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Taken from Chapter 2: The High-School Years, and Chapter9: Emotional Disorders
Talking About Sex With Your Teen
Anxiety and Avoidant Disorders
Depressive Disorders
TALKING ABOUT SEX WITH YOUR TEEN
As daunting a task as it may seem, this is one of the more important jobs of parenthood. Teenagers need not only the biological basics they get in health and hygiene classes at school?--they need parental guidance, too. Thoughtful but frank talk about sexuality before sexual experimentation begins may also open lines of future communication about your teen's sexual concerns and behavior. If you're afraid of this subject and keep avoiding it, your youngster may develop the same attitude and may avoid discussion and sharing with you. Be honest and sensitive as you employ some of the following strategies for discussing sex with your teen:
Be proactive rather than reactive.
Teens often say they'd like to discuss sex with their parents but can't seem to get the words out. Don't wait for your teen to come to you. Initiate the discussions yourself. Teens whose parents discuss sex openly with them are more likely to wait to have sexual intercourse than their uninformed counterparts. The issues of pregnancy and contraception are equally important for boys and girls to understand.
Give her permission to say no. If you issue an edict that under no circumstances is the teen to have intercourse, don't be surprised if she rebels by doing just that. On the other hand, she's more likely to feel good about saying no if you help her understand why that is a wise option. For example, you might want to acquaint her with some common ploys, such as If you love me, you'll sleep with me, and so on. Let her know that a truly loving relationship between two people doesn't involve coercion.
Avoid trying to scare her into abstinence.
If your teen is feeling rebellious, scare tactics may push her over the edge or scare her so badly that later it will prove a burden to enjoying an adult sexual relationship.
Help her understand that sex is more than intercourse. Sex is an act that also involves the feelings of both partners. Let her know that there are ways to express her sexuality without having intercourse before she is ready. She should be aware that it is not all or nothing. She can enjoy a physical relationship without having intercourse.
Respect her privacy.
The minute your teen walks in the door from a date, don't demand to know what happened that evening. Let her know that you trust her. Stress, however, that if she is being sexually active or considering it, you expect her to behave responsibly.
Try to avoid overreacting.
If your teen comes to you with a question about AIDS, for example, don't automatically assume the adolescent has been exposed to the virus. Simply answer the question without accusations or jumping to conclusions. Later ask if there was a particular reason for the question. Use this topic as a way to keep channels open. Don't insist there must be some secretive reason for the curiosity.
If, despite your efforts, you just can't discuss sex with your teen, have someone stand in for you-?your spouse, perhaps a relative or a trusted friend, your teen's doctor, or a favorite teacher. If your teen has been active in church, then a trusted member of the clergy may also be helpful.
ANXIETY AND AVOIDANT DISORDERS
Everyone experiences anxiety. It is a natural and important emotion, signaling through stirrings of worry, fearfulness, and alarm that danger or a sudden, threatening change is near. Yet sometimes anxiety becomes an exaggerated, unhealthy response.
Given the array of changes and uncertainties facing a normal teenager, anxiety often hums along like background noise. For some teenagers, anxiety becomes a chronic, highpitched state, interfering with their ability to attend school and to perform up to their academic potential. Participating in extracurricular activities, making and keeping friends, and maintaining a supportive, flexible relationship within the family become difficult. Sometimes anxiety is limited to generalized, free-floating feelings of uneasiness. At other times, it develops into panic attacks and phobias.
IDENTIFYING THE SIGNS
Anxiety disorders vary from teenager to teenager. Symptoms generally include excessive fears and worries, feelings of inner restlessness, and a tendency to be excessively wary and vigilant. Even in the absence of an actual threat, some teenagers describe feelings of continual nervousness, restlessness, or extreme stress.
In a social setting, anxious teenagers may appear dependent, withdrawn, or uneasy. They seem either overly restrained or overly emotional. They may be preoccupied with worries about losing control or unrealistic concerns about social competence.
Teenagers who suffer from excessive anxiety regularly experience a range of physical symptoms as well. They may complain about muscle tension and cramps, stomachaches, headaches, pain in the limbs and back, fatigue, or discomforts associated with pubertal changes. They may blotch, flush, sweat, hyperventilate, tremble, and startle easily.
Anxiety during adolescence typically centers on changes in the way the adolescent's body looks and feels, social acceptance, and conflicts about independence. When flooded with anxiety, adolescents may appear extremely shy. They may avoid their usual activities or refuse to engage in new experiences. They may protest whenever they are apart from friends. Or in an attempt to diminish or deny their fears and worries, they may engage in risky behaviors, drug experimentation, or impulsive sexual behavior.
PANIC DISORDER
More common in girls than boys, panic disorder emerges in adolescence usually between the ages of fifteen and nineteen. Feelings of intense panic may arise without any noticeable cause or they may be triggered by specific situations, in which case they are called panic attacks. A panic attack is an abrupt episode of severe anxiety with accompanying emotional and physical symptoms.
During a panic attack, the youngster may feel overwhelmed by an intense fear or discomfort, a sense of impending doom, the fear he's going crazy, or sensations of unreality. Accompanying the emotional symptoms may be shortness of breath, sweating, choking, chest pains, nausea, dizziness, and numbness or tingling in his extremities. During an attack, some teens may feel they're dying or can't think. Following a panic attack, many youngsters worry that they will have other attacks and try to avoid situations that they believe may trigger them. Because of this fearful anticipation, the teen may begin to avoid normal activities and routines.
PHOBIAS
Many fears of younger children are mild, passing, and considered within the range of normal development. Some teenagers develop exaggerated and usually inexplicable fears called phobias that center on specific objects or situations. These intense fears can limit a teenager's activities. The fear generated by a phobia is excessive and not a rational response to a situation. The objects of a phobia usually change as a child gets older. While very young children may be preoccupied with the dark, monsters, or actual dangers, adolescents' phobic fears tend to involve school and social performance.
Several studies have revealed an increase in school avoidance in middle?school or junior?high years. With school avoidance, excessive worries about performance or social pressures at school may be at the root of the reluctance to attend school regularly. This leads to a cycle of anxiety, physical complaints, and school avoidance. The cycle escalates with the worsening of physical complaints such as stomachaches, headaches, and menstrual cramps. Visits to the doctor generally fail to uncover general medical explanations. The longer a teenager stays out of school, the harder it becomes for him to overcome his fear and anxiety and return to school. He feels increasingly isolated from school activities and different from other kids. (See also School Refusal, Truancy, and Dropping Out, page 141.)
Some youngsters are naturally more timid than others, As their bodies, voices, and emotions change during adolescence, they may feel even more self?conscious. Despite initial feelings of uncertainty, most teens are able to join in if given time to observe and warm up. In extreme cases, called social phobia, the adolescent becomes very withdrawn, and though he wants to take part in social activities, he's unable to overcome intense self?doubt and worry. Gripped by excessive or unreasonable anxiety when faced with entering a new or unfamiliar social situation, the adolescent with social phobia becomes captive to unrelenting fears of other people's judgment or expectations. He may deal with his social discomfort by fretting about his health, appearance, or overall competence. Alternatively, he may behave in a clowning or boisterous fashion or consume alcohol to deal with the anxiety.
Because so much of a teenager's social life gets played out in school, social phobia may overlap with and be hard to distinguish from school avoidance. Some teens with social phobia may try to sidestep their anxious feelings altogether by refusing to attend or participate in school, Classroom and academic performance falls off, involvement in social and extracurricular activities dwindles, and, as a consequence, self?esteem declines.
Some teens may experience such a high level of anxiety that they cannot leave the house. This disorder, agoraphobia, seems to stem from feelings about being away from parents and fears of being away from home rather than fear of the world. In fact, a number of children who demonstrate severe separation anxiety in early childhood go on to develop agoraphobia as adolescents and adults.
CAUSES AND CONSEQUENCES
Most researchers believe that a predisposition towards timidity and nervousness is inborn. If one parent is naturally anxious, there's a good chance that their child will also have anxious tendencies. At the same time, a parent's own uneasiness is often communicated to the child, compounding the child's natural sensitivity. A cycle of increasing uneasiness may then be established. By the time this child reaches adolescence, his characteristic way of experiencing and relating to his world is tinged with anxiety. Some research suggests that children who are easily agitated or upset never learned to soothe themselves earlier in life.
In many cases, adolescent anxiety disorders may have begun earlier as separation anxiety, the tendency to become flooded with fearfulness whenever separated from home or from those to whom the child is attached, usually a parent. Adolescents can also have separation disorders. These teens may deny anxiety about separation, yet it may be reflected in their reluctance to leave home and resistance to being drawn into independent activity. Separation anxiety is often behind a teen's refusal to attend or remain at school.
School avoidance can follow a significant change at school, such as the transition into middle school or junior high. It may also be triggered by something unrelated to school, such as a divorce, illness, or a death in the family. Some youngsters become fearful about gang activities or the lack of safety in school.
A worried teenager performs less well in school, sports, and social interactions. Too much worry can also result in a teenager's failing to achieve to his potential. A teen who experiences a great deal of anxiety may be overly conforming, perfectionistic, and unsure of himself. In attempting to gain approval or avoid disapproval, he may redo tasks or procrastinate. The anxious youngster often seeks excessive reassurance about his identity and whether be is good enough.
Some teenagers with anxiety disorders can also develop mood disorders (see Depressive Disorders, page 209, and Bipolar Mood Disorders, page 217) or eating disorders (see page 260). Some teenagers who experience persistent anxiety may also develop suicidal feelings or engage in self?destructive behaviors; these situations require immediate attention and treatment. (See Teenage Suicide, page 213.) Anxious teens may also use alcohol and drugs to self?medicate or self?soothe (see Experimenting With Alcohol and Drugs, page 94) or develop rituals in an effort to reduce or prevent anxiety (see Obsessive?Compulsive Disorder, page 201).
HOW TO RESPOND
If your teenager is willing to talk about his fears and anxieties, listen carefully and respectfully. Without discounting his feelings, help him understand that increased feelings of uneasiness about his body, performance, and peer acceptance and a general uncertainty are all natural parts of adolescence.
By helping him trace his anxiety to specific situations and experiences, you may help him reduce the overwhelming nature of his feelings. Reassure him that, although his concerns are real, in all likelihood he will be able to handle them and that as he gets older, he will develop different techniques to be better able to deal with stress and anxiety.
Remind him of other times when he was initially afraid but still managed to enter into new situations, such as junior high school or camp. Praise him when he takes part in spite of his uneasiness. Point out that you are proud of his ability to act in the face of considerable anxiety. Remember, your teenager may not always be comfortable talking about feelings that he views as signs of weakness. While it may seem at the moment as though he's not listening, later he may be soothed by your attempts to help.
If fearfulness begins to take over your teenager's life and limit his activities, or if the anxiety lasts over six months, seek professional advice. His doctor or teacher will be able to recommend a child and adolescent psychiatrist or other professional specializing in treating adolescents.
Managing anxiety disorders?as with any adolescent emotional disturbance?usually requires a combination of treatment interventions. The most effective plan must be individualized to the teenager and his family. While these disorders can cause considerable distress and disruption to the teen's life, the overall prognosis is good. (See also Emotional Factors Producing Illness, page 177.)
Treatment for an anxiety disorder begins with an evaluation of symptoms, family and social context, and the extent of interference or impairment to the teen. Parents, as well as the teenager, should be included in this process. School records and personnel may be consulted to identify how the teen's performance and function in school has been affected by the disorder.
The evaluating clinician will also consider any underlying physical illnesses or diseases, such as diabetes, that could be causing the anxiety symptoms. Medications that might cause anxiety (such as some drugs used in treating asthma) will be reviewed. Since large amounts of caffeine, in coffee or soft drinks, can cause agitation, a clinician might look at the youngster's diet as well. Other biological, psychological, family, and social factors that might predispose the youngster to undue anxiety will also be considered.
If a teenager refuses to go to school, a clinician will explore other possible explanations before labeling it school avoidance. Perhaps the teen is being threatened or harassed, is depressed, or has an unrecognized learning disability. He may also be skipping school in order to be with friends, not from anxiety about performance or separation.
If the teenager has engaged in suicidal or self?endangering behavior, is trying to self medicate through alcohol or drug use, or is seriously depressed, these problems should be addressed immediately. In such cases, hospitalization may be recommended to protect the youngster.
In most cases, treatment of anxiety disorders focuses on reducing the symptoms of anxiety, relieving distress, preventing complications associated with the disorder, and minimizing the effects on the teen's social, school, and developmental progress. If the problem manifests in school avoidance, the initial goal will be to get the youngster back to school as soon as possible.
Cognitive-Behavioral Therapy
In many cases, cognitive?behavioral psychotherapy techniques are effective in addressing adolescent anxiety disorders. Such approaches help the teenager examine his anxiety, anticipate situations in which it is likely to occur, and understand its effects. (See Cognitive?Behavioral Therapy, page 323.) This can help a youngster recognize the exaggerated nature of his fears and develop a corrective approach to the problem. Moreover, cognitive?behavioral therapy tends to be specific to the anxiety problem, and the teen actively participates, which usually enhances the youngster's understanding.
Other Therapies. In some instances, long?term psychotherapy (see Individual Psychotherapy, page 320), and family therapy (see Family Therapy, page 326) may also be recommended.
Medications. When symptoms are severe, a combination of therapy and medication may be used. Antidepressant medications, such as nortriptyline (Pamelor), imipramine (Tofranil), doxepin (Sinequan), paroxetine (Paxil), sertraline (Zoloft), or fluoxetine (Prozac), or anxiety?reducing drugs, such as alprazolam (Xanax), clonazepam (Klonopin), or lorazepam (Ativan) may be prescribed in combination with cognitive or other psychotherapy. When tricyclic antidepressant medications such as imipramine are pre?scribed, your teen's physician may want to monitor for potential side effects by conducting periodic physical exams and occasional electrocardiograms (EKGs).
Depression is a term used to describe a common condition characterized by feelings of sadness, gloom, misery, or despair. Most people experience temporary depression at various points in their lives. Teens with a depressive disorder, however, experience disturbing symptoms that are beyond the range of normal sadness or depression.
The teen years are often a time of brooding and melancholy, but some adolescents are especially prone to frequent and very distressing periods of depression. Your teenager may have a depressive disorder if his mood is consistently sad or if he sees his life and future as grim and bleak.
IDENTIFYING THE SIGNS
There are two basic types of depression: major depression, which lasts at least two weeks, and the milder but chronic dysthymic disorder, in which a long?standing depressed mood seems to be connected with the teenager's temperament or disposition. Teens with depression may also have anxiety or exaggerated fears. (See Anxiety and Avoidant Disorders, page 196.) Not all youngsters with severe depression appear depressed. Instead, they may seem irritable or moody, swinging from great sadness to anger.
Usually there are other clues or signals that a youngster is depressed. He may lose interest or pleasure in many activities. He may sleep or eat too little or too much and may have difficulty concentrating or making decisions. Feelings of worthlessness, guilt, or anger may find expression in suicidal thoughts or ruminations about death.
During a period of depression, a teenager may look sad, tearful, withdrawn, uncharacteristically listless, and dull. He may seem to lack initiative or may appear agitated. He may neglect his appearance, looking dirty, with mismatched clothes and disheveled hair. This is not a fashion statement. His movements are slow; his voice sounds monotonous; his speech reflects hopelessness and despair. He frequently says things such as I'm stupid or No one loves me or I'm bad. While sensitive at these times to rejection by others, the depressed teen often has a negative or depressing effect on others, causing them to avoid him.
Teens with dysthymic disorder have milder symptoms of depression?a depressed, irritable, volatile mood; appetite and sleep changes; diminished energy; low self?esteem; feelings of hopelessness; poor concentration and indecisiveness?for a year or longer. This chronically depressed mood colors every experience, impression, and response, and the teen experiences most things negatively.
CAUSES AND CONSEQUENCES
Depression is a complex and multifaceted condition. Likely rooted in a genetic and/or biochemical predisposition, depression also can be linked to unresolved grief, possibly in response to early real or imagined losses of nurturing figures. Depression may also reflect that the adolescent has learned feelings of helplessness rather than feeling empowered to seek solutions for life's problems. Depressed thinking tends to be negative, hopeless, and self?defeating?reinforcing further feelings of depression.
Some seriously depressed adolescents have experienced early life and environmental stresses, including childhood trauma (see Childhood Trauma and Its Effects, page 205), such as the death of a parent or other significant person. They may live in families where they regularly witness or are victims of parental aggression, rejection or scapegoating, strict and punitive treatment, and parents abusing each other. Such family pressures may contribute to the development of depressed mood disturbance in a teenager.
Girls appear to suffer from feelings of depression during adolescence more often than boys (this continues into adulthood with women experiencing more depressive episodes than men). Complex neurobiological and sociocultural factors are the likely explanation for this difference. Because boys are often encouraged to translate feelings into actions, their depression is more likely to produce external behavioral disturbances and acting out. Girls, on the hand, are more often focused on or preoccupied by their internal feelings. As a result, they may be acutely self-conscious about their bodies and performance.
Depression usually interferes with a teenager's social and academic functioning. When an adolescent is depressed, school performance usually deteriorates. While depressed, a teenager cannot concentrate. He believes himself to be hopelessly unable to finish schoolwork, and he may skip classes and see his grades drop. Feeling depleted, listless, and incompetent, he may lose interest in extracurricular activities and drop out.
While teenagers are naturally more likely to sleep late in the morning whenever possible, a depressed teen will nap excessively throughout the day or go to bed early in the evening. He may complain of headaches or stomachaches, especially before attending a new social event. (See Emotional Factors Producing Illness, page 177.)
Hopelessness, despair that things will never change, and a general feeling of deadness may be expressed in suicide attempts or dangerous and self?injurious behavior. In addition, depressed teenagers may use drugs or alcohol, in some cases as self?medication to try to relieve their depression. (See Teenage Suicide, page 213.)
During adolescence, teens with severe depression may also have other emotional disorders, including delinquent behavior (see Antisocial and Delinquent Behavior, page 154), school attendance problems (see School Refusal, Truancy, and Dropping Out, page 141), anxiety disorders (see Anxiety and Avoidant Disorders, page 196), substance abuse (see Substance Abuse Disorders, page 279), and eating disorders (see Eating and Nutritional Disorders, page 260).
HOW TO RESPOND
In trying to decide whether symptoms are serious enough to seek help, talk with your teenager. Let him know that you see his sadness. By showing interest and the desire to help him understand his feelings, you bring hope to the teen. Parents often have difficulty understanding why a teen feels such a catastrophic sense of loss or perceived failure, so it's important to listen carefully to the teen and to try to imagine yourself in your youngster's position. Without pressuring him, point to activities he enjoys and handles successfully. Help build self-esteem by recognizing small triumphs and admiring his competence.
At the same time, try to determine whether the teenager seems capable of handling the feelings on his own or whether he seems overwhelmed. If the symptoms persist, particularly if they begin to interfere seriously with multiple areas of his life, ask his doctor or his school for the name of a child and adolescent psychiatrist or other professional trained to work with adolescents.
Treatment should begin with a full evaluation, which usually includes all members of the family. The assessment must include an evaluation of the risk of suicidal behavior and will seek to rule out substance use or an underlying physical disease or illness that could also produce depressive symptoms, as well as distinguish depression from simple bereavement.
Parents will be asked to describe symptoms and such behavioral changes as irritability, moodiness, and sleep and appetite changes and to report the duration of symptoms as well as any possible precipitating event.
Many parents who are also seriously depressed may have trouble accurately describing their teenagers' symptoms. They may either view everything in negative terms, therefore exaggerating problems, or be so preoccupied with their own depressive symptoms that they fail to observe their adolescent accurately. In such families, it is not uncommon for parents to be unaware of their teenager's sadness, suicidal thoughts, and sleep disturbances.
Individual Psychotherapy. Therapy offers support and empathy while encouraging exploration of the depressed feelings and symptoms. While creating a sense of safety by setting limits on dangerous behavior, a therapist will encourage a teenager to express his upsetting feelings, usually a sense of loss, powerlessness, aggression, or danger. Therapy helps the adolescent deal with these feelings rather than act them out. If a teenager's self-esteem seems particularly low, therapy may work to improve confidence and competence through skills training.
If a specific circumstance or event has precipitated the depression?divorce, for example-therapy gives the youngster a chance to resolve some of his feelings and accept even an unhappy reality.
Cognitive-Behavioral Therapy. Often effective in treating depression in adolescents, cognitive therapy focuses on the irrational beliefs and distorted thoughts that are part of depression, such as a negative view of the self, the world, and the future. Usually a depressed teen personalizes failure, magnifies negative events, and minimizes positive events and attributes. Sometimes these negative thought patterns have been formed or reinforced by the teen's home environment. Cognitive therapy focuses on identifying negative thought patterns or distortions and on helping the adolescent change his thinking. (See also Cognitive?Behavioral Therapy, page 323.)
Group Therapy. Group therapy for depressed teens can help them develop or improve social skills, which can lead to a greater sense of mastery and improved self-esteem. Teens may find it easier to express feelings in a supportive peer?group environment. This can be especially helpful during a developmental stage when peer groups are an increasingly important resource. Support groups for parents can help them manage specific problem behaviors, use positive reinforcement, better communicate with adolescents, and become better listeners for their youngster. (See also Group Therapy, page 328.)
Family Therapy. If the teenager is willing and able to work within a family context, family therapy can address certain problems that may worsen depression in teens: lack of generational boundaries; severe marital conflict; rigid or chaotic rules; and neglectful or overly involved parent?child relationships.
Family therapy can also help parents manage specific problem behaviors, use reinforcement correctly, listen and communicate with their teenager in an age?appropriate manner, and support the teenager as he prepares to move beyond his family structure. In addition, other family members with psychiatric disorders may be identified during family sessions, and they can be assisted in getting their own treatment. (See also Family Therapy, page 326.)
Medication. In moderately and severely depressed adolescents, antidepressants, such as bupropion (Wellbutrin), desipramine (Norpramin), fluoxetine (Prozac), imipramine (Tofranil), nortriptyline (Pamelor), paroxetine (Paxil), sertraline (Zoloft), and venlafaxine (Effexor), may be prescribed in combination with psychotherapy. Before the teen begins taking a medication, specific target symptoms should be identified in a discussion between the youngster, the parent, and the physician. Possible side effects and other aspects of the medication should be fully discussed; when tricyclic antidepressant medications, such as imipramine, are prescribed, your child's physician may want to monitor for potential side effects by conducting periodic physical exams and occasional electrocardiograms (EKGs).
Hospitalization. Any seriously depressed adolescent at risk for suicidal or selfendangering behavior must be immediately assessed. If he is preoccupied with suicide or has a well?thought?out plan, this constitutes an emergency situation, and his safety should be assured. (See What to Do in Emergencies, page 316.) That a teenager could be so unbearably unhappy that he would choose to kill himself is something that's almost too painful for a parent to examine. But with the increasing prevalence of teen suicide, no parent can afford to ignore the possibility.
Before the mid-1970s, suicide by adolescents appeared to be a rare event; now one out of ten teens contemplates suicide, and nearly a half million teens make a suicide attempt each year. Sadly, suicide has become the third leading cause of death for high school students. 1ndeed, the actual rate of death by suicide may be higher, because some of these deaths have been incorrectly labeled "accidents."
CAUSES AND CONSEQUENCES
One reason for the increased risk of death by suicide among teens is that the means of committing suicide are now so readily available: Firearms, pills, and other potential weapons of self?destruction can be easily obtained. Although more girls attempt suicide than boys, more boys than girls die by their own hand. This is partly related to the methods: Boys frequently use guns, which are more likely to have lethal consequences than an overdose of pills, a common method used by girls.
Underlying Factors. Researchers agree that life today brings greater pressures and stresses, and many adolescents have difficulty dealing with them by virtue of age, temperament, and upbringing. Other contributing factors include an increase in turmoil within families, societal violence, and feelings of despair.
Essentially, a suicide attempt results from the teen being completely overwhelmed and unable to cope. This might occur after a single catastrophic disappointment such as the breakup of a relationship; sometimes it's the result of a long decline, such as continual failure in school with unbearable feelings of frustration, anger, and shame. Other trigger factors can include profound changes within the nuclear family, such as divorce, remarriage, or the death of a parent; intense family discord; unreasonable parental expectations; a troubled relationship with parents; moving to a new community; a history of losses; and the suicide of a peer or family member.
IDENTIFYING THE SIGNS
Young people under extreme stress often exhibit signs of depression. Since most adolescents experience mood swings, it can be difficult to distinguish serious depression from normal emotional lows. Duration of the lows is a very good clue: If your teenager's gloomy mood lasts for longer than two weeks, and he can't seem to shake it off and have fun, you have good cause to be concerned.
You need to be watchful for other symptoms of depression:
- Have his eating and sleeping habits changed?
- Has he undergone a marked personality change, either exhibiting angry actions or rebellious behavior or becoming suddenly shy and withdrawn?