The Crisis in Youth and Young Adult Mental Health
Aaron J. Krasner, M.D. President, American Society for Adolescent Psychiatry
Everyone knows that adolescence is a time of rapid biological, psychological, and moral development, yet not everyone knows that most psychiatric conditions begin by age fourteen and continue throughout life. Developmentally sensitive periods, such as toddlerhood and adolescence, are ripe for the onset of problems because “moving parts get broken.” This means that with biological volatility comes vulnerability, so it is no wonder that psychiatric practice prioritizes the study of adolescence, even though its developmental challenges are difficult to map and understand.
Rates of adolescent psychopathology have skyrocketed since 2011. Today’s teens, who represent the Zoomers (1999-2020), along with their parents, have encountered greater risk and demonstrated lesser resilience compared to previous generations of teenagers. Their experience of 9/11, Hurricane Katrina, the Gulf and Afghanistan wars, rising rates of domestic and foreign terrorism, the 2008-2009 financial crisis, the opioid epidemic, the proliferation of school-based and other mass shootings, climate change, police brutality, partisan and racial divides, the ascendence of social media & big technology, and widening economic and health disparities are just a few influences affecting risk and resilience.
So, is there really any doubt as to why Zoomers (and their parents) have developed greater rates of depression, anxiety, self-harm, suicidal ideation, and substance abuse?
Of course not.
When we consider particularly at-risk youth, e.g., females, those of color, minorities, and LGBTQ youth, the situation is even bleaker. The rates of adversity and corresponding psychiatric syndromes for these youth are, quite simply, staggering. These have prompted concerned organizations and the US Surgeon General himself to declare a state of emergency. Let us not forget that when kids suffer, their parents suffer along with them, and the numbers confirm that parental rates of substance abuse, psychopathology, and dissatisfaction with family life have never been higher.
Given the complexities of the brain, the astounding number of confounding environmental variables, and the challenges inherent in development, ascertaining causes for the pre-pandemic increases in rates of youth psychopathology has not been easy. One study in 2015 examined the interaction between social media, sleep, and the development of psychiatric conditions (Woods & Scott, 2016). That study argued convincingly that teen girls were addled by cyberbullying, their relentless seeking of external validation through social media and correlated nighttime dysphoria and insomnia. Consequently, they were at higher risk for development of chronic depression, self-harming behaviors, and suicidal ideation, undoubtedly influenced by the proliferation of the smart phone and social media at that time and since. That study aptly captured one alarming fact: 86% of teens sleep with their phones in their hands or under their pillows. Big technology and social media have likely exploited vulnerable teens in the design of social media functionality for the purpose of expanding profit margins and exposing new markets while their parents have often lacked the tools and skills to take effective control to counter their influence.
When the COVID19 pandemic struck in March of 2020, our teens and families were already stressed and hurting. With challenging but necessary public health mitigation strategies, additive stressors (primarily seclusion/isolation) poured gasoline on a raging fire and the results have been near catastrophic. For at risk teens and families with pre-existing risks or conditions, parents who were front line workers, and families with fewer resources, the rates of persistent psychological distress, adolescent depression and anxiety, adolescent self-harm and suicidal ideation, and adult substance use and depression rates soon doubled (Racine et al, 2021). In the absence of resilience training and skills, it is no surprise that these trends are persisting.
Parental wellbeing is a known and important variable influencing normal teen development and in the development of teen psychopathology. For this reason, the surgeon general and others have identified loneliness/isolation as a common risk factor for escalating rates of psychiatric problems among both teens and parents. Loneliness is a common, universal human experience involving feelings and cognitions that reflect emotionally from perceived deficiencies in social relationships. Loneliness may be associated with physical health problems, depression, anxiety, low self-esteem, peer rejection, victimization, aggression and social withdrawal, and problems with attention span. Among teens, loneliness/isolation in the pre-pandemic period resulted in and/or from unregulated use of social media and it has skyrocketed because of risk mitigation practices imposed during the pandemic (Thorisdottir, et al, 2022). Similarly, rates of parental loneliness/isolation have increased because of pandemic-related disruptions to work, socialization patterning, and home childcare & schooling demands. Higher rates of family psychopathology, dysfunction, and adversity have occurred as a result.
Interestingly, these environmental influences and related psychiatric manifestations created detectable neurobiological changes in the context of a longitudinal study of brain development at Stanford University (Gotlib, et al, 2023). Researchers noted that shifting patterns of cortical thinning and related shifts in subcortical structures, including the limbic system, which are typically associated with higher rates of stress presented ubiquitously among cases and controls. These researchers reported that the pandemic had not only adversely affected the mental health of adolescents, but also has accelerated aberrant brain maturation in a manner typically consistent with pathological trauma.
Prior to the pandemic, the adolescent mental health care delivery system was already shaky. With the addition of many more cases since, the system is truly not functioning well. Despite recognition of the importance of adolescence in psychiatry, we have not developed a coherent approach for screening and assessment. There is insufficient support for parents, families, and communities most afflicted with the increasing numbers of anxious and depressed teens. The dissemination of available, affordable, and effective treatments - limited at least in part by the paucity of qualified clinicians – continues to be woefully inadequate. The American Society for Adolescent Psychiatry is presently engaged in an effort to change this through an aggressive program of training for psychiatrists and primary care providers which will allow for the spreading of research-driven approaches to assessment, level of care determinations, and effective individual and family treatments.
Fixing the antecedents to this massive increase in teen suffering may not be feasible in the short term, but investing in our teens, their parents, and the collective is possible. Psychiatrists and other mental health professionals can influence the allocation of more money to invest in prevention, clinical care, research, and advocacy. We can also encourage, through additional training and consultation, a developmentally sensitive focus on the interacting systems so influential for teens. We can train many more adolescent psychiatrists and allied mental health providers using existing and developing training programs such as ours mentioned above. We can empower current clinicians to address common risk factors – such as loneliness/isolation - and we can empower more engagement across the board to protect our families and the clinicians who can help them.
The American Society for Adolescent Psychiatry has committed itself to doing our part in responding to this crisis. We ask you to join us in taking these constructive steps together.
References:
Gotlib, I. H., et al. (2022). "Effects of the COVID-19 Pandemic on Mental Health and Brain Maturation in Adolescents: Implications for Analyzing Longitudinal Data." Biol Psychiatry Glob Open Sci.
Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatr. 2021 Nov 1;175(11):1142-1150. doi: 10.1001/jamapediatrics.2021.2482. PMID: 34369987; PMCID: PMC8353576.
Thorisdottir IE, Agustsson G, Oskarsdottir SY, Kristjansson AL, Asgeirsdottir BB, Sigfusdottir ID, Valdimarsdottir HB, Allegrante JP, Halldorsdottir T. Effect of the COVID-19 pandemic on adolescent mental health and substance use up to March, 2022, in Iceland: a repeated, cross-sectional, population-based study. Lancet Child Adolesc Health. 2023 May;7(5):347-357. doi: 10.1016/S2352-4642(23)00022-6. Epub 2023 Mar 10. PMID: 36913961; PMCID: PMC10005790.
Woods, H. C., and H. Scott (2016). "Sleepy teens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem." J Adolesc 51: 41-49.