Addressing Childhood Anxiety, Depression and Mental Health Concerns

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Anxiety and depression are on the rise in children and teens. Societal pressures, academic stress and social media have all played a role. Early detection and intervention by parents and pediatricians is getting more kids the help they need. Psychologist Elizabeth Harris, PhD and psychiatrist, John Hertzer, MD, discuss evidence-based treatment options and the importance of a tailored approach to each child’s unique needs.

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Macie Jepson
We as Americans, especially our kids, have more modern conveniences than any other time in our history. We start our car with a key fob. We order our meals. We don’t even have to go anywhere. It’s just delivered to our doorstep without even talking to anybody. We’re watching television when we want, what we want. Of course, the computer is at our fingertips with our cell phones. I mean, I would say life is pretty good, right?

Pete Kenworthy
Yeah. But yet, according to a Gallup poll from January this year, 2024, only 47% of Americans are happy with their personal lives, and young Americans are a lot less happy than older Americans. People under the age of 30 are so unhappy in fact that they’ve dragged the United States out of the top 20 happiest countries in the world for the first time in the Gallup, happiness reports history. and consequences are in far too many cases deadly. Why are so many young people sad while often getting good grades surrounded by friends and with a whole life ahead of them? Hi, I’m Pete Kenworthy.

Macie Jepson
And I’m Macie Jepson, and this is The Science of Health. Pete and I have been talking about doing a podcast on adolescent depression, suicide and general and happiness for really a long time. It is a huge topic to tackle, probably that’s why we haven’t gotten around to it already. But I think we both decided that this is really too disturbing to not talk about. Approximately 2 million adolescents attempt suicide each year in the US. Among pediatric deaths more than 25% are by suicide. It’s the second leading cause of death for children and young adults ages 10 to 24 causing more death than any single major illness. It’s second only to unintentional injuries.

Pete Kenworthy
Yeah. It’s certainly time to talk about it. Macie, your kids have dealt with the suicide of a classmate. My kids have certainly seen their share of anxiety and depression among their friends and themselves. It’s not something that’s hush hush anymore. In fact, our kids’ generation talks openly about mental health and its value. Which brings me to something else I hear a lot. Is there a bigger problem today? Are we better at diagnosing something or are kids just flooded with mental health data so much that they jump to that conclusion about themselves? These are all things we’ll get into. Here to join us are Dr. Elizabeth Harris, specializing in child and adolescent psychology, and Dr. John Hertzer who specializes in child and adolescent psychiatry, both at University Hospitals in Cleveland. Thank you both for joining us.

John Hertzer, MD
Thanks for having us.

Elizabeth Harris, PhD
Thank you.

Pete Kenworthy
The numbers here are staggering. But before we dive into that, can you give us a snapshot of kids’ mental health over the span of your careers? Has there been a steady increase in your practice or did it spike suddenly? Dr. Harris, you go first.

Elizabeth Harris, PhD
Well, when I started my work with youth about 15 years ago, common reasons for referral were conditions like ADHD, depression, anxiety, disruptive behavior disorders, and these youth struggled with problems like school refusal and sometimes they were at risk for school expulsion. They had other difficulties with their parents getting along with peers, bullying at times. And mental health conditions in youth, I feel in recent times have become increasingly more complex. So while all of these conditions we still see frequently, we’re starting to see even more complex conditions with eating disorder, things like OCD, panic disorder, concerns around physical illness, substance use disorders, also suicidal ideation and attempts, gunshot victimization. And all of this is coupled with traumas that they’ve experienced throughout their life. So, I would say that while we’re seeing a lot of the same conditions, they’ve become increasingly more complex over the recent years.

John Hertzer, MD
Yeah, I agree with Dr. Harris’s good points. I’ve been in practice for 20 years now, and if you look over the last decade, the broad range of the youth population ages three to 17 have been modest increases in depression and anxiety, but the more compelling statistics are related to our adolescent population, which we’ve seen increases roughly in the area of 10% of that population with anxiety or depression in both areas, and now it’s closer to 15%. And I know over the course of our conversation today, we’re going to go through some reasons for that. But I also want to point out the positive side. This certainly suggests, and I’ve seen it happen in real time, that we’re doing a better job of screening for kids with both anxiety and depression in our pediatric offices throughout the nation and also here at the Rainbow Primary Care Institute.

A closer look at the adolescent population, statistics are our compelling and, in some instances, very sobering as well. According to the Centers for Disease and Control, 2021 rates of major depression were 15%. Twenty percent of our adolescent population seriously considered attempting suicide. Ten percent actually attempted suicide, and notably upwards of 40% reported persistent sadness or hopelessness. And within your question about our individual practices, we always have been busy throughout our careers by virtue of us being specialists. We’re also aware that a fraction of kids who need help are actually receiving help. Now that is changing as well. Just ask any pediatrician in our community or otherwise, and they will share, and perhaps this is on the low side, that about 30% of their visits have either a primary or secondary concern about behavioral health issues. Related to this, the National Institute of Health demonstrated in a study published in the Journal of American Medical Association last October that roughly a third of youth with anxiety or depression receive treatment. Barriers to that probably are beyond the full scope of today’s conversation fall into a couple main categories, namely stigma and access.

Macie Jepson
We’re using the words anxiety and depression in the same sentence a lot today. So, I’d like us to break that down first. Are they different? And how often are kids dealing with both, if they are?

Elizabeth Harris, PhD
I’ll start off with anxiety. Anxiety in kids is pretty common. Part of the problem is it can be difficult to recognize, and that’s because anxiety does not look the same as it would look in adults. For example, you might see kids that have difficulty with sleep routines. They may have disrupted sleep. You may see that they have disrupted eating patterns, or you might even see that they are having difficulty with concentration. But in addition to this, this impacts their ability to concentrate throughout the day. They might have irritability or you might see more frequent outbursts in these children. Not only will you see constant worry and negative thoughts, but other signs might be frequent crying. It might be separation anxiety. It might be excessive toileting or even stomach aches.

Macie Jepson
And depression. Let’s talk about that. It sounds like it might be harder to actually notice?

John Hertzer, MD
First of all, I’m going to frame my comment with one more statistic if you’ll indulge me. Namely that 75% of psychiatric disorders diagnosed among adults have their roots in childhood and adolescence. Therefore, the earlier we can identify and treat, we believe the better off the outcomes will be. Depression that rises to a clinical concern is when a child or teen is sad, often accompanied by irritability over a two week period or longer, and experiencing other symptoms such as loss of interest in activities, sleep or appetite changes, low energy, trouble concentrating, thoughts of death, feelings of worthlessness. Putting all these together, this is considered a major depressive episode. Certainly, there are also degrees of depression that may not arise to the major depressive threshold, but certainly warrant attention with a mental health professional. Depression and anxiety, to your point, Macie, can occur together, which is what we refer to as comorbidity, defined as two or more disorders occurring in one person simultaneously. Rates vary, but a fair estimate is that 25 to 50% of youth with depression also meet criteria for an anxiety disorder, and 10 to 15% of youth with anxiety also meet criteria for a depressive disorder.

Macie Jepson
So, what other medical diagnoses are kids facing that lead to mental health issues?

John Hertzer, MD
So, as Dr. Harris mentioned, ADHD is a common condition that we see in our practice. And about 15% of kids with ADHD have depression. About 30% of kids with ADHD have anxiety, and ADHD can cause significant impairment in school, home, interpersonal relationships, quality of life and functioning. So, one can imagine how untreated ADHD can lead to other mental health conditions. Also related to eating disorders. Fifty to 75% of patients with eating disorders also have depression and anxiety. Certainly, genetic factors influence both conditions. Of note anxiety more often than not, predates the eating disorder and depression more commonly after the onset of the eating disorder. Substance use and mental health is the prototypical two-way street. Each can lead to the other effective treatment of one can lead to a better prognosis for the other. And conversely, persistence of one will likely limit the progress of the other. Also, it’s worth noting that our brains are developing into our early adult years such that teenagers are susceptible to immature brain circuits regulating decision making and impulse control, rendering them more susceptible to substance use.

Elizabeth Harris, PhD
I think that that’s absolutely right. Substance use and eating disorders, these are all conditions that pre-existed. These aren’t new conditions to us. In fact, we’re pretty used to dealing with complicated cases as we work in a tertiary care environment. However, what we’re seeing is that these numbers are increasing. We have a difficult time explaining it. As researchers, we do take the time to look into what’s going on in our communities, in our environments to see how well we are diagnosing these things, and also to see what it is that is influencing the increase in numbers that we’re seeing lately.

Pete Kenworthy
Is it oversimplifying things to suggest that some kids just aren’t happy. They don’t necessarily have an underlying disorder, so if so, what is that unhappiness linked to and can it be solved with more support or without therapy or medication? Does that make sense?

Elizabeth Harris, PhD
Yes. Well, I think it’s important to acknowledge that you’re absolutely right. Some of these things of these symptoms that we’re mentioning aren’t necessarily indicative of a mental health disorder. So, we do have kids who experience sadness, who experience worry, and those are completely normal feelings. You will see kids who will go in their room and stay there who sleep a little bit more, especially in the teenage years. So, in some cases, therapy isn’t necessarily warranted. Sometimes it’s just a matter of they need a little extra sleep because they’re in that age range where there’s more growth, there’s more brain development, and we will see those things increase in terms of the behaviors that we think are concerning but may not be. But in other cases where they do happen to need to see one of us, we look for those types of symptoms in more excessive amounts where these symptoms are happening in more severe cases.

And it’s okay for a parent to come to one of our offices and just find out if, in fact, it is something that they should be concerned about. Because more than happy to say, oh, your child is doing well, they’re just a teenager. And in other cases, we’ll say it looks like you need the support of one of us.

So, what we’ve noticed is that there are a lot of contributors to what a child presents as. Some of those can be stressful events. So, for example, in 2015, 39% of adult Ohioans reported having experienced two or more adverse childhood events. So, we thought that that was a pretty concerning number. In addition to that, upbringing has changed. So, a lot of people maybe years back we’re used to the traditional nuclear family consisting of Mom and Dad. That’s not what we’re seeing now necessarily. I mean, we do have some families that are still intact, but we see a lot of kids who have experienced living in one parent households, who’ve experienced divorce. We see kids who are being raised by their grandparents or some other guardian.

And this presents complications, especially if they do have some sort of contact or very minimal contact with their biological family. So, in 2010, the selfie was born with the introduction of iPhone 4. At that time, we saw a staggering increase of mental health concerns. For example, we saw a 145% increase in the diagnosis of depression in teenage girls. We saw a 161% increase in teenage boys of depression. We saw a 139% increase in anxiety in kids aged 18 to 25, both boys and girls. We saw a 188% increase in ER visits for self-harm in adolescent girls. We saw a 91% increase in suicide rates for 10 to 14-year-old boys, a 167% increase in the suicide rate of 10 to 14-year-old girls. Not to mention we’re just coming out of a pandemic. So, that just added insult to injury in that a lot of the finances are being pinched in households of all types. But to add to that, low income households have had a really hard time just feeding their families. In fact, parents have reported that in the past 12 months they haven’t had enough money to purchase food for their home.

Macie Jepson
Let’s talk a little more about comparing ourselves to what’s real and what’s not real. There’s a lot out there on social media that is not real, and this is causing issues with our children. You touched on it. Can we go a little deeper? How do we get our children out of that rut?

Elizabeth Harris, PhD
It is really difficult. There are a lot of things in schools where you’ll see that kids are more competitive than they used to be. In fact, you’ll find that they know each other’s grades. They will see who can do the best, who can finish first. Kids sometimes experience anxiety when they see the first kid finish with their exam because they wanted to be the first kid to finish their exam. We mentioned before social media is a contributor, so it’s normal in social media to be compared to the rest and to look the best and to be the best. And we have a lot of conversations often about how these are stills and you can’t really see the life behind these still pictures say on social media platforms like Instagram, Snapchat. You don’t know what the rest of their world looks like. So, these kids are actually kind of working up against something that is almost impossible to create and it causes a lot of stress on them. It does create a lot of danger in terms of how they feel about themselves in terms of how they feel that they’re able to cope with society and compete in today’s society when in fact they could be just bringing their own strengths and doing perfectly fine. But it’s really hard to convince kids of that when they hear other things around their schools and amongst their peers.

Pete Kenworthy
A lot of what you’re talking about sounds like parenting, but at the same time you’ve talked about a lot of families aren’t maybe what they used to be or it’s not a mom and a dad. I don’t know. Parents don’t have time. They don’t see their kids as much as they’d like to. Because those things are happening. Does that necessarily mean that therapy or medication is necessary or does the kid just need to understand that they have great qualities too? Does that make sense?

Elizabeth Harris, PhD
It does. So, our favorite answer is it depends. So, what we’ll find is that oftentimes it could be just the conversation between the child and the parent. Other times that is a difficult conversation to have. So, a parent may come into my office, for example, and find that they can’t have the same conversation with their child and receive the same response as what they receive if they’re sitting in my office or if I say the exact same thing. Sometimes the use of a mental health professional sometimes just goes a little bit further along, but also in some instances, the problem is so severe and pervasive in their mind that they do require medication intervention. And I need to refer to my colleagues such as Dr. Hertzer here, when therapy just isn’t enough.

Macie Jepson
I think sometimes it’s important…I know we’ve had these conversations with our kids, especially when they were younger…to say life isn’t perfect. We as parents aren’t perfect. I think kids at a certain age expect life to be perfect and it’s not. And acknowledging that and saying we make mistakes, life is sometimes hard. Is there value to that?

John Hertzer, MD
Yes. And it also speaks to kind of when we diagnose something. With any condition, there’s that criteria that it has to be significantly impacting one’s functioning. So, one can be going through an emotional stage of their life, but not having it significantly impact their functioning and therefore doesn’t rise to the level of a clinical diagnosis. Now, when it does, we certainly want to be there for our patients and their families every step of the way. And let me tell you, over my two decades of practice, I have consistently impressed with parents, guardians and other family members who are supporting these kids of how resilient they are. It can be very difficult times for a child going through a mental health crisis, and they sometimes can last a while. And every time I see parents in the office, I’m impressed by how they’re managing these challenging times.

Pete Kenworthy
All right. So, back to stressful events that were brought up. What about bullying? Is that a big concern among mental health patients?

John Hertzer, MD
Very big concern, Pete. Thanks for bringing that up. A big concern for a number of reasons, including that it’s a risk factor for suicide. I’m going to read the definition of bullying, according to American child and adolescent psychiatry, as the intentional individual or collective aggressive behaviors that intimidate and cause the physical or psychological discomfort of another individual or group. It usually occurs within the context of a power imbalance and can be direct, indirect or digital. Pretty heavy definition to read, let alone to experience as a child or teenager. And on the heels of our fellow faculty member, Dr. Marcie Hall recently sharing a wonderful podcast on the value of kindness, this, of course, goes the opposite direction, namely, victims of bullying are at increased risk for anxiety, depression, health complaints, eating disorders, school absenteeism, running away, alcohol and substance use, self-injury, accidental injuries, poor school performance, and as I noted a moment ago, suicide. Bystanders of bullying, it’s also important to recognize, also may feel guilt related to inaction and are also prone to depression, anxiety and substance use. Bullies themselves also commonly have unaddressed mental health needs. So, it’s important to intervene, as left unaddressed, there is a higher rate of criminal convictions as adults along with becoming abusive toward romantic partners and children. I mention all of this, Pete, to your question, namely to say the stakes are very high.

Macie Jepson
Are you seeing an increase? Are people getting meaner or am I just imagining that?

John Hertzer, MD
Well, it’s around the clock now. The days of leaving the bully on the playground are over. And that’s where the real concerns about cyber bullying are relentless.

Macie Jepson
And I would ask you why, and I’m guessing the answer is because of these unaddressed issues throughout family and life, and you said the bullies themselves have issues that haven’t been addressed, right?

John Hertzer, MD
Yeah. So, we have to look at everybody involved and approach that accordingly. Because I mentioned the stakes are high. There’s also a tremendous upside. Treating mental health conditions can change the trajectory of lives. We know in our juvenile detention centers that upwards of 80% of kids have an untreated or undertreated mental health condition. So, with our own Dr. Bruce, we have him going to our juvenile detention center and he is intervening.

Macie Jepson
Among kids 12 to 17, the prevalence of major depressive episode is more than twice as high among females than males. First of all, what is major depressive episode and why more girls than boys?

John Hertzer, MD
Oh, good question, Macie. It’s not fully understood, but I’m going to give a answer that may help us head toward that direction. Major depressive episode is a two week episode, as I shared earlier, with sad mood often accompanied by irritability and multiple symptoms occurring at the same time and leading to impairment and functioning. Girls tend to show more cognitive and physical symptoms of depression, cognitive being guilt, negative self-assessment, fatigue and general concerns about health, which may make them more likely to receive medical attention. And as I referenced earlier in our conversation, once one is in a primary care physician’s office, namely pediatrician, there are screenings that occur that will help explore whether somebody also has anxiety or depression. And girls are more prone to stress from social media use and more likely to experience sexual violence as well. Girls tend to internalize emotions, boys more externalize, such as with more visible irritability and aggression, which may not be interpreted as depression. So, the gap may not be as wide as the statistics show in boys, it may be masked in other ways.

Macie Jepson
And yet more males die by suicide than females. Why is that?

John Hertzer, MD
Yes, you’re right. Suicide rates in adolescents and young adults, two to four times higher in males compared to females. In part, males tend to use more lethal means such as firearms and hanging. They’re less likely to seek help, as I mentioned a moment ago. They’re more impulsive and aggressive, which become mediators for suicidal behaviors. Avoidance strategies make it more difficult to cope with emotional struggles and lead to hopelessness, again, often in the absence of seeking help. Related to the earlier points as well, young women may be more likely to seek help, have a general readiness to talk about emotional problems and to identify friends and professionals as sources of help, all of which serve as protective factors. Suicide is the second leading cause of death for youth behind accidents. And suicide rates sadly have been increasing over the last 15 years, although the last two years, fortunately there seems to be a downward trend.

But those increases that I mentioned over the previous 15 years, upwards of 50%, which was similar increase in Ohio as was nationally. They measure this in per a hundred thousand youth. It was 10.7 per a hundred thousand youth a few years ago. And to your question, Macie, 70% were male. Forty-four percent had known mental health diagnosis and 27%, again, a fraction of those that we would like to have in treatment were receiving treatment. Now, there’s not enough data to draw conclusions, but family stress, social media access and stigma contribute. Just want to review a few risk factors, if I may. Previous suicide attempts, self-harm, past or current suicidal ideation, presence of a mood disorder, trauma, substance use, lack of family social support, access to firearms, life events such as being bullied or recent losses, family history of mental health, substance use disorder, the L-G-B-T-Q population combined with being in an unsupportive environment, eating disorders, anxiety, especially when co-occurring with substance use. So, we need to reach more youth who need our help.

Elizabeth Harris, PhD
In addition to all of these complicated factors, one thing that we do know is that expressing emotion is one of the things that you can do to reduce the experience of symptoms of anxiety and depression. And traditionally, what we had seen is that girls had been more emotionally expressive than boys just based off of how we are reared as children. But I wanted to mention Dr. Hertzer said that he was really impressed with how patients are doing so much better based off of how the parents are engaging more with their kids. And I wanted to just add to that. We are seeing less instances of boys holding in their emotions because parents are being more informed and involved in allowing their boys to be more emotionally expressive just as girls are.

Pete Kenworthy
With parents, you talk about like are we paying enough attention, or guardians, or are we paying too much attention? We’ve heard about helicopter parenting and how that puts a lot of stress on kids. And we try to protect our kids, right? But are we causing more issues? And I know the answer is it depends, but expand on this, how parents’ role plays into this.

Elizabeth Harris, PhD
Sure. And you’re absolutely right, it does depend. But I’ll speak on the circumstance where maybe parents are paying a little too much attention. Because there is an increasing awareness of mental health concerns in youth, sometimes parents are watching a little bit more closely to the point where they engage with their teachers more. They intervene more. They may even speak with parents of the bullies or the kids who are bullying more. And the problem with that is is that it kind of removes that child’s ability to be able to defend themselves and to be resilient and find ways of engaging with their peers in the best way they know how. So, one thing that I can say about both kids who bully and also kids who receive the bullying is that kids do the best that they can. And sometimes you have to allow for kids to do the best they can while providing them support but not taking over for them because that then stifles their ability for growth. So, what we want to see is that our kids are being more self-sufficient and that they’re able to manage these complicated circumstances not only in youth but also in adulthood because there will come a point where parents will be available and involved, but we expect for them to be able to leave the nest and to manage complicated circumstances on their own.

Pete Kenworthy
It’s a delicate balance, really, right?

Elizabeth Harris, PhD
Yes.

Pete Kenworthy
You want your kid to learn how to fail, how to be resilient like you said, and yet you want to protect your kid. That’s your kid.

Elizabeth Harris, PhD
Right.

Pete Kenworthy
So, it’s tough.

Elizabeth Harris, PhD
Right. And there is beauty in making mistakes. There is beauty in failure because from that comes growth.

John Hertzer, MD
And there’s enough instances to mention right now where I may see a child or teen and with the purpose of whether the child or teen needs to be on medication. And over the course of those conversations which occur with parent and child together and each of them individually, I may learn something from the child or teen that I will then present as a tremendous opportunity for the parent to hear from me what I’ve heard from the child that adjustments in certain things at home indeed could pay big dividends. And including not having the child have to go on medication, which is certainly important intervention. And we do it with a lot of purpose and to help the child, but there are instances where somebody may not need medication when other interventions can occur that can get things moving forward in a positive direction.

Pete Kenworthy
I’m glad you brought up medication. I’d like to take a moment to talk about the difference between the kinds of care that both of you provide, right? Typically, psychologists can work hand in hand with psychiatrists, right? But is it as simple as let’s start with psychology and see how things go, and is there truth to the belief that psychologists offer therapy while psychiatrists look to medication when dealing with more severe cases? Dr. Harris, we’ll start with you.

Elizabeth Harris, PhD
So, you’re absolutely right. Psychologists do deal more with the therapy aspect of treatment. But what we’ll find is that sometimes we receive, like I mentioned before, families who will come into our offices and we find that they’re actually just needing a little bit of support and we are able to provide them with an evaluation. Sometimes it’s benign and we can say, go ahead and live your life and enjoy your child because there’s nothing that we necessarily need to intervene with. There are other times where therapy alone might be really all that they need because maybe the condition isn’t to the degree that medication would be supportive. There are other times where psychiatry alone, where medication only is indicated, and then in more severe conditions, it is important for both of us to work together where that person receives medication therapy, but they also receive psychotherapy at the same time, which actually renders the medications to be more effective while they’re receiving therapy. There’s research to support that. So, the answer is, again, it depends. But yes, we do find that sometimes therapy alone is best and sometimes working together is best.

John Hertzer, MD
Yes, exactly. I agree with Dr. Harris. And we know somebody’s in a severe major depressive episode, the combination treatment of therapy and medication provides the best results in most cases. Other instances, therapy alone may work with referral to a psychiatrist or an advanced practice nurse who they essentially do the same thing as we do as psychiatrists. And we tell parents, we have FDA approved medications for anxiety and depression in youth. And what does that mean? I tell them it’s been studied and found to be both safe and effective. And that’s reassuring to parents. It’s not that they’re without potential side effects, but that’s why we continue to meet and we monitor the medication response and tolerability. And we also share that this is not necessarily meant to something to be a long-term intervention. Certainly, it’s shorter than a few weeks, but it’s not necessarily years that we need to treat somebody with medication. As I mentioned earlier, brains are always developing and maturing in many ways into our mid-twenties. And with that maturation can come a better ability to manage emotions as well. But what we would tell parents is if we get a good 18 months to two years of stability then we talk about what’s going on in one’s life first and foremost. But if things are pretty stable otherwise, then we can talk about gradually tapering off medication to see how they do.

Pete Kenworthy
I think it’s important to mention here, for example, I used to think a surgeon always wants to cut someone open and do surgery. And what I’ve learned in my 10 years here at University Hospitals is lots of times surgeons are trying to find every possible solution before surgery. And my guess is you’re the same way, right? You’re not necessarily looking to medicate as a first step. You’re looking to evaluate first and see if it’s really necessary.

John Hertzer, MD
Evaluate first and along with the symptoms that I mentioned earlier, talk about how somebody’s functioning. If their functioning is pretty impaired and a departure from what they’ve been accustomed to, then that would be an instance that we would certainly consider medication along with working with psychologists like Dr. Harris and therapists in the community to kind of gauge progress and to collaborate along the way.

Pete Kenworthy
But I guess what I’m getting at is there are certainly instances where people come to you and say, I think my child needs some sort of medication. And you say, I don’t really think they do.

John Hertzer, MD
Yeah. I tell parents one of the most important decisions I make is determine when medication is not necessary.

Elizabeth Harris, PhD
I just wanted to add also that there are instances where medication is indicated, and I’m fully confident in my psychiatry colleagues being able to explain that they will prescribe when necessary and they won’t when it’s not. But sometimes it’s just difficult for them to walk into their doors. And sometimes therapy will just consist of me just introducing them to the idea of considering medication as an intervention. Sometimes that takes a session or two; sometimes it takes more than a few. But eventually they do come around to the fact that medication is not produced for the purpose of sustaining the condition or for the purpose of sustaining their child on medication. But in fact, the goal is to get them off of the medication as soon as possible.

Macie Jepson
I’ve heard the word just like a reset sometimes, and I bet you’ve had conversations with parents who say, no, no, no, no medication. That’s not necessary. So, chemical imbalances, they can’t correct themselves, I’m guessing, even with therapy. I mean, there are times when something needs to be reset. Am I right, Doctor?

John Hertzer, MD
Yes. The medications themselves work on neurotransmitters we all have in our minds and bodies, those related to anxiety and depression, specifically serotonin and norepinephrine. So, it’s just kind of enhancing the capacity for these neurotransmitters to help with mood and overall anxiety as well.

Macie Jepson
So, what should parents look for? I mean, what scares me is the comments, well, they were happy, they seemed fine. They had everything going for them. Kids are really good at hiding their emotions. And these are the things we hear oftentimes after a death by suicide. What are we missing?

John Hertzer, MD
In part it is that we are not identifying and getting kids the help that they deserve early enough or at all. Additionally, there can be instances where one is not in a depressive episode or a heightened state of anxiety who sadly dies by suicide, virtue of an event occurring, an impulsive act ensuing thereafter. But what we tell parents to watch out for in their kids is concerning changes of a pattern of changes in any number of things, loss of interest in previously enjoyed activities being one of them, avoidance of preferred social opportunities, such that would be a hallmark anxiety symptom, becoming more withdrawn, lack of future orientation, not talking as much about future events. Certainly, suicidal statements, of course, And it takes a village as they say: teachers, coaches, other parents. People who interact with the youth in our community are very important in terms of identifying needs of our children to get them help.

Elizabeth Harris, PhD
And another thing I’ll add to that is that. Yeah, these conditions can be really concerning when they lead to suicide attempt or death by suicide, but there are ways to intervene, and that may be just increasing the conversation. One thing that I mentioned earlier is that it is important for our children to be encouraged to be emotionally expressive. And while we do want them to eventually be self-sufficient and to be able to manage their situations on their own, we also want them to lean on us in the times where they need us. So, just having conversations with them when we think that things are going well might reveal circumstances that we didn’t know existed. So, keeping the communication lines open, being not judgmental about what you hear when you hear it, taking the role of being an active listener and also not comparing that child’s experience to maybe what your experience was as a child and having these preconceived ideas of what you think childhood or teen years should look like.

So, keep an open ear and stay open to the idea that the child is going through a struggle and that you may be someone who may be able to provide support to them in the ways that they inform you to do so. So, one thing that parents sometimes have a difficult time with that becomes a theme in therapy is that sometimes we need our kids to teach us how to parent them. And the kids sometimes shake their heads when I say that. But it’s important because we grew up in a certain era and things look completely different for our kids now. So, we need them to inform us on what the world looks like to them and how we can be supportive to them. And we can use our experiences and maybe even our expertise to be able to guide them along the way so that they can be resilient.

Macie Jepson
It’s important to acknowledge that this process isn’t a child only process. It sounds like it’s oftentimes a family process.

Elizabeth Harris, PhD
It is.

Macie Jepson
When you see a situation, you don’t send the child straight to the psychologist alone necessarily. Am I right?

Elizabeth Harris, PhD
You’re right.

John Hertzer, MD
And in terms of follow-up visits, it’s such a rewarding profession for us to be in, in part because we can see on visit one a child, be withdrawn, not talking and have that weigh on the parent, visibly weigh on the parent. And a few visits later, the child comes into the office initiating conversation, talking about going out and doing things, enjoying things, having parents be visibly more at peace as well, and talking about, among other things, how that child is interacting better with their siblings and going back to what they had been accustomed to seeing with those interactions for years before they identified an issue.

Pete Kenworthy
I think that’s really important and awesome that you brought that up, right? Despite a lot of this sobering conversation that we’re having today, the sun still comes up again, right? There’s a lot of good that comes from the work that you guys do and tons of good, right? It’s not all about these terrible statistics that we’re talking about and these terrible events that we’re talking about. There is a way out, right? And so, with that, I’d like to kind of tie a bow on everything. If you could offer some final thoughts to kids, to parents who are considering care for mental health. And I guess the underlying theme here is there’s definitely hope.

John Hertzer, MD
There’s hope. Help is available. The help is evidence-based. It’s been studied, it’s been proven to be effective, and we see sustained benefits with these interventions as well.

Elizabeth Harris, PhD
Absolutely. And I would add that it’s important to believe in yourself, to believe in your child, to believe in your family unit, and when you’re unsure that we’re available to you to provide whatever support there is that we can. When you come into one of our offices, I say it’s prosthetic because it’s unusual for you to have conversation about what are the expectations for X, Y, Z, but it shouldn’t be prosthetic. Actually, it should be a regular practice where you maybe sit in the living room together or sit outside, sit around the dinner table and just talk about what it is that you hope for each other. So, the people pleasing aspects sometimes has to deal with assumptions, assumptions around what they think everybody wants from them rather than what they want to see from themselves and what in fact people do see in them.

Pete Kenworthy
Thank you so much, child and adolescent psychologist, Dr. Elizabeth Harris and Dr. John Hertzer, a psychiatrist specializing in child and adolescent psychiatry at University Hospitals in Cleveland. We really appreciate both your time.

John Hertzer, MD
Thank you, Macie and Pete.

Elizabeth Harris, PhD
Thank you.