Inside the Adolescent Mental Health Crisis

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michael barbaro

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.”

Today, why the mental health crisis afflicting America’s youth has become so widespread, and why seemingly everyone has been so unprepared to handle it. I spoke with my colleague, Matt Richtel, about what his investigation has found.

It’s Tuesday, August 30.

Matt, for the past couple of years, you have been exploring a topic that especially throughout the pandemic has become a lot more visible to people, which is that kids, and especially teenagers, in the United States are in the throes of a mental health crisis. So tell me about that reporting.

matt richtel

Yeah, a couple of years ago, we noticed that young people are dealing with mental health distress, and we started to look into the numbers to ask what’s really going on. In 2019, Michael, 13 percent of adolescents reported having a major depressive episode. And that was a 60 percent increase from 2007.

michael barbaro

Wow.

matt richtel

Suicide rates, which had been stable from 2000 to 2007 among this group, leapt nearly 60 percent by 2018. So we started with a basic set of facts. Curiously, this was not the set of facts alone that told us we had something significant to investigate.

michael barbaro

What do you mean?

matt richtel

Well, there was a separate set of data. When I was an adolescent — at the risk of dating myself — in the ‘80s, the public health risks were very different. They were binge-drinking, drunk driving, cigarette use was still very high, teen pregnancy, and early experimentation with sex. These were known as externalized risks. They were happening, say, in the physical world.

michael barbaro

Right.

matt richtel

The new set of risks are internalized risks. There had been a transformation in the kinds of risks facing adolescents. And so my editors were gracious enough to give me enough time to try to unpack the reasons why, and we’ve been at it for a couple of years.

michael barbaro

The nature of the threats to young people have changed. They’ve become not external, but literally internal.

matt richtel

Yes. So the question became not only why have the mental health disorder spiked, but why did it catch us off guard? How did this sneak up on us, and what the heck do we do about it?

michael barbaro

So how did you go about answering those questions of not just how we got here, but why it seems we’re so unprepared for it?

matt richtel

I started by talking to adolescents and their parents. I talked to scholars, and then I talked to the clinicians, the pediatricians, the people on the day-to-day front lines dealing with a lot of this stuff.

melissa dennison

OK. Matt’s calling me. Hey, Matt, how are you, hon?

matt richtel

I am well. How are you?

michael barbaro

And what did you learn from the pediatricians?

matt richtel

In talking to pediatricians around the country, I lucked out in meeting Dr. Melissa Dennison.

melissa dennison

It’s nice to see a smile on your face. There’s a smile on my face, too! [LAUGHS]

matt richtel

Dr. Dennison grew up in a poor rural part of Kentucky —

melissa dennison

I was the daughter of farmers —

matt richtel

— and became committed to becoming a pediatrician.

melissa dennison

I chose to be a pediatrician, because pediatricians were most like me — the most family-oriented and, in my opinion, nicest people. They felt like — and I feel like — children are the most important people around.

matt richtel

She wound up in this town of Glasgow, which is about 40 minutes from the farm where she grew up. And when she got into the pediatrician business in the ‘90s, she was dealing with what we think of as old-school pediatrician issues.

melissa dennison

Well, pediatricians at that point were pretty much infectious disease doctors.

matt richtel

Broken bones and bruises —

melissa dennison

A lot of ear infections, a lot of pneumonia —

matt richtel

— and strep throats and runny noses —

melissa dennison

A lot of rashes —

matt richtel

— antibiotics.

melissa dennison

The main prescription was amoxicillin. Parents felt like that would take care of anything. And then, we did a lot of well child care. We did a lot of immunizations, those kind of things.

matt richtel

But now, in the last, say, decade, increasingly, she’s seen those alongside a different set of issues.

melissa dennison

So for the last 10 to 15 years, pediatricians were told that they should be able to handle bread-and-butter attention deficit disorder. But on top of that, we’ve also had to take care of a lot of children with anxiety, depression —

matt richtel

Issues around mood and attention. You know, she started to see people cutting themselves and people who profess to be suicidal.

melissa dennison

Oh, I never saw anybody cutting themselves back in 1990, and I didn’t have teenagers come in and say, I think I’m anxious. I think I need anxiety medicine. And of course, today, I see it all the time.

matt richtel

And it really sunk in to her that her practice had to change, and it was changing.

michael barbaro

Right. I mean, what do you do when you’re a pediatrician who has trained for the flu and for chickenpox, and suddenly, you have someone coming in saying, I’m having thoughts about taking my own life? What does she say about that?

melissa dennison

When I did my residency, we maybe had a month of child psychiatry.

matt richtel

The first thing she says is, this is not what I trained for.

melissa dennison

You were kind of told, you don’t really need to know that much about it, because if you get into a pinch, you’re going to be able to send your child to a child psychiatrist. Just concentrate on the other things.

matt richtel

And she’s trying to come up to speed with these issues around her, and that was partly because there were not great resources around her to help these young people.

melissa dennison

In this community, we have two child psychiatrists that are located about 40 minutes from here. At this point, they pretty much do not take Medicaid. They take private insurance. And the wait to get in to see them is sometimes three to four months long.

matt richtel

As much as you want to think of rural poor Kentucky as the place that wouldn’t have these mental health services, she’s consistent with what’s going on in a lot of places in the country.

melissa dennison

So we have done a lot of psychiatry, just because there’s no place for them to go. Nowadays, a 1/2 to 3/4 of what I do are anxiety medicines, attention deficit medicines — those kind of things.

matt richtel

So she becomes the de-facto front-line provider for a bunch of really complicated mental health issues.

melissa dennison

You know, I would just love to be able to get a child psychiatrist to see the ones that I don’t feel comfortable with, helping me know which medicines would work better, or help me try to tweak some things that’d really help these people out.

michael barbaro

So Matt, when we think about why we were caught off-guard when it comes to this mental health crisis among young Americans, it seems pretty clear that a big reason why is that the primary medical point of contact for young people — pediatricians — were just not trained to handle this.

matt richtel

Yes. And then, in 2019, this fairly remarkable statement comes out from the American Academy of Pediatrics. And I just — I want to quote it, because it’s so powerful.

michael barbaro

Please.

matt richtel

They wrote, quote, “Mental health disorders have surpassed physical conditions,” unquote, as the main source of impairment and limitation among adolescents.

michael barbaro

From the traditional threats you mentioned, of alcohol, pregnancy, to internal threats of mental health.

matt richtel

Correct. And then, this report also says, quote, “Pediatricians need to take on a larger role in addressing mental health problems,” and says, quote, “yet, the majority of pediatricians do not feel prepared to do so.”

michael barbaro

So just three years ago, the professional association of pediatricians is saying, we’re not prepared, and we know we’re in the middle of a crisis.

matt richtel

That’s right, Michael. And imagine, if the doctors are playing catchup here, what is it like for the young people, the adolescents, the teens experiencing this pain, saying, what the heck is going on?

michael barbaro

We’ll be right back.

Matt, you said that you have spoken to a lot of kids themselves about the state of their mental health and about their lack of, for lack of a better word, readiness to deal with it. So what have you learned from those conversations?

matt richtel

Yeah. It’s where I’ve learned the most. And actually, one of the young people, C, a gender-nonbinary young person in Utah, I have been talking to for the better part of three years.

c

I was born in December of ‘99, so I’m a ‘90s baby.

michael barbaro

Tell me about C’s story.

matt richtel

C grew up in a comfortable family, loved.

c

I was surrounded by love, and running around in my yard, and having a pretty great childhood.

matt richtel

But C started to feel restless and sad, depressed, anxious.

c

The first time I kind of had an inkling that what was happening to me was not supposed to be happening to me and was not just a healthy part of growing up was when I started experiencing really intense physical symptoms of depression. I would throw up and have sweats, and I would shake, and I would have really awful pain in my chest and in my neck.

matt richtel

And C starts experiencing these feelings as early as third grade, and they get very intense.

c

It hurt really, really bad, and it is exhausting. It’s physically and mentally exhausting to be in that amount of pain, constantly, and to not have really a direct answer about why it’s happening. It’s not like you have a cold —

michael barbaro

Now, third grade seems extremely young for someone to be afflicted with this level of mental pain.

matt richtel

Yes. And it actually speaks to a much larger, more pervasive issue, which is puberty.

c

So I hit puberty so crazy early. And I was still in elementary school, and suddenly, my brain is working, like, 20 times faster on the dark crap. Suddenly, everything is like a million times harder.

matt richtel

Puberty is hitting earlier by a lot, as compared to even a century ago. Girls had their first menstruation at around the age of 14 in 1900. Now, it’s around 12.

Boys are following a similar pattern, and it had been dropping even before that. This is a very significant point in our conversation.

michael barbaro

Well, explain that. Why is that significant — a few years earlier onset of puberty — to the mental health of young people?

matt richtel

So we think of puberty, or we tend to generalize it as something having to do with sex or reproduction, but really, a lot of it’s happening in the brain. That’s where a lot of the action is.

The brain is preparing this creature to be aware of social information — in fact, to crave social information as a way of figuring out how to fit in to a much more complex world than the one where the child was cared for. Hierarchy becomes apparent. Competition becomes apparent.

All this information that a young person was either blind to, didn’t see, or didn’t care about suddenly becomes vivid.

So puberty has been happening earlier, but the rest of the brain has not developed any faster — parts of the brain that help make sense of the information that is suddenly so stimulating.

michael barbaro

There’s a mismatch here.

matt richtel

You’ve got a neurological mismatch, and the so-what of that mismatch depends in no small part on what the environment is like around you. For instance, if you’re 150 years ago, and you’re sensitized to a whole bunch of social information, the mismatch takes less of a toll.

You may have trouble digesting information, but there’s less around you and in front of you to make sense of. But what happens when there becomes a cascade of social, hierarchical, competitive information?

michael barbaro

Got it. A big thing happening here is that young people are going through puberty faster, and therefore are being overwhelmed with feelings, and they’re simultaneously being overwhelmed with stimulation. And I’m guessing that ranges from Instagram to what’s ever streaming on Netflix or HBO, and it’s leading young people to be very unhappy.

matt richtel

Yes, and it’s tempting, Michael, to say that this is just social media or a particular app. But it’s really the pace of a technologically driven world, and it comes out in a myriad of ways — your parents, if you’re an adolescent, feeling pressure to have you keep up, the way you are aware of other people’s academic and athletic performance, along with all the news events, climate change, or shootings, or whatever it might be, cascading in at a time your regulatory functions aren’t there to help you make sense of how seriously to take what information.

michael barbaro

So how does this all play out for C — the concept of early pubescence and an environment that’s overstimulated?

matt richtel

So C does, I guess, in a way, perversely — what a lot of young people do is look to the internet itself for some comfort, for some escape.

c

So I got my first iPod Touch, first gen, when I was probably 10 years old, and it was a birthday present. And I was so stoked —

matt richtel

C gets an iPod from their grandparents.

c

And they’re like, nothing bad is going to happen when we give this 10-year-old an iPod Touch. What could go wrong?

matt richtel

C goes online.

c

And I ended up on social media, because —

matt richtel

— posts pictures of themselves they think are flattering.

michael barbaro

Mm-hmm.

matt richtel

This is a way to feel better about themselves.

c

Because nobody warned me. They tell you about stranger danger, but I was not actively seeking these people out. I posted a picture of myself, and then people would come to me and harass me. And —

matt richtel

But lo and behold, what happens is what you might imagine. Men begin to send C terrible, offensive, sexualized images, ask for images from C. C’s essentially assaulted and can make no sense of what’s happening to them.

c

And I never imagined that just existing would bring so much, you know, negativity and disgusting-ness into my DMs. But it sure did.

matt richtel

So C is feeling terrible, feeling confused, doesn’t know how to talk about this. There’s no language out there. Tries to talk to adults. Nothing seems to work. C winds up developing a self-destructive coping mechanism — self-harm.

c

I had a pencil in class, and I would sit at my desk, and I would sharpen my pencil, and I would just kind of sit there and dig at my leg with it for all day. And it was addicting, and I loved it. And that was probably the first time that I figured out that a grounding mechanism could be — not even pain, but just any sort of physical sensation outside of the somatic pain of depression was better than just sitting there and dealing with it.

matt richtel

C has a number of visits to hospitals as C goes through this, trying to solve it. And in the fact that C is turning to hospitals, they are also representative of an emerging trend. Over the last decade or so, the number of young people going to emergency rooms for self-harm-related incidents is up 300 percent.

michael barbaro

Wow.

matt richtel

And not just self-harm — suicidal ideation, symptoms of anxiety and depression, obsessive thinking, rumination, aggression. And remember, this is a place that for a long time was dealing with acute physical injuries — the result of car accidents, or people playing in the park, the concussion, the broken arm. And now, the emergency rooms are seeing a massive increase in mental health-related conditions.

michael barbaro

Mm-hmm.

matt richtel

So when the young people are showing up, the emergency rooms are themselves ill-equipped to deal with mental health issues. This is from the mouths of the ER docs themselves. To one, they say, look, we are trained to deal with the gunshot wound, these terrible, acute issues, but then to move people to the next level of care.

michael barbaro

Right.

matt richtel

The thing is, this is a mental health issue that by definition, in many ways, is chronic. And the doctors there are not equipped. They’ve never been taught to deal with this.

So guess what happens? What happens is young people go in, and they wait. Every night, in emergency rooms across the country, there are at least 1,000 young people spending the night waiting in a room to get to the next level of care where they can be helped. There are at least 1,000, but as many as 5,000 a night in the US, in emergency departments, waiting for somewhere to go.

michael barbaro

So after all this reporting — years, now, of trying to make sense of all this — what in your mind are the steps required to make everyone we’re talking about here better-prepared to handle this crisis?

matt richtel

I’m thinking about this from the listener’s perspective and imagining that many of them are thinking that the answer might be medication.

michael barbaro

Right.

matt richtel

Over the course of the reporting, I’ve talked to lots of adolescents taking medications. C took Zoloft. Medications are complicated. They can be vital and lifesaving when properly prescribed.

Experts will also say that they are prescribed in combinations we don’t understand for safety and effectiveness. You know, in some ways, what they’re getting at is that we are prescribing medications in the absence of dealing with two fundamental structural changes that we have not addressed as a society.

One is a neurological mismatch, and the other is the mismatch between the kinds of ailments young people are dealing with and the way society is structured. So whatever we do going forward, while medication may be a part of that conversation, it can’t be the final answer. So where does that leave us?

michael barbaro

Yeah, where does it leave us?

matt richtel

It leaves us at this big idea, I think — recognizing that given the complexity of the world and the early onset of puberty, the mass of information coming at young people, we have to do a better job providing the structure that acts partly as the regulatory function of the young person’s brain.

michael barbaro

Hmm.

matt richtel

So what would that look like? Well, there are a few therapies that are beginning to emerge, that are specifically aimed at trying to help young people through these periods of intense emotion when their regulatory functions aren’t there.

Broadly speaking — and there are a number of different options, but broadly speaking, you can think of things like cognitive behavioral therapy, which is a type of therapy that isn’t like that Freudian stuff where you talk about your mom and your dad, but as its name suggests, is around behavior and cognition.

What am I feeling? What am I experiencing, and how do I cope with that? Various versions of this aim to help people through these moments of intense emotion, not by saying to them, just calm down, go for a walk, have you really tried to do your homework?

Instead, they try to validate that this actually is a real, overwhelming sensibility or feeling or emotion that the adolescent is experiencing. And then, take a variety of steps to help move the adolescent out of that place, so that they can begin to consider other options, to consider different coping mechanisms that are less self-destructive, and to ultimately understand that in fact, they were overwhelmed, that this was a temporary state, and that they can come out the other side of it a more reasoning person, someone who can make sense of this intense emotion that they’re experiencing.

michael barbaro

So therapies that are very practical, but also really, really honor and respect what these kids are going through.

matt richtel

Yes. And that is where we’ve sort of fallen behind as a society — and somewhat understandably, because you can imagine, 50 years ago, the answer was, go to your room. You’re not paying attention in school. In fact, many of these problems that cropped up in prior generations were seen as something wrong with the kid. It’s something wrong with the mismatch.

michael barbaro

So Matt, is something like cognitive behavioral therapy being more widely adopted if, as you’re saying, it seems to be a part of the solution?

matt richtel

This goes to the point about how we’re behind. We don’t have enough therapists in this and in other fields. There’s not enough counseling. There’s not enough people who are trained. There’s not enough families who can afford this stuff.

When we get there, though, Michael — and I’ll sound a bit naive in saying this — I want to give you my chief reason for hope. Could you imagine if people started to have a teen-life crisis instead of a midlife crisis? Meaning, they learn to cope with difficult emotions and decisions and opportunities and choices earlier on in life, whether that might create a runway for a richer healthier life going forward. Like, there’s an opportunity here.

michael barbaro

To learn how to deal with really hard stuff, even though it’s at a really early age, if we all agree it’s important to address it and to teach it.

matt richtel

The crisis has forced us to have a learning moment. And I guess in some ways, that’s what happened for C.

c

You know, people treat you like it’s your fault. And then, suddenly, a doctor came in and told me that I’m going to be OK, because you’re hurt, but you’re not broken forever.

You’re not just going to wallow in your depression forever. We’re not going to let you. And that was the first time that somebody made it not my fault.

matt richtel

C had begun to learn better coping mechanisms, learned to understand that this thing that’s inside of C that maybe was partly genetic, maybe triggered by an environment and an early puberty, can be addressed, and that C has some control over that situation.

michael barbaro

So C has navigated this.

matt richtel

C has navigated this, and C has learned that they must navigate it from here on out.

michael barbaro

Well, Matt, thank you very much for all of us. We appreciate it.

matt richtel

Michael, thank you so much for having me. I appreciate it.

michael barbaro

We’ll be right back.

Here’s what else you need to know today. In Iraq, supporters of a prominent Muslim cleric stormed the presidential palace in a series of clashes that left about 12 people dead and highlighted the country’s political chaos.

The clashes followed an announcement by the Shiite cleric, Muqtada al-Sadr, that he was retiring from politics. Sadr won the largest number of seats in Iraq’s parliament last October but failed to form a government.

And on Monday, Ukrainian forces said they had launched a military offensive in the country’s South, potentially signaling the start of a long-awaited operation to retake a key area from the Russian military. The offensive is focused on Ukraine’s Kherson region, whose capital was the first major city to fall to Russian forces when the invasion began.

But it’s unclear whether Ukrainian forces actually have the capacity to take back the territory. Today’s episode was produced by Michael Simon Johnson and Rikki Novetsky, with help from Stella Tan. It was edited by Patricia Willens and Michael Benoist; contains original music by Marion Lozano; original audio from Kassie Bracken, Elliott deBruyn, and Ben Laffin; and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.