please visit LurieChildrens.org.