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Transforming the understanding
and treatment of mental illnesses.

Facebook Live: The Youth Mental Health Crisis

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SHELLI AVENEVOLI: Hello, and welcome everyone. Thank you so much for tuning in today. I am Dr. Shelli Avenevoli. I am the deputy director of the National Institute of Mental Health. My background and scientific expertise are in developmental psychology, which focuses on understanding how humans grow and change across the lifespan. During the next half hour together today, I'll be talking to you about adolescent development and mental health. I'll summarize what we know about brain development, as well as social and emotional development during the first two decades of life. I'll also discuss the challenges that our youth are facing today and how these challenges pose risk to wellbeing and mental health. I'll cover topics such as youth suicide, the effects of technology, and the pandemic on adolescent health, and what the research says about supporting the mental health of current and future generations of youth. I'll also use the last five minutes or so to take some of your questions. So please, enter them as comments under the live stream post below. And I'll do my best to get to as many of them as possible.

It's important to note that I won't be able to provide specific medical advice or referrals today. Please do consult with a qualified healthcare provider for diagnoses, treatment, and answers to your personal questions. If you need help finding a provider, please visit our website at nimh.nih.gov/findhelp. If you or someone you know is in crisis right now, please call or text the 988 Suicide and Crisis Lifeline at 988. You can also visit the 988lifeline.org website for more information and help. The lifeline provides 24 hours a day, seven days a week, free and confidential for people in distress. They also provide prevention and crisis resources for you and your loved ones, as well as best practices for professionals in the United States. Okay, so now that we have the introductions out of order, let's get started. There's really no question that today's youth are experiencing increased stress and mental health challenges. A recent advisory from the US surgeon general highlighted that we are in the midst of a youth mental health crisis. Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor outcomes in young people with up to one in five children in the US with a recorded mental, emotional, developmental, or behavioral disorders.

Mental disorders do often begin in childhood and adolescence. Examples include anxiety disorders, attention deficit hyperactivity disorder, autism spectrum disorder, depression, eating disorders, and post-traumatic stress disorder. For many adults who have mental problems, their symptoms were present but not always recognized or treated in childhood and adolescence. For a young person with symptoms of a mental disorder, the earlier treatment is started, the more effective it can be. Early treatment can help prevent the more lasting and severe effects as a child grows up. There really are a lot of changes that take place during adolescence. Adolescence is a period of dramatic development of the brain, of the body, even of our social context. These changes allow an adolescent to develop the full range of physical, cognitive, emotional, and social skills that they need to become a mature adult. But it is also the case that some of these changes can make children and adolescents more vulnerable to mental health problems and mental disorders. So let me start by taking a few minutes to talk to you about brain development. We know that brain development is a process.

The brain actually does not finish developing and maturing until the mid to late 20s. That may be surprising to some. During adolescence, the brain undergoes significant restructuring that increases the efficiency of the brain. So this is all good because it helps our brains work more efficiently. The unused connections in the processing part of our brain, which we call the gray matter, those are pruned away. So if we're not using those connections, we sort of cut those away. And at the same time, the connections that we are using a lot, they're strengthened. This restructuring of the brain takes place in different areas of the brain at different times. So you see parts of the brain maturing earlier than other parts of the brain. I like to think of a developing puppy, where you see the large feet develop before the rest of its body. Adolescence is often characterized by the imbalance of this maturation process where the subcortical parts of the brain-- you may have heard us refer to them as the limbic system and the reward systems. Those develop earlier in adolescence. But the front part of our brain, which we call the prefrontal cortex, is one of the last regions to mature. This is the area responsible for skills like planning, prioritizing, and controlling impulses. So it may not be surprising that because these skills are developing at different rates, adolescents may be more likely to do things like engage in risky behaviors without considering the potential consequences of their decisions.

We know that brain development and development more generally is influenced by a host of factors, from genes to biology. But it's also heavily influenced by our environments in which we live. Some examples of environmental influences include our nutrition, the things that we eat, poverty, and deprivation, our social connections, our social relationships, and other environmental exposures like air quality or water quality. The environmental influence we know the most about is stress and trauma. We know from our research that there are differences in the structure and function of the brain in people who were exposed to early life stress and trauma compared to those who were not. Early exposure to stress increases risk for just about every health condition, and that includes mental health. Now, it is the reality that everyone experiences some stress at some point in their lives, and it is the case that most people exposed to stress do recover and do not experience long-term negative effects from those experiences. However, there's still a significant minority of people who will have more chronic experiences of illness because of those early experiences.

We are really just still trying to understand how and when exposures to trauma and stress cause enduring problems, why sometimes they do and sometimes they don't. Our understanding of how stress and other experiences interact with each other and with a child's own biology to affect brain development and ultimately health and mental health is incomplete. Right now, we are supporting, together with other institutes at the NIH, the Adolescent Brain and Cognitive Development study. Often referred to as the ABCD study. It's a longitudinal study of 10,000 children, conducted at 21 sites across the US, and reflecting diversity of the United States in terms of sex, race, ethnicity, socioeconomic status, and urbanicity. We're looking forward to the study yielding critical insights into the foundational aspects of adolescent development and how those periods of growth affect at the development of substance use and mental disorders.

Okay. I'm going to shift gears just a little bit for a little while and focus our discussion here on suicide prevention. What we know about suicide risk and prevention, we know that, in 2020, suicide was the second leading cause of death for early adolescents, 10 to 14-year-olds. And the third leading cause of death for older adolescents were 15 to 24-year-olds in the US. Between 2007 and 2019, rates of suicide among youth increased by 57%. That is a significant amount. We have seen some decreases between the years of 2018 and 2020. We don't yet have the rates for 2021. But overall, even though we've seen small decreases, the rates remain high and are still rising in some groups. So even if the overall rate is decreasing, we see increases in certain subgroups. Minority youth are disproportionately affected by suicide, particularly compared to White youth. For example, suicide rates among American Indian and Alaska Native people are the highest of any racial and ethnic group in the US. That's true for adults and for adolescents. But we've also seen stark increases in suicide rates among Black youth and among Asian or Pacific Islander youth as well.

We are also seeing concerning increases in suicide among five to nine-year-olds. And for the first time, suicide is the 10th leading cause of death in these young children. So what are we doing about this problem? Suicide prevention has been a high priority at NIMH for a long time. We've been working to reduce the rates of youth suicide by supporting research that helps us better understand the causes of the rising rate of youth suicide and identify the most effective ways to reduce a child's risk for suicide. We are encouraging practice-based research aimed at testing child-focused prevention interventions. And we are funding research that has developed screening tools to help us identify those kids at risk before they engage in dangerous behaviors. We are working collaboratively with other agencies and with groups like the National Action Alliance for Suicide Prevention to expand screening for suicide risk and for delivery of care in medical settings, like the emergency department or primary care. We know that the majority of individuals who die by suicide are seen by a healthcare provider in the weeks or months prior to their death.

Research focused on these kinds of settings where we know people seek care has the ability to help us change practice and ultimately reduce the rate of suicide. At NIMH, we also recently convened a four-part virtual research roundtable series, which we called Risk Resilience and Trajectories in Preteen Suicide. This is focused on really understanding the causes of suicide risk among very young people, what we know about it, how we talk to children about it, how we screen them, and what we can do to prevent in these very young individuals. Okay, so I'm going to shift gear a little bit and move you on to a new topic. Now I want to come back and talk about the effects of things like technology and social media, what we actually know about these things and their impact on development and mental health. So the US surgeon general's advisory on youth mental health, which I alluded to earlier, highlighting that we're in the middle of a youth mental health crisis, that advisory also drew special attention to the need to better understand how youth engage with digital technologies, social media, gaming, and other online content, and how that engagement impacts their wellbeing and their mental health.

Children and adolescents, no doubt, have increasing access to and spend an increasing amount of time engaging in these online activities and consuming content on these platforms. We know that there are scientific studies that have reported negative impacts of social media and technology use on child and adolescent development. And research suggests that spending a lot of time online distracts from things like actual social connection, in-person social connection. So even adolescents who spend a lot of time engaging socially on social media report higher levels of loneliness and other symptoms despite this regular social media interaction. So spending a lot of time on social media also distracts from things like physical activity, sleep routines, significant amounts of sleep, and in-person activities. And we know that all of those things are important for mental health. So if you're not addressing those issues, you will see negative mental health outcomes. There is also, however, some emerging research to suggest that social media can also be a useful tool that we can use to identify children at risk for mental health or emotional disturbances. So in addition to understanding its harms, it's important to determine how best to leverage these kinds of digital technologies and platforms to enhance mental health and identify those in need of intervention.

They're going to stick around for a while, so it's really ideal that we focus on how we can leverage these opportunities. There's really still a lot we don't know about the impact of digital technologies and social media and the like on our youth and on their mental health. So we'll be focusing on doing a lot more research in this area, focusing on kids as young as-- very young children all the way through the teen years. Right now, we're supporting research looking at patterns of social media use and their associations with things like suicide, self-harm, and depressive symptoms. The ABCD study that I mentioned earlier will also be evaluating the impact of adolescent development and mental health and substance use as well. And we are getting a lot of interest and research in this area, not just from parents and adolescents themselves but also from a variety of other stakeholders, from the president, from congress. In fact, the FY '23, the fiscal year '23 president's budget for NIMH suggested a $5 million increase to support additional research in this area.

Okay. So now, shifting to not just focus effects of social media and digital technology use and mental health, but what do we know about the pandemic effects on development and mental health? What do we know so far? Well, the pandemic has been an intensified period of stress for all people. But what's really important to note is that, for children and adolescents, the pandemic has occurred during a time of formative development when social connection and other activities are vital for healthy development. And children's experience of the pandemic, it's not the same for every child or adolescent. It varies by individual. It varies within the communities that they live in. During the early phases of the pandemic, many children were isolated from typical support networks, like peers, like teachers, or coaches. Other children, because they spent much more time in the home, may have witnessed domestic violence or even experienced increased child abuse or neglect during the pandemic.

And there are over 200,000 children who have lost parents during the pandemic, and many more have lost other loved ones. So the experience of the pandemic is not equal across all children and adolescents. So what do we know about the impact? We know a lot, as I mentioned earlier, about the impact of stress and trauma sort of broadly. And children, like adults, have similar reactions to experiences of stress and trauma. The most common reactions are things like they have negative affect. They have problems sleeping or are having some health concerns. Or they just perceive additional stress. But there is also a subgroup that may experience symptoms of depression, anxiety, acute stress, and even complicated grief for those who've lost loved ones. So the bottom line, in a nutshell, is that the pandemic has been really challenging for mental health.

We know that one in four youth globally - so this is across the globe - are experiencing clinically elevated depression symptoms. So that's 25% of all youth. And one in five or 20% are experiencing clinically elevated anxiety symptoms. And just to give you some context on that, this is double what were the rates before the pandemic. Data from the ABCD study shows that social determinants of health and living in states with lower vaccine rates is associated with increased stress, sadness, and COVID-19 worry. And what's really important to consider is that the pandemic has impacted certain subgroups of our population even more than others. So for example, those with pre-existing mental health problems, they experienced worsening of symptoms during this time and greater challenges to accessing care. Black youth were more likely than other youth to lose a parent or caregiver to COVID-19. Latino youth reported higher rates of loneliness and poor or decreased mental health during the pandemic. Asian American, Native Hawaiian, and Pacific Islander youth reported increased stress due to COVID-19-related hate and harassment.

Similarly, we saw very high rates of thoughts of suicide among LGBTQ-class youth. And the inequities in access to care that we saw long before the pandemic were only amplified during the years of the pandemic. So what are we doing about this in terms of research? At NIMH, we've really tried. We know that the pandemic is having a negative effect, and we are assessing that. But we're also trying to focus on research that can identify mitigating factors, ways that we can mitigate the negative impact. So we funded research, for example, on developing school interventions to improve mental health during and after the pandemic. We've been focusing on gaps related to mental health for health disparity populations and other vulnerable populations during the pandemic. We've been looking at the long-term consequences of the pandemic, both in terms of normative development as well as in terms of mental health, and trying to identify again those factors that might promote resilience in these contexts.

NIH is also funding understanding things like lung COVID in children and adolescents and adults as well. And we've recently hosted a conference at NIMH focused on youth mental health disparities, trying to identify how we can bring greater access to care within these communities. Okay, so it can be really tough for you if you see a child struggling to know when is the right time to get in touch with a healthcare professional. Sometimes, what you experience is really just part of normal development. And other times, it can be a sign of a problem. So what should you do? What should parents and teachers look for? Two of the most important things for you to consider is whether those behavioral signs or symptoms last for weeks or months. So if they last more than a day or two or for a week at a time, a week or more at a time, you might consider reaching out to a healthcare professional. Likewise, if those issues are interfering with the child's daily life at home, in school, or with friends, this is also an important sign that you reach out to a healthcare professional.

On our website that we listed before - and we'll show you again at the end - we have lists of other warning signs that you might consider. And we've divided them for young children and for older children. These include things like frequent tantrums, talking a lot about worries or fears, complaining about stomach aches, headaches. In older children, in adolescents, it looks like things like losing interest in things they typically enjoy, sleeping too much or too little, spending time alone when that's not typically what they do. And of course, engaging in self-harm behaviors or smoking, drinking, or using drugs are all warning signs. So what can parents, teachers, and youth do to help? During these stressful times, we first need to meet our children and adolescents' most immediate needs. We need to get them medical care if they need them. We need to make sure they're safe. And we need to keep them on routines, providing routines for our kids.

Second, we need to help minimize additional stressors for them. So if you can keep your children out of things like your financial difficulties that can only add to the burden, that's a good thing. Do engage them in activities they value. Also, I think the most important thing for parents, teachers, and youth is that you pay attention to the signs that the child is struggling or showing signs of distress, some of which I just mentioned, and then connecting these children to care with a qualified mental health specialist. And your pediatrician can help you find that kind of qualified person. We also need adolescents to take good care of themselves. We need them to work on ways to cope, like exercising, being active and eating healthy, getting regular and sufficient sleep, keeping a journal. A journal can help them identify and challenge their own negative thoughts in stressful times. Do relaxation exercises. There are plenty of apps available for this. And most important, having them talk to family, friends, or a trusted adult when they are struggling. The important point to keep in mind here is that mental disorders are treatable, and it's really about identifying people who struggle and getting them to the care that they need.

All right. So I think now is a good time for us to pause and take a few questions. Okay, so one question. Can you speak to the issue of sleep disturbance and adolescents? So adolescents are phase-shifted during this time, so it's very normal that an adolescent will want to go to bed later and wake up later in the morning. That part of it is very normal. But syncing that normative pattern with the expectations of getting to school on time or sports practices in the late evening or the early morning often can cause some sleep disturbances in youth because what happens is, they participate in all those activities and then do not get sufficient sleep or have a sort of standard sleep routine. Using digital technologies has also caused some sleep disturbances in adolescents as well. So routinizing adolescents, trying to get them to respect sleep and prioritize sleep is an important thing. With younger children, having rules about turning off phones at a certain time of night can be beneficial.

Second question. How can we prepare our teens to manage stressors that come with their transition into adulthood? This is a great question. We can help teens manage stressors by talking about things, by talking with other peers who are going through the same period of transition, talking with trusted adults who have already been through those periods of transition, and also just keeping them focused on things like taking care of themselves, as I mentioned. Sleep, exercise, meditation, these kinds of things can sort of mitigate the effects of a stressful transition. We probably can't undo the reality that transitions into young adulthood with more responsibility and more obligation. We can't stop that, but what we can do is help an adolescent learn how to negotiate those challenging transitions. So third question. Has the more widespread use of and access to telehealth mental health services due to the pandemic impacted the overall health of teens? So we're still waiting for more research to come out in this area. There's definitely been some really hopeful data that have come from it that suggests more youth, and adults too, are getting more access to care. And they're actually staying more engaged in care for longer. That's what some of the early data have showed us.

There are some negative findings as well suggesting that this doesn't work as well for all populations of youth. For example, some minority groups don't utilize telehealth in the same way that other groups do. So there are pros and cons. And I think the bottom line is, if you can find telehealth options that work for you, it can be a very positive experience and enable you to engage and maintain quality care. Next question. Can you explain more about how social media can potentially benefit mental health? Well, I think the point is is that kids are accessing these social platforms on a daily, hourly perhaps, basis. And I think it's going to-- there are some programs already out there - and I won't name specific platforms, but - that have tried to come up with ways that, if a youth is talking or conversing with other youths about a topic, pop-ups might come up. So if they're talking, for example, about suicide or worries, things like the suicide prevention helpline will pop up.

There are other investigators who are suggesting that there may be ways, by understanding social media use, that we can actually identify youth in distress. And as I mentioned earlier, the most important thing to do is to find people early and bring them to care. So if you know someone's in distress, if you know they're struggling with mental health symptoms, identifying them and bringing them to care is key. So these digital platforms can be a means of identifying kids, of providing them educational information, and also potentially providing eventually some level of access to care or opportunities to link to care. Okay, I'll take one more question. Is there any info on the pandemic's effect on the health, mental health, and development of children born in 2020 and beyond or those who are currently five and under? That's a great question. I don't, off the top of my head, have specific memory of them. I can tell you we are supporting research that we don't have the answers to yet, things like we're trying to understand the impact of mom's exposure to COVID while she's pregnant and what are the neurodevelopmental outcomes in youth. And so far, those studies have suggested - this is not definitive - that there may not be any long-term neurodevelopmental effects.

In terms of a child's social and emotional development, the focus has been more on their interactions with peers and the lack of opportunity early in the pandemic to do this. But as I mentioned, everyone's experience with the pandemic has varied. So it's been really hard to sort of parse out some of these various factors. So I would say we don't know a whole lot yet. But research is in progress, and we will know more soon. Well, thank you all so much for your questions, and thank you so much for joining us today. Unfortunately, I think we're at the end of our time together. This is a really important discussion, and I hope you continue to think about it. And I hope that the information was helpful to you. Please do reach out for help if you need it. That's the bottom line here. And as a reminder, if you or someone you know is in crisis, please call or text the 988 Suicide and Crisis Lifeline or visit 988lifeline.org for more help or information. A great place to start in finding help is our website, nimh.nih.gov/findhelp. And for more information about child and adolescent mental health, we have several bits of information on our nimh.nih.gov/children website. So thank you all again for joining me, and have a great rest of your day.