Teenage

Adolescence is both a time of tremendous gains and some inherent losses. You can help your teenage patients through this turbulent time by asking a few specific questions, checking their psychosocial functioning, and distinguishing the somewhat common depressive symptoms from a true depressive disorder. Approximately 10% of patients will need further evaluation sometime during their adolescence, and a few will require urgent referral to protect their safety if you uncover any suicidal ideation or planning.
As children enter adolescence, they make major gains--in intellectual capacity, autonomy from their parents, and physical stature--all things that bring them closer to adulthood. Increasingly, they readily go to school independently, even driving during the later high school years, and participate in activities with less or no adult supervision.
We often look at adolescence as the second major time in fife, the first during the beginning 2 or 3 years of life, with rapid, multifaceted growth. But what people often don't appreciate as much is that, as a child becomes a teenager, they lose a bit of their childhood. Part of the expected moodiness of adolescence stems from puberty and hormonal changes, but some also comes from an unspoken, even unconscious, undercurrent of loss.
The home is no longer seen as the center of their universe. Developmentally, adolescents become closer to adults who are not their parents. They might suddenly develop an intense relationship to a teacher, coach, or friends. This is often appropriate as they transition to adulthood and test out different relationships. Teenagers often have several of these close ties and integrate aspects of these relationships into their emerging identity. Teens learn to transition from counting on their parents, to relying on friends and, in early adulthood, looking primarily to themselves for decision making.
In our society, this transition often takes about a decade, starting when a child is 12 or 13 years old. Educational requirements have extended this transition, so it doesn't end for many people until they are out of college.
You can see a variation or cycling concerning levels of maturity within this 10-year period. Sometimes, teenagers will get very, very close (commonly called a "crush") to a teacher, coach, or friend and almost forget their parents. Then some kind of problem will arise--they don't make the team, feel rejected by a friend, or they get a "D" on a test--and they go back to ward their parents, for a while. With each cycle, adolescents become less dependent on their parents and more comfortable with trying to make it in the world. By the time they are in college, they may cycle for weeks with very little refueling from the parent "gas station."
The undercurrent of loss of their childhood during this time is normal and nothing you have to change. It's just an expected, normal part of everyone's development.
The loss experienced by parents often is more obvious. They might talk about their teenager and say: "He's never home. He's always somewhere else with his friends, and we miss him." We also expect parents to become sad when the adolescent or young adult leaves home, and "empty nest syndrome" is a common topic.
Parents often will ask you if their child's withdrawal, moodiness, or introspection is a sign of depression or part of teenage life.
This can be a challenging question for pediatricians in primary care. You are asked to figure out if the adolescent in front of you is experiencing a real depression or just cycling through the common mood variations of adolescent development.
Adolescent depression can be more subtle to diagnose. It's not like attention-deficit / hyperactivity disorder, which you can see in your waiting room when a child is all over the place or when you talk with the child in an exam room and he cannot stay on topic. In contrast, most adolescents and adults can put on a front, yet feel depressed. Until symptoms and functional impairment become quite severe, no overt sign might be apparent that they are depressed.
The differential diagnosis also is difficult, because a high percentage of seventh-, eighth-, and ninth-graders will report depressive symptoms if you give them a questionnaire.
Look for more intense, multiple depressive symptoms. This can distinguish a real depression that warrants additional intervention from the normal day-to-day challenges of junior high school. Approximately 30%-40% will report not feeling good about themselves, feeling down, or withdrawing from family and friends at the some time. Although most teen patients experience these depressive symptoms as part of development, expect 5%-10% of your patients to report serious depression.
The next question to ask is how long have the symptoms lasted? Usually, 1-2 days is considered a normal variation. If they have symptoms every day for 2 weeks or longer and feel like they cannot escape them, a real depression is more likely. They also might report they are regularly in a bad mood and have major trouble getting into a good mood or having fun.
Also ask about functioning each time you see an adolescent. How are you sleeping and eating? How are you doing in school? How are you getting along with your friends and family? Has there been a clear change in these areas paralleling the change in mood and energy?
If you think an adolescent has major depression, you have to immediately consider their safety. Depressed adolescents are at increased risk for substance use, drunk driving, and suicide, all major causes of mortality.
You have to screen every depressed teenager for suicidal ideation at this point. You do have to ask whether they have thought about harming themselves, whether they have any specific plan about how they will harm themselves, and at least ask about two of the most common means of self-harm (you should ask both the teenager and the parents).
Are they, their parents, or their grandparents taking medication that could be used for an overdose? If so, how is that medication stored? Next, are any guns accessible to the teenager? You should be concerned about access if adolescents have any kind of suicidal ideation. Can they get to something that can kill them while they feel depressed, have an urge to end their suffering, or act impulsively when their judgment is impaired?
If the suicidal risk is high enough, if you feel that you cannot "connect" with the teenager, or if the patient is both "hopeless and helpless," you have to act quickly, even that day. A small minority of patients will reveal an active wish and/or plan to kill themselves. An emergency psychiatric evaluation is indicated.
Often, there is a wish to help an adolescent quickly, and you might wonder if you should prescribe antidepressant treatment right in your office at this initial consult. However, I don't advocate for pediatricians to start antidepressant treatment on their own unless they have a special interest, some training or experience, and can provide comprehensive follow-up.
Adolescent depression is very complicated and often is best addressed with a combination of medication, life changes, and therapy. If at all possible, when you identify a depressed adolescent, get a comprehensive mental health evaluation that addresses any family problems, family history of psychiatric disorders, a more in-depth look at the child's school performance as well as his or her personality. The pediatrician could have a role in monitoring the antidepressant component of a comprehensive treatment plan, but only pediatricians with some added expertise should really be taking on depression on their own.
Some variations of adolescent depression worth noting include dysthymia, a long-lasting, chronic, low-level depression. You might also see teenagers with comorbid anxiety and depression, and often one component is predominant at a time. In addition, you might encounter the small percentage of kids who are manic. Manic adolescents can be euphoric, talk with pressured speech, focus on grand plans or ideas, and/or write prolifically in a journal about their schemes with the focus on volume more than content.
Taking care of depressed teenagers in primary care, even in collaboration with a mental health professional, is rewarding as most improve, but stressful. The clinician worries about all the risk factors from drinking to suicide. If interested, read more and gradually take more responsibility for your depressed adolescents with the support of a mental health colleague.
Ask the Expert
Go to www.pediatricnews.com to ask Dr. Michael S. Jellinek, one of our Behavioral Consult columnists, questions about his column or quandaries you face in your practice. See what questions your peers are asking. So why wait? Join the conversation today!
MICHAEL S. JELLINECK, M.D.
DR. JELLINEK is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. He has no relevant disclosures. E-mail him at [e-mail].
For more information, see guidelines from the American Academy of Pediatrics that address the identification, assessment, and initial management of adolescent depression in primary care (Pediatrics 2007;120:e1299-312).
For a list of DSM-IV criteria for major depressive episode, see Table I in the following publication (J. Fam. Med. 2009;58:187-92).
Jellinek, Michael S.