Child and reproductive psychiatrist Misty Richards, MD, MS, puts it bluntly: “Our teen girls are not okay.”
The program director for UCLA’s Child and Adolescent Psychiatry Fellowship recently cared for a girl who attempted suicide after receiving a college rejection letter. “Her self-worth was measured in achievement and external accolades, and she felt she couldn’t be anything other than perfect,” Richards said in an interview. “We’ve had to create a backup call system in the emergency department at UCLA to get more help for the numbers of teenagers—specifically teen girls with suicide attempts or serious injurious behavior like cutting—who are in absolute crisis. We’ve never seen numbers like this before.”
In interviews with JAMA, Richards and other clinicians nationwide said that teen girls are experiencing unprecedented levels of mental distress. Survey data back this up. In the 3 decades that the Centers for Disease Control and Prevention (CDC) has tracked high school students’ health and well-being, there has never been a time when teen girls have reported more sadness, hopelessness, and suicide attempts. The latest biennial CDC Youth Risk Behavior Survey, administered in the fall of 2021, was the first conducted since the start of the COVID-19 pandemic. The data show that mental health has worsened for all adolescents, but especially for girls.
According to the survey findings, which included data from more than 17 000 students in 152 public and private schools, 57% of teen girls reported feeling persistently sad or hopeless in the past year—a nearly 60% increase from 36% in 2011. In contrast, 29% of teen boys reported feeling this way in 2021, an increase from 21% in 2011.
During this 10-year period, a nearly 60% increase also occurred in the percentage of teen girls who seriously considered suicide. In 2021, 30% of girls had these thoughts compared with 14% of boys, an increase from 19% and 13%, respectively, in 2011. And 13% of girls reported having had a suicide attempt in 2021 vs 7% of boys.
“The disparity in mental health between boys and girls is not new, but the large and rapid rise in poor mental health among girls over the last decade compared with boys is particularly alarming,” said Kathleen Ethier, PhD, who directs the CDC Division of Adolescent and School Health.
Even before the COVID-19 pandemic, experts were sounding the alarm that US youth were experiencing a mental health crisis, especially related to anxiety and depression. “The COVID-19 pandemic enhanced the cracks that were already present in the lack of psychiatric care and in the maladaptive coping skills of our youth,” Richards said.
And although the latest data highlight the fragile mental health of teen girls, boys aren’t doing particularly well either. The survey measured depression by asking teens to report whether they felt sad or hopeless, which is often how girls express depression, according to Martha Fairbanks Perry, MD, section chief of adolescent medicine and a professor of pediatrics at University of North Carolina School of Medicine. The survey, however, may not accurately detect rates of depression in boys, whose symptoms tend more toward increased irritability, anger, or aggression. “But even if the gap between girls’ and boys’ rates of depression is not as wide as the survey portrays,” Perry said, “the gap has widened, which means that teen girls’ mental health has worsened.”
Students who identify as lesbian, gay, bisexual, questioning, or another nonheterosexual identity also fared poorly in the survey: 69% of them reported persistent sadness or hopelessness in the past year and 22% of them reported having had a suicide attempt.
The report noted that there were few consistent patterns of racial and ethnic differences in teens’ mental health and suicidal thoughts in 2021, and that large percentages of students in all groups had persistent feelings of sadness or hopelessness. One notable finding, however, is that Black students were less likely to report having poor mental health and persistent sadness than some other groups but were more likely to have had a suicide attempt than Asian, Hispanic, and White students.
COVID’s Toll on Girls
The social isolation that occurred during COVID-19 was particularly challenging for teen girls, noted Mitchell Prinstein, PhD, chief science officer for the American Psychological Association. “Girls are accustomed to a greater level of emotional intimacy, nurturing, and support within their peer relationships,” he said. “During COVID, those relationships were disrupted.”
Many girls looked to social media to recreate the face-to-face peer connections that were lost during pandemic lockdowns. “Social media comes with big risks because it intensifies the comparisons and competition among girls,” Richards said.
More time spent on social media meant that girls were barraged by unrealistic messaging about ideal body size and shape, added Perry. She has little doubt that social media content contributed to eating disorders among teen girls. “We have been inundated with teens in distress, but we are seeing a tremendous increase in girls with eating disorders, which puts them at higher risk for suicide,” she said.
Cyberbullying also has become a significant concern for teenage girls. In the CDC survey, 20% of girls reported being electronically bullied compared with 11% of boys.
“Anything unique or slightly different about a teenage girl, such as weight, performance in school, or friend groups, will be targeted by her peers,” says Richards. “It’s hard to operate in a harsh society driven by social media that puts so much stress and emphasis on a moving target of perfection that doesn’t exist. Cyberbullying can lead to awful injury.”
A particularly disturbing finding from the survey is that 18% of girls had experienced sexual violence—up 20% since 2017—and 14% had been forced to have sex against their will, a 27% increase since 2019.
“If you ask girls if they’ve experienced sexual violence, you’ll find that it is happening at an incredibly alarming rate,” said Elizabeth Wallis, MD, MSHP, director of the division of adolescent medicine at the Medical University of South Carolina. “Sexual violence is probably underreported because girls face tremendous barriers in reporting. When I report a sexual assault to the police, I sometimes worry about the ramifications for that girl. Sexual trauma also increases the risk of anxiety and depression, along with [posttraumatic stress disorder].”
The survey did not ask whether perpetrators of sexual violence were classmates or people outside of school. As girls spent more time at home during the pandemic, they may have been at greater risk of experiencing sexual violence from family members or other adults, said pediatric psychologist Cody Hostutler, PhD, clinical director for behavioral health integration at Nationwide Children’s Hospital. “Kids report abuse most frequently to teachers, and it’s frightening to think that during COVID, girls were disconnected from ways to report sexual abuse,” he said.
Teens on the Edge
Young people had perilously high rates of suicide attempts before the COVID-19 pandemic. According to new research in JAMA, the proportion of pediatric mental health hospitalizations with a diagnosis of attempted suicide or self-injury jumped from about 49 000 in 2009 to nearly 130 000 in 2019. These cases represented 64% of pediatric mental health hospitalizations in 2019, an increase from 31% a decade earlier. And of almost 202 000 pediatric mental health hospitalizations in 2019, girls represented 61%.
“Girls are more likely to present to hospitals with suicidal thoughts and attempts, whereas boys are more likely to die from suicide because they often chose more lethal means,” said senior author JoAnna Leyenaar, MD, PhD, MPH, vice chair of research in the department of pediatrics at Dartmouth-Hitchcock Medical Center. “But,” she added, “the gap between suicidal deaths between girls and boys has been narrowing.”
The intense psychological stressors created by the COVID-19 pandemic, long wait times for distressed kids to see mental health professionals, and adolescents’ own impulsivity is a perfect storm for increased suicide risk, according to Prinstein. Unlike adults who often carefully plan a suicide after a long period of suffering, “kids are more likely to engage in suicidal behavior in an impulsive moment when they are feeling particularly upset or stressed,” he said.
Pediatric and primary care clinicians should be screening children and adolescents for suicide ideation, according to experts, but a sizeable proportion don’t. The American Academy of Pediatrics recommends that all youth aged 12 years or older should be screened for suicide risk, and children aged 8 to 11 years should be screened when clinically indicated. A national survey of 377 pediatricians found that although most have had patients who have attempted or died by suicide, 39% don’t always screen for suicidal ideation, and few use a suicide-specific screening tool. The survey, published this January, also found that about 4 in 10 pediatricians do not feel prepared to counsel patients and families on suicide prevention.
Screening teens only for depression doesn’t always identify all those who are at risk of suicide, added Hostutler. When he and his colleagues studied the detection of suicide risk in teens with no recent history of depression or self-harm, they found that clinicians in pediatric and primary care practices who used only standard depression screening missed identifying some at-risk kids.
“The purpose of the study was to see if it was necessary to add a suicide-specific screener, such as the Ask Suicide-Screening Questions—and it was,” Hostutler said.
“It’s also important for pediatricians to talk to families about reducing access to lethal means, such as asking about guns in the home and how they are stored,” said Leyenaar, who is a pediatric hospitalist.
The American Foundation for Suicide Prevention has partnered with the American Academy of Pediatrics to develop the Blueprint for Youth Suicide Prevention. Their goal is to educate pediatricians and other clinicians and health professionals about suicide risk factors and warning signs in children, as well as preventive protocols. “Not too long ago, we didn’t know we could prevent suicide, but now we have interventions and treatments that can really help kids,” said Jill Harkavy-Friedman, PhD, senior vice president of research for the American Foundation for Suicide Prevention.
Most teens thinking about suicide won’t make an attempt, added Harkavy-Friedman. “But it’s important to always take suicide ideation seriously, which means finding out more, getting a further history of risk, and then making a plan together. A teen thinking about suicide doesn’t necessarily have to be sent to the emergency room.”
How Pediatricians Can Help
With so many children and adolescents enduring poor mental health, pediatric and primary care clinicians are increasingly being called on to diagnose and manage these conditions, often without adequate training. “We don’t devote enough time in residency training to build pediatric mental health skills,” Wallis said. A 2020 survey by Leyenaar and colleagues found that only a third of nearly 2100 pediatric residents and recent graduates felt highly competent to assess their patients’ behavioral and mental health conditions and less than a fifth said they were competent in their treatment skills.
Large pediatric practices may have the luxury of a dedicated mental health clinician on staff to provide immediate assessment and care of patients with mental health concerns. Other practices rely on pediatric crisis stabilization units staffed by clinicians with expertise in child and adolescent behavioral health—pediatric social workers, therapists, or marriage and family therapists—who serve as a bridge to pediatric psychiatric care in the community, Richards explained. They provide immediate acute care to children and families in a mental health crisis, preventing an unnecessary visit to the emergency department, and find mental health specialists who can take over kids’ longer-term care.
Another collaborative care model cropping up around the country is a child psychiatry access program, or CPAP, through which primary care clinicians consult with child and adolescent psychiatrists. In a recent study that examined the CPAP experiences of 74 primary care clinicians in Washington, DC, 71% felt more comfortable treating their patients’ mental health concerns when they had ready access to child psychiatry support by phone.
According to Hostutler, pediatricians can use brief but effective interventions when teens are experiencing depression or anxiety, such as counseling them on coping skills and getting enough sleep and physical activity. “Ask teens to schedule activities they find meaningful, such as painting, walking in the park, or calling a friend—and [to] commit to doing them even when they don’t feel like it,” Hostutler said. “These interventions can be very powerful strategies for kids who don’t have immediate access to a mental health provider to start to feel better.”
The most sustainable solution to increasing kids’ access to mental health care is to train general pediatricians to provide it, according to Peter Jensen, MD, board chair of the nonprofit Resource for Advancing Children’s Mental Health (REACH) Institute and former associate director of child and adolescent research at the National Institute of Mental Health.
“Pediatricians are frustrated that they don’t know how to help the many patients with mental health problems in their practices,” said Jensen, who founded the REACH Institute in 2006 to train pediatric faculty and physicians in the community to diagnose and manage the most common pediatric mental health conditions. Teams of pediatricians and child and adolescent psychiatrists teach an interactive 30-hour course spread over 6 months. Small groups of physicians develop their clinical skills by taking turns presenting challenging cases from their own patients and receiving problem-solving guidance from team instructors.
“To change physician behavior, we need to change skills, which is a very hands-on experience, unlike continuing medical education lectures,” said Jensen, who estimated that REACH has now trained about 6000 physicians, most of them pediatricians.
Studies of REACH-trained physicians have found that their patients have lower rates of psychiatric hospitalizations, emergency department referrals, and polypharmacy, Jensen said, and that the physicians are more comfortable prescribing antidepressants, mood stabilizers, and antipsychotics.
Wallis took a REACH course in 2013 after realizing how many kids in her practice needed mental health care. “I was comfortable treating [attention-deficit/hyperactivity disorder], but I wasn’t sure how to safely prescribe medications to a child who was depressed,” she said. Today her practice is devoted to pediatric mental health, and she extends her expertise to other pediatricians as a REACH instructor. “After REACH training, I love hearing pediatricians say, ‘I can do this,’ which means more kids will be able to get mental health care.”
According to Jensen, about 20% of a general pediatrician’s patients will have mental health problems, and three-fourths of those patients can be managed by a well-trained pediatrician. “[O]ver the course of their careers,” he said, “think about the thousands of kids they will now be able to help.
To access the post about this discussion, please click here.