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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Now, we continue our week-long series on teen mental health, as part of the station's programming during Mental Health Awareness Month, that's May if you didn't know. We've decided to focus on youth because it seems like the teens are not all right, and everybody says so. There was that startling report by the CDC released in March, revealing that the mental health of children and teenagers has been on a decline over the last decade, not just during the pandemic.

Furthermore, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association, collectively declared child and adolescent mental health to be a national emergency. They used that phrase. Seeing this as the emergency that they say it is, we will be getting to the root of the youth mental health crisis over the course of the five episodes this week, and coming up with some solutions, we hope, so we can help the kids in all their lives.

So far in the series, we've explored two theories as to why teens of this era are struggling with their mental health so much. One being a gradual, yet noticeable loss of independence over the last few decades, and another being the usual scapegoat, social media. Today, we want to move from the broader-arching theories about why teens are depressed, we're going to zoom in and talk to a psychologist who treats teens in her practice. Think about it. More often than not, kids often have specific grievances and situations in their lives that influence their emotions, of course.

Maybe they're influenced by the factors that we discussed in those theories, but they're probably not sitting there thinking, "I don't have enough independence, therefore, I'm anxious and depressed," or even, "Social media is why I'm sad." With all this buzz about a teen mental health crisis, it's hard to set normal emotional turbulence within teens, from behavior that requires professional help. Hard to sort those two things apart.

Let's get into some coping strategies for these normal teenage mood swings as well as indicators that your teen may be in more serious trouble. Joining me now is Lisa Damour, PhD, psychologist, co-host of the podcast, Ask Lisa: The Psychology of Parenting, and author of several books, including The Emotional Lives of Teenagers: Raising Connected, Capable, and Compassionate Adolescents. Dr. Damour, thanks so much for joining us for this. Welcome back to WNYC.

Dr. Lisa Damour: Thank you. Thank you for having me on.

Brian Lehrer: Listeners, we'll open the phones right away. Do you have a teenager at home or anywhere in your life that's seemingly struggling with their mental health? Maybe you are a teenager struggling with your mental health. Now's your time to ask Dr. Damour for some advice about your, or your loved one's situation. 212-433-WNYC. Our phones are open. 212-433-9692. As calls are coming in, Dr. Damour, let me start by getting your take on some of the contents of the CDC report from 2011 to 2021, that full decade, they noted an increase in the percentage of kids who report experiencing persistent feelings of sadness, or hopelessness, and in those seriously considering suicide. Does this line up with what you observe in your practice?

Dr. Lisa Damour: It does. We have been seeing rising rates of depression and anxiety over the last decade. Of course, this was all worsened by the pandemic, but what was described in that report, and then certainly, the very worrisome numbers that were in their most recent data collection that was published in February, they covered from the fall of 2020 to the fall of 2021, teenagers reported tremendous distress, which very much maps on to how miserable teenagers were in the pandemic itself.

Brian Lehrer: Is it possible that one factor here is that kids are just more equipped than they ever were before to name and discuss their struggles? Because attitudes and education surrounding mental health, in general, have become more open, are leaning more toward honesty, whereas in the past, they suffered in silence? They're just reporting more frequently on these emotional states that teens in the past may have had as much?

Dr. Lisa Damour: It's a fair question, because, certainly, today's teenagers do talk more about their internal lives and they, in many places and ways, feel much less stigma about doing so, which is a good thing. What I can tell you is that from the methodological standpoint, we always try to control for that, not just the fact that kids are more willing to talk about it, but actually just that there's really something there. Based on the methodologies that are used, we actually think this is real, that in fact, distress and anxiety are rising, depression is rising, and it's not simply an artifact of kids being more open than they have been in the past.

Brian Lehrer: I want to note, again, as we have on the last two shows, the gender and sexuality differences. It's so striking in the CDC report that 29% of boys but 57% of girls reported persistent feelings of sadness or hopelessness. In a separate report, that NPR did a story on, one in five LGBTQ-plus kids reportedly have attempted suicide. What kinds of unique issues are you seeing as relates to gender and sexual orientation?

Dr. Lisa Damour: To start with the gender piece, I think one of the things we need to acknowledge is that some of this may be about the questions that are asked and how they're asked. One of the cardinal rules in psychology is that when girls are distressed, they tend to collapse in on themselves, and have what we call internalizing disorders, more depression, more anxiety. Whereas when boys are in distress, they're more likely to externalize, to act out, to get themselves in trouble, to engage in what we call delinquent behavior.

The CDC report asks about low mood, it asks about feelings of distress, and so, unsurprisingly, girls are reporting those at a higher rate than boys. It's not asking questions that might pick up distress as it often manifests in boys, in terms of, "Have you been really hard on the people around you lately? Have you been engaging in delinquent behaviors?" Those kinds of things aren't as carefully assessed by the CDC data. That may be part of why girls come out of those data looking unusually troubled. It's just the nature of the questions that are asked.

As for kids who are sexual minorities, what we know is that this is incredibly stressful, that our culture is not always as supportive and protective of those kids as they deserve. It's not a huge surprise, though it's very distressing to see the numbers, that teens who are not conventionally straight, or they don't fit those traditional categories or the categories we've always recognized as being more conventional, that they're going to report feeling a lot of strain and a lot of distress because they are sexual minorities.

Brian Lehrer: We hear so often about how the medical establishment discounts the physical state and the emotional state of women compared to men, girls compared to boys. So much research on all kinds of things was done on men over the decades. Did you just basically say that the mental health establishment is more sensitive to the needs of girls than to boys, and therefore they may be missing how boys are as distressed as girls on a percentage basis?

Dr. Lisa Damour: I wouldn't go so far as to say I said that, but what I would say is that the questions we ask are often about the things kids are more likely to report, in terms of their own low mood or their own sadness. I do think that there's a likelihood that we are missing some of how boys are more likely to express their distress in terms of being hard on the people around them. I do think, though, that there is something broader where boys are suffering quite a bit, and we're not always detecting it, as well as I think we should, or not always asking the kinds of questions that would help us pick that up.

Brian Lehrer: Let's take a phone call. Here's Jen in Westchester. You're on WNYC. Hi, Jen.

Jen: Hi, Brian. Hi, Dr. Damour. Yes, I've got a middle child right now who's in the trenches of her teenage years, and I feel like I'm being held hostage by her mental health issues and needs. I grew up in the '80s where nobody cared, and I had all those angsty, depressed, and risk-related feelings, and I was still expected to function. I was still expected to go to school, and do homework, and play on the sports teams and get through it, because nobody cared to listen.

My teen, on the other hand, has all this healthy language and verbal skills to verbalize her feelings, and yet, that seems to be the hang-up each morning when I'm begging her to get out of bed to go to school. I've tried to get all my teens to journal daily because that's how I survived. I basically survived by journaling and listening to the radio. That was my self-soothing, my medicinal healthcare and it's not working with my teen right now. Help.

Lisa Damour: Brian, should I-

Brian Lehrer: Dr. Damour-

Lisa Damour: -jump in here? [crosstalk]

Brian Lehrer: -can you help? You jump right in. We're doing all our part by being on the radio. [laughs] Since that helped Jen get through her teenage years, the radio. Seriously, how can you assist?

Lisa Damour: One thing I would say is for any teenager who is struggling to get out of bed on a regular basis, we would want to have an assessment to check for depression. That depression often takes that form in teenagers. Another form it can take is teenagers who are highly irritable. We expect teenagers to be cranky sometimes, but we don't expect them to be irritable all of the time. If a teenager's mood is getting in the way of their ability to live their lives or to function, that's a great time to reach out to your pediatrician or a mental healthcare professional in your community to get a proper assessment and to check to make sure that that teenager is getting all of the care they need and deserve.

As for the question about how should teenagers handle their moods in general. What the caller gets at is that coping is critically important. That distress on its own is not necessarily a sign of a mental health concern. What we're really interested in is how kids are coping, how anybody of any age is coping. What we want to see is coping that brings relief and does no harm. Where journaling is a great example. Listening to music is often a way that kids cope.

Those are very effective. We want to see those. We want to see kids steering clear of any form of coping that comes with a price tag, whether it's abusing substances or tearing at relationships, or not getting out of bed. If we see coping where it's coming at a cost, that's usually a time to bring in a mental health professional.

Brian Lehrer: Jen, I hope that helps at least a little bit. I'll let you ask a follow-up question if you have one.

Jen: Oh, I have several, but I'm more than happy to just listen to the conversation between you and Dr. Damour. I think the toughest part is that I feel that there's this strange balance that she's been given language to help identify some of her challenges such as symptoms of personality disorder. Part of me thinks that's great. She's been given some identifiers and we can learn about that and we can-- the first step is always awareness.

Also, I feel that she's using it as a weapon or a shield that when she's being asked to step up to what is standard behavior, standard manners, standard level of functioning, we're talking basic completing homework assignments, doing chores that contribute to the home, contributing with family obligations. She will then bring out these identifiers as an excuse to not engage with those things. Does that make sense?

Brian Lehrer: Dr. Damour, anything to add on that point?

Lisa Damour: One of the ways we can think about this is that the job of all of us is to help teenagers regulate their emotions. Teenagers are going to have very powerful feelings. They're going to experience intense emotions themselves. That on its own is not problematic. What we want is for them to be able to regulate their feelings, and we have options for how that can happen. One thing that usually helps with regulation is expressing the feeling, talking about it, naming it, describing it.

It also is true though that sometimes that doesn't work. That in talking about the feeling, either there's not sufficient relief, or it actually leaves the kid feeling worse, especially if they're going into a cycle of talking and talking and talking about it. We call that rumination. When expressing feelings is not providing adequate relief, we then look for ways to help kids tame or bring those feelings back under control so that they're not dominating the landscape of their lives.

What I would say is I listen to Jennifer and I think about any parent or caregiver out there, if what your teenager is doing isn't working, or what you are trying to help your teenager do isn't working, then it is definitely time to get some support from the outside because what we want are regulatory strategies for emotions that actually bring relief.

Brian Lehrer: Jen, I hope that's helpful. Thank you very much for calling in. Relevant to this, there's a quote from your website that I think really jumps out. You're write, "Mental health isn't about feeling good, but about having feelings that fit the moment, even if those feelings are unwanted or painful." I'm just going to say it again, "Mental health isn't about feeling good, but about having feelings that fit the moment, even if those feelings are unwanted or painful." Kind of a mind-blowing sentence. Can you elaborate?

Lisa Damour: Sure. In some ways, I'm glad to hear it's mind-blowing. On the other hand, I just feel like this is what we've believed as psychologists forever. We've just done a terrible job of getting the word out to the general public. What has happened instead is that, I would say especially over the last decade, the cultural discourse has come to equate being mentally healthy with feeling good. That you know you're mentally healthy or your kid's mentally healthy if there's a sense of feeling calm or relaxed or at ease or even happy comes up a lot.

Psychologists like all of those things, but they actually don't figure into how we assess mental health. When we are assessing a mental health question, we're asking two questions, really. One, do the feelings fit the context? Two, are they being managed adaptively? If a kid's best friend moves away, we expect to see sadness. We expect that child to be quite distressed. We expect that kid to be worried about who they're going to hang out with. Those are negative emotions. Those are unwanted, they are unpleasant. They are also proof of that young person's mental health.

I think that's the place where the discourse in the culture has moved so far away from how we understand things as academic and clinical psychologists, is that, for us, often, distress is evidence that that young person works perfectly, whereas so often in the culture, the presence of distress is equated with having a mental health concern.

Brian Lehrer: We are in our teen mental health week here on The Brian Lehrer Show each day on the show, Monday through Friday at this time. Our guest today, Lisa Damour, PhD, psychologist, co-host of the podcast, Ask Lisa: The Psychology of Parenting, and author of several books, including The Emotional Lives of Teenagers: Raising Connected, Capable, and Compassionate Adolescents. Jacqueline in Queens. You're on WNYC with Dr. Damour. Hi, Jacqueline. [crosstalk] Oh, there we go. Sorry about that. We didn't have you at first. Now we've got you up.

Jacqueline: It's okay. Greetings, everyone. Thank you for having this session. I have a question. I have a 14-year-old teenager. I'm a Black woman and my daughter's a Black girl. I wanted you to talk about the intersections of mental health because, for her, having a sad or a bad day sometimes can be seen as her being angry, especially when Black teenagers are adultified.

My fear sometimes, especially for her, she goes to a predominantly white school that when she is going through an emotion versus receiving the care to know like, "Hey, this is an emotion versus anger," there can be some reasons in which she would hold back how she really feels because I don't want to be the angry, violent Black girl in a space of white peers. Can you just touch on the differences in how some groups are allowed to have those moments of sadness while other groups sometimes may not always be able to have those moments of sadness without being misjudged?

Lisa Damour: Absolutely, Jacqueline. I'm so glad you're bringing this up and you are describing something that is very well documented in our literature and our clinical experience around Black adolescents. There are a few things we see that are exactly what you are bringing light to. One is that Black teenagers as a group, you use the term adultification. That's exactly the same that we use in the research literature, that they are seen as older than they are.

This is something we've replicated consistently, and that this has different implications, sometimes breaking down by gender. Sometimes it's the case that as a result of that, Black girls are seen as more sexual than white girls of the same age, and Black boys are seen as more violent or dangerous than white boys of the same age. There's also very developed literature around what you're describing in terms of Black girls and the expression of anger.

You are correct, it is not a safe thing often for girls to do in a school setting, and it may not even be that they're expressing anger. It may be mere assertion, it may just be trying to express displeasure. It's quite well documented that they are disproportionately disciplined within school settings for what adults in those settings are perceiving as angry or disrespectful behavior, vastly more than white girls of the same age.

Very sadly what you're describing is extremely well documented. There's no question about it. It's something that I think to talk about the adultification of Black teenagers, and to get into those details, I'm not sharing anything you are now living that Black families do not know. I think it's really critical for the rest of us to appreciate the undue burden that is placed upon Black teenagers because of that.

Brian Lehrer: We're identifying this bias. Is there any advice that you can give to Jacqueline to help her daughter cope? Really, I think we all agree that the burden should really be on white society to adjust and see people more equally but in the context of her actual situation in her actual mostly white high school, is there any advice you can give to Jacqueline, and by extension, her daughter?

Lisa Damour: I feel incredibly humble as a white woman advising a Black family on how to raise their teenagers given our relative understanding of the realities of this in terms of lived experience. What I will say as a general rule for teenagers who may be marginalized for any variety of reasons, is I would actually ask them to identify who are the adults in your school who feel safe to you, who you feel that you can trust, who you feel you can go to.

It may be another adult of color, it may be somebody who is not of the same racial or ethnic background, but it can help students if they feel like they've got an advocate and a safe place and someone they can check in with about how things are going or about how they're really feeling or about when they feel like they're being treated unfairly. Looking for those advocates, looking for those safe spaces within schools, which hopefully all schools have, can be a proactive place for young people to go. Brian, like you said, the burden here really is not on the Black families. It really belongs on the rest of us to be mindful of this bias.

Brian Lehrer: Jacqueline, is there anything you want to share in terms of advice to other families who may be in a similar situation to what you described?

Jacqueline: I like the advice that I was given as far as finding folks that the students feel comfortable with. Just out there, I wish schools were more intentional about finding social workers or counselors that reflect the community. I know that's really hard to find because there is a shortage of Black and brown folks in the field, but it goes a long way to have someone there that reflects the culture of the students because the students feel a little bit more comfortable expressing themselves in this space.

It's not about a person being Black, white, or brown. It's more so building a relationship so we can get to a better space versus not having anything at all. I just think that I wish more schools were more intentional about finding support services that reflect the population they serve or underserve.

Brian Lehrer: Jacqueline, thank you so much. I hope Dr. Damour is helpful to you and I think you've been helpful to other parents just by telling your story and sharing those thoughts that you just shared. Thank you so much. Dr. Damour, I've been hearing that one of the patterns since the pandemic school lockdowns, now, of course, kids are back for a while already but one of the patterns that some teachers and parents are seeing is more absenteeism, including kids not going to school for relatively long periods of time and that it's more than it was before the pandemic. Is that something that you've experienced in your practice?

Lisa Damour: I'm hearing this everywhere. I actually travel quite a bit. I go to a lot of different kinds of schools and I am hearing from schools across the socioeconomic spectrum across the country that they are seeing rates of, they call it different things in different places, but truancy or chronic absenteeism or chronic school avoidance like they have never seen before. I'm really glad you're bringing it up because I think it's really happening quite a bit more than it's being reported on.

There are a lot of explanations for this but there's one overarching principle that is critical for any parent to know when a teenager is feeling disinclined to go to school for any variety of reasons, which is that avoidance feeds anxiety. This is really one of our cardinal rules in psychology, which is if we're frightened of something and then we avoid that thing, a short-term experience actually is that our anxiety goes down. If I'm nervous about going to school because I've got a big test and I'm feeling more and more anxious as the day of the test is approaching, if I don't go to school that day, my anxiety will plummet. I'll feel quite a bit better.

That has two effects. One is it actually is reinforcing. If you do something and it feels good, you want to do that thing again, so it reinforces avoidance as a solution. The other is whatever I imagined about that test or about how scary school would be remains unchallenged by facts, sort of sealed in amber because I didn't go and discover, "Oh, actually the test wasn't that bad," or, "It turns out the teacher was going to give us a little more information before we took it," or any of those things.

Those two factors actually help to entrench avoidance over time and then for school in particular, that can be true for avoiding social events, anything, but for school in particular, it becomes very, very problematic when kids don't go to school because very, very quickly they are out of the loop socially and they are out of the loop academically, which makes it that much harder to return because kids don't like feeling like they don't know what's going on or that everything has moved on without them.

The almost universal guidance that psychologists offer when a kid is having a hard time going to school or disinclined to go to school is-- we call it graduated exposure. You can call it baby steps, that you have to get them in somehow, even if it's only for part of the day or even if they're only in the office for a while, while they're working on anxiety management strategies so they can get themselves to class. Wholesale avoidance quickly snowballs into a very significant problem.

Brian Lehrer: What can schools do?

Lisa Damour: What schools can do I think in part is to help get the word out that avoidance feeds anxiety. I think part of why that's so important is that avoidance feels good. I really-- I'm empathic about this, parents who are letting kids stay home because the kid is so scared or worried or anxious about going to school, they are lovingly advocating for their kid. I really understand that that is where they are almost always coming from. I think that part of what we need to do is to help adults who are caring for kids understand that that kind of advocacy will over time actually make things worse even if in the moment it just feels like so much the right thing to do.

The goal here, really, is to help kids develop strategies for managing anxiety if that's what's keeping them out of school. We have those. Breathing techniques really work. Challenging one's own thoughts about how bad something's going to be or how ill-equipped one is to manage that thing also works. It's really a matter of helping kids build up anxiety, management strategies, helping kids wade in slowly, and doing what we can to prevent avoidance as the solution to the problem because it almost always makes things worse over time.

Brian Lehrer: Margaret in Noyack, you're on WNYC with Dr. Lisa Damour. Hi, Margaret.

Margaret: Hi. Good morning. Thank you so much. Hi. I'm a parent of a 14-year-old girl and I just also wanted say I really appreciated Jacqueline's comments because really what I wanted to talk to was a shortage, what I perceive to be a shortage of mental health practitioners. We're lucky this generation doesn't see therapy I don't think as the stigma that it might have been to my parents, but I was driving my kid to Queens, I was taking her to the Upper West Side, a lot of practitioners didn't want to see her on Zoom for reasons that I think are probably sound but made things really difficult. We couldn't find anything local.

I'm speaking from a relatively privileged perspective. I'm a white person with good insurance who can go out of network because I get some coverage and my kid doesn't want to see a man, which I understand. That makes sense to me. That cuts down some of our options, but I'm not even worried about like, "Is this person going to reflect her culture?" I don't think any of the people that we were even considering seeing were people of color, for example. Is there anything being done about what I perceive to be a shortage? Am I mistaken about that? Are there any resources you can recommend?

Lisa Damour: You are 100% right about this. When we talk about the mental health crisis in adolescence that it's arisen, it's actually a two-part problem. One is that we have this surge in distress among young people. The other is that the workforce of clinicians who care for teenagers was already full and probably overwhelmed before the pandemic began. Caring for teenagers is actually very specialized work. There aren't a lot of us who do it, and it takes time to actually become skilled at it.

When the surge in need happened, we were in no position to quickly scale up the workforce to meet the need. You're absolutely describing what is going on. Then, as Jacqueline mentioned, we have an incredible paucity of clinicians of color and it does matter to have clinicians who look like you feel familiar, understand your lived experience. What we need to do now and what we were talking about doing now, but I know it is certainly going to feel like too little, too late. Is one, up in the workforce of clinicians who are good and seasoned at caring for teenagers.

Two, building up the pipeline of clinicians of color who care for teenagers and actually kids of all ages. These things take time, but they are certainly becoming a very high priority, but in the conversation about why we're in a crisis, that is the often undiscussed other half of the problem.

Brian Lehrer: Margaret, thank you very much. I want to just take your temperature on something that we discussed in this series earlier in the week before you go. We discussed a theory on Monday with a guest, who believes in it, that children and teens haven't been able to build the confidence and skills they need to face life's challenges as much as in past generations because of increased supervision and a loss of independence. Kids aren't allowed to go out and do things on their own as much because parents fear for their safety, or parents feel structured activities are going to train them better and make them happier.

I'm curious what you make of this theory, and if you think there needs to be a widespread societal change in this country of how parents balance kid's needs for protection and for freedom.

Lisa Damour: I think it's hard to connect the dots between why something happened in the past and why something is happening now. I feel always very cautious about that inference. What I will say is kids need independence. They need to be able to build independence and confidence in their ability to manage themselves. I also think that as a function of increased supervision, we're actually seeing a very safe generation of teenagers. They wear helmets, they wear seatbelts, they generally don't smoke. There's things that kids today don't do that we were doing in the 70s that we shouldn't have been doing.

You can look at it from lots of sides. I think that may be one explanation of what's happening. I think another explanation that we have really good data for is that kids just don't sleep as much as they used to. There's very clear links between reduced sleep and increased mental health concerns. I think that sometimes we leave sleep out of the conversation because it's boring and we know we know, but it's actually huge. Teenagers need to be getting about nine hours of sleep a night, which very few do. For me, when I'm trying to figure out what's going on or where can we make improvements, one of my first questions is how much is this kid sleeping?

If they're not sleeping enough, why aren't they? Is it social media? Is it that they have a ridiculously demanding academic schedule? Is it that they're working two jobs to try to support their family in addition to going to school? I think we can make inferences about the past, but I really love looking at sleep because it is right here right now and it's often something where some adjustments can be made.

Brian Lehrer: That's all the time we have for now. My guest has been Lisa Damour, psychologist, co-host of the podcast Ask Lisa: The Psychology of Parenting, an author of books including The Emotional Lives of Teenagers: Raising Connected, Capable, and Compassionate Adolescence, published just this year by Ballantine Books. I could tell from the response on the phones that people have found your advice and your insight so helpful, Dr. Damour, so thank you very, very much.

Lisa Damour: Thank you for having me.

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