Focus Area 8: Mental Health Basics
4. Mental Health Disorders Prevalent Among Youth
Adolescent Depression
Depression is categorized as a mood disorder, also known as affective disorders. Depression is a serious medical illness involving the brain. It produces feelings of being ‘down’ or sad which persist and interfere with a person’s everyday activity and ability to enjoy life. Depression typically starts between the ages of 15 and 30.
RISK FACTORS FOR ADOLESCENT DEPRESSION
There are many factors that can increase the likelihood of developing or triggering adolescent depression:
- Genetics – family history of depression, suicide, dysfunction
- Death or loss
- Conflict
- Witness to or victim of violence, physical or sexual abuse
- Major life events
- Serious illness, ongoing chronic pain, or physical disability
- Substance abuse
- Being gay, lesbian, bisexual, or transgender in an unsupportive environment
WARNING SIGNS OF ADOLESCENT DEPRESSION
It can be difficult to tell the difference between the typical highs and lows that are just a normal part of going through adolescence and more serious symptoms of teen depression. But if you’re noticing changes, pay closer attention, don’t just automatically chalk it up to adolescence.
If there are signs and symptoms that last weeks or months, and you know that those are interfering with a young person’s daily life at home, at school, or in your program, or impacting their social life and relationships with friends, that could be a clue there is more than “growing pains” going on.
Not all teens experience depression in the same way but these are some possible warning signs for adolescent depression:
- Difficulty with relationships
- Increased irritability, anger, or hostility
- Extreme sensitivity to rejection or failure
- Low self-esteem and guilt
- Social isolation; poor communication
- Persistent boredom; low energy
- Hopelessness
- Decreased interest in activities or inability to enjoy previously favorite activities
- Frequent complaints of physical illnesses (e.g. headaches, stomach aches)
- Frequent absences from school or poor performance in school
- Poor concentration
- A major change in eating and/or sleeping patterns
- Talk of, or efforts to, run away from home
- Thoughts or expressions of suicide or self-destructive behavior
Differences in depression for adolescents and adults
It’s important to understand that depression can look different in youth than it does in adults. As a youth worker, you need to be aware that some of the most common symptoms we’ve come to see as characterizing depression are not always present in youth experiencing depression. Here are some important differences:
Sleep Adults experiencing depression often struggle with insomnia or sleep too much. Youth experiencing depression generally sleep about the same amount, but their sleep patterns are irregular.
Mood Adults with depression tend to be sad or withdrawn, whereas youth with depression generally are irritable and angry.
Interpersonal Relationships Depression often causes adults to isolate and youth may too, but they typically remain social with their close friends.
Knowing these differences and understanding the specific risk factors and warning signs of adolescent depression will definitely help you recognize when you need to intervene and seek more assistance for a young person.
Depression takes many different forms and presents with many different faces.
How a youth experiences depression varies by individual. Here are three stories from Different Faces of Depression that contrast youth struggling with depression, each describing their own unique journey:
Sandy, a 16-year-old European-American middle-class female lives in and goes to school in an affluent area. Sandy’s symptoms of depression were mostly internalized. She struggled with low self-esteem, was sensitive to failure (or perceived failure), had poor eating habits and intermittently engaged in self-harm behaviors. Sandy often described her depression as feeling “stuck” and not feeling motivated or able to change her behaviors and feelings. Ultimately, Sandy benefitted from a long term therapeutic relationship that focused on seeing her own strengths and weaknesses as “good enough” and finding a source of internal motivation that was not based on external feedback from others.
Calvin, an 18-year-old middle class African-American male attends school in an affluent area. Calvin experienced his depression much more externally, at least as others would observe it. He was irritable and angry towards his friends, family, and school staff. He was having trouble with communicating his emotions leading to difficulty in relationships. Calvin was also dealing with expressed thoughts of suicide and using chemicals to moderate his intense emotions. Calvin, in therapy, was tearful and seemed exhausted by the energy he was expending on a daily basis. He began to feel better when he started sharing his internal emotions with people around him. They gained a better understanding of his behaviors and could support him more effectively. He also connected with a physician to begin medications which made chemical use less necessary.
Kim, a 14-year-old European-American female in a middle-class area. Kim’s symptoms were much more existential (focused on the meaning of life and death). She spent time talking and thinking about the point of it all. She lost interest in activities and being engaged with her peer group. Kim became frustrated with the perceived superficial behavior of her peers and had a hard time making friends. She described her depression as “gray.” Kim’s depression began to lift when she was able to name different colors in her days and weeks (even “negative” colors) which showed more diversity in her emotions and gave her hope.
What are the themes?
What’s your impression about depression from these images?
The compilation of those Google Image searches, along with the three youth stories described in Different Faces of Depression, are useful for coming to see that depression is not one-dimensional.
No mental health concern always looks a certain way. Unfortunately, stereotypes do exist and it’s important to recognize if you yourself may have some preconceived notions, or negative impressions about depression that would not be helpful in your work.
In the first Google search, most likely the images had a theme. For example, results included photos in muted colors or black and white, people sitting alone, curled into a ball, sitting in a stairwell, crying, etc.
If this was the only picture you had of depression, you probably wouldn’t recognize many people who are suffering because they would not fit into that image. Calvin and Kim, described in Different Faces of Depression, are two examples that clearly show depression in a different light.
The second Google search probably revealed a much more diverse array of images. Some sad, some happy, some mug shots, some photos of people in groups or in activity. The second search illustrates the idea of depression in the context of a life. It is multi-dimensional.
It will help you to remember that when a young person is struggling with depression, they do not “become” depression. They continue to be a person with their own history, strengths, resiliencies, and interests.
The symptoms of their depression sometimes may make it harder to see the person behind the disorder. But that is exactly what the youth need you to do.
ACTIONS FOR A YOUTH WORKER
Unless you are a mental health professional, your role as a youth worker is not to diagnose the disorder but to recognize the signs of depression. You are often the first line of defense so you need to know what to do when you recognize or have concerns about a youth who may be dealing with depression.
While it is okay to talk with youth about depression and provide them some advice, it is critical to understand you are not a substitute for a mental health professional and appropriate treatment.
Consult with your supervisor and find channels to ensure youth receive the help they need.
SUICIDE IDEATION
Suicide ideation is not a disorder in and of itself, but rather a symptom of depression. Suicide ideation means having thoughts of harming or killing oneself.
Youth workers are in an excellent position to notice warning signs and intervene early to help a young person get the support they need. This is vital as suicide is the second leading cause of death for people between the ages of 15 to 24. Thousands of people are treated for self-inflicted injuries in emergency rooms every year from attempted suicide.
Although it is difficult for most people to talk about suicide, as a youth worker you really do need to become comfortable talking with youth about suicide, even if it makes you - or them - a little squeamish. It is not discussed nearly enough considering the impact it has on young people, either personally or with family and friends.
RISK FACTORS FOR SUICIDE IDEATION
Anyone can be vulnerable to thoughts of suicide at any stage in life. Some of the risk factors for suicidal thoughts or actions:
- Impulsiveness
- Hopelessness
- Isolation
- Being arrested
- Using/abusing alcohol, drugs, or other substances
- Having a disabling and/or chronic illness
- History of abuse, abusiveness, or family violence
- Experiencing a serious personal loss (relationship, friendship, rejection, job loss, failing at school, cut from a team, etc.)
- Prior suicide attempts by self or family
- Recently started anti-depressant medications
There is a higher risk of suicide ideation for children or adolescents in the first few months of taking an anti-depressant. They should be closely monitored by a mental health professional as well as the prescribing physician, especially during those first few months.
While you need to always be on the lookout for the warning signs of suicide ideation, if a youth confides to you that they have started taking anti-depressant medications, pay extra attention.
WARNING SIGNS OF SUICIDE IDEATION
A high percentage of teens who attempt suicide give clear warning signs before taking any actions. There is typically time to intervene so be especially alert and aware when a young person is communicating:
- Hopeless statements e.g.“I just don’t see this ever getting any better.”
- Worthless statements e.g.“Things would be better/happier if I weren’t here anymore.”
- Giving away belongings
- Losing interest in hobbies, school, work
- Saying goodbye, withdrawing from social relationships
- Having a lack of future planning
- Wondering, writing, or drawing about or showing a preoccupation with death
- Engaging in reckless or dangerous behaviors
- Having a definite plan for completing suicide
ACTIONS FOR A YOUTH WORKER
As a youth worker, well aware of your role and responsibility, if you think suicide ideation is a concern for a youth you are spending time with, your first move should be to consult with your supervisor as soon as possible.
Remember, consulting with your supervisor is not a breach of confidentiality. it is a best practice for youth work. In the case of a youth exhibiting warning signs of suicide, you have an obligation to report the information to your supervisor. This is not a situation you should try to shoulder on your own.
Whether you observe the warning signs yourself or simply hear about them from the youth, you need to have the courage, the confidence, and the competence to have a conversation with that young person.
Sometimes, people are afraid to ask a young person directly about suicide because they see it as possibly putting that idea in their head. The truth is, if you’re seeing any warning signs at all, that young person already has the idea in their head. Asking them about it is exactly what you need to do.
As the adult whom the youth chose to confide in, remember:
- MAKE SAFETY THE TOP PRIORITY.
- Exploring existential ideas is often a part of adolescent development. While it may not be a warning sign, it is still worth being curious about. Talk with the youth to get a better sense of their emotional state.
- It is important to be clear with the youth that safety comes first and that if the situation is serious enough, you will need to make sure others are involved to keep the youth safe.
Questions to Ask When Having the Conversation
Remember that there is a common misperception that talking with a young person about suicide will just give them ideas. That’s not the case and talking about suicide is a good prevention and intervention strategy. To help you prepare for what will be a difficult conversation to have, here are some questions you could ask the youth:
- “Are you thinking about killing yourself?”
This is not an easy question to ask but studies show that asking at-risk individuals if they are suicidal does not increase suicides or suicidal thoughts. You are attempting to assess the real threat or danger of the situation.
- “Do you know how you would do it?”
This gives you a sense of how much they have thought about suicide and whether or not they are in planning mode.
- “Do you have access to that method?” (e.g. a gun, drugs)
This will let you know how likely they are to actually complete the plan they may have formulated or imagined.
- “Can you keep yourself safe?”
The answer to this question will let you know what immediate action you need to take:
If their answer is “no,” involve professional help, your supervisor, and parents/guardians immediately, as the youth may need to be hospitalized.
If the answer is “yes,” a couple of follow up questions to ask are “Who would you like to include in this conversation so you’re not alone in keeping yourself safe?” and “How can we let your parents/guardians know how you’re feeling?”
- “May I follow up with you about this?”
Asking permission allows the youth to continue to have some say over who knows private information and how it’s handled. They may not want their basketball coach, for example, asking about their suicidal thoughts at every practice.
If you know that the youth’s care is being handled and other professionals and their parents are involved, you may not be the person they want to follow up.
Did you notice that these questions do not ask whether or not you may let someone know? Instead, they ask how you and the youth – collaboratively - can involve their parents or other people. It’s vital that you not diminish your responsibility to protect the youth from harm.
For the youth’s safety, this is not an issue to be kept to yourself.
They may not want you to tell anyone and in fact they are likely to ask you not to. But this is a time where it is worth a youth being upset with you in order to keep them safe. It’s a good practice to be upfront with young people about your responsibility as it relates to confidentiality.
SELF-HARM
Self-harm, just like suicide ideation, is not a distinct disorder but another symptom of adolescent depression. Self-harm is also referred to as self-injury. It’s important to make a key distinction here about the difference between self-harm and suicide. The two are often confused but in fact, self-harm is the deliberate harming of one’s body without the intent of suicide.
Youth who self-harm likely do it in order to:
- Feel something
- Stop negative emotions
- Convert emotional pain into physical pain, making it easier to deal with
- Avoid doing something unpleasant
- Get a reaction from loved ones (an indicator someone is struggling)
- Feel better
In contrast, youth who are thinking about or planning suicide typically want to end all feeling.
Ultimately, self-harm is a coping strategy, though a maladaptive or harmful one. The youth engages in the behavior as a way to deal with intense emotions.
RISK FACTORS FOR SELF-HARM
Most people who self-harm are teens and young adults. Self-harm often begins in the early teen years when emotions are very volatile. At this age, young people are starting to experience more peer pressure, increased loneliness, and more conflict situations with parents and others in positions of authority.
- A young person who has friends who are self-harming is more likely to also begin that behavior.
- Exposure to traumatic life events such as neglect or abuse, questioning their personal identity or sexuality, or being socially isolated may create risk factors.
- Certain mental health disorders including depression, anxiety, and eating disorders are commonly associated with self-harm.
- People who self-harm are more likely to be highly self-critical and poor problem-solvers.
WARNING SIGNS OF SELF-HARMING BEHAVIORS
When someone mentions “self-harm,” most people think of cutting. While that is one good example, there are many different methods of self-harm. Examples include but are not limited to:
- Scratching
- Burning with a lighter or by vigorously rubbing a pencil eraser on the skin repeatedly
- Hitting
- Biting
- Ingesting or embedding foreign objects into the body
- Hair-pulling
- Interfering with the healing of wounds
When asked about self-injury marks, it is not uncommon for youth to attribute it to some other cause. For example, a youth might say the marks are an injury from a pet (e.g. a cat scratch). Their answer may be true, but it is still worth keeping an eye on that youth to see if they have “cat scratches” often or if they seem to be getting worse or more frequent.
ACTIONS FOR A YOUTH WORKER
Although self-harm typically does not have the intention of suicide, the risk for suicide does increase as the incidences of self-harm increase. Self-harm can be an early warning sign of suicide, but it is often not a suicide attempt in and of itself.
Because of the risk of self-harm leading to suicidal ideation, consult with your supervisor for guidance if you suspect a youth is engaging in self-harm. Be alert for the warning signs. Any form of self-injury is a sign of bigger issues that need to be addressed.
Know that the young person may feel embarrassed or ashamed about their self-harming behavior. You may feel alarmed or scared yourself. Remember that what this young person needs most from you is to be supportive, caring, and non-judgmental.
As with the other mental health concerns discussed in this module, it is important to educate yourself.
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