When a secondary school drama teacher was casting the lead role for a recent production, she was looking for something different. So, when an unknown student who wasn't part of the school's normal theater crowd came in for tryouts, the teacher had her doubts. But after the girl's first audition, she knew she had found her star. "She has an edge to her that's really intriguing," she says. "It was just what I wanted for the part."
The instructor was surprised again when, after a few weeks of rehearsals, both the school counselor and the girl's mother came to her.
"Each of them said that because of the experience of being in the play, the girl had improved 100 percent," she says. "Turns out she was having a lot of trouble -- she didn't have any friends, was doing poorly in her classes, and was even considering leaving the school. But theater is a pretty scrappy environment that makes room for anyone, and once she got involved here, she really came out of her shell, both academically and socially."
A school play may have turned things around for that student, but on any given day, millions of other American adolescents aren't so fortunate. A recent report by the U.S. Office of the Surgeon General shows that about 11 percent of youths -- about four million -- have a major mental-health disorder that results in significant trouble at home or school or with peers, and only one in five of these children actually get the treatment they need.
Left untreated, depression and other mental-health problems set a child up for a potentially long and difficult transition into adulthood; more than half of all cases of adult mental illness begin in the teenage years. And some don't make the transition at all: Suicide is the third leading cause of death for adolescents. And, as seen with the recent tragedy at Virginia Tech, mental-health problems left untreated can sometimes have even more horrific consequences.
"Depression is definitely more visible in teens now," says Dr. Jeff Bostic, director of school psychiatry at Massachusetts General Hospital and assistant clinical professor of psychiatry at Harvard Medical School. "We live in a time when we should be the happiest that we've ever been in human history, but we're not. We live in a complicated society where kids have 500 channels of television, most of which get their attention by scaring them, and we, as human beings, weren't made to be jacked up all the time."
"School is also a very complicated place now," he adds. "Kids are being told they're not going to have a good quality of life if they don't do every little thing exactly right. They're scared to death, and therefore rates of depression and anxiety are up."
"All the factors line up to indicate that it makes sense that there is a higher incidence of depression now than there was ten or twenty years ago," says Ann Vander Stoep, a University of Washington child psychiatric epidemiologist. "Where I find myself kind of scratching my head is trying to figure out if we are seeing a dramatic increase in the number of depressed kids or if we are just better able to identify them. I think it's some of both."
One obvious fact is that schools are becoming increasingly aware that children have mental-health issues, and the idea that schools have a big role to play in their students' mental well-being has prompted response from public and organizational sectors. The federal government's New Freedom Commission on Mental Health recently recommended that school mental-health programs be expanded; the American School Health Association officially supports increased funding for mental-health services in schools, and the American Psychiatric Foundation's mental-health education program, Typical or Troubled?, has been implemented in seventy-three high schools across the nation.
The Developmental Pathways Research Program is another example. Created by Vander Stoep and her research partner, Dr. Elizabeth McCauley, the program studies the effectiveness of screening middle school students for signs of emotional distress. They partnered with the Seattle Public Schools system to implement their program, an important component of which is providing on-site interventions to students showing signs of trouble.
"We chose middle school students because it's rare to see a sixth grader with a full-blown diagnosis for depression," says McCauley. "But the warning signs may be there, and early support to a vulnerable child may prevent the episode."
"An episode of major depression seems to leave a footprint," explains Vander Stoep. "It's better to avert a full-blown episode and get a kid on track than to try to intervene after it's occurred."
Though working directly in schools with this kind of study makes sense, researchers and educators alike were at first concerned that they might be opening a can of worms. "The schools were nervous that we would turn up all kinds of kids who needed serious help and they wouldn't be able to handle it; they were already maxed out with the care they were giving," says Vander Stoep.
But of all the kids they've screened, about 15 percent showed signs of distress, and of those, only a very small proportion ended up needing relatively high levels of intervention. Follow-ups with parents determined that almost three-fourths of their children had received the assistance they needed, and much of that help was right on site at the schools' health care centers.
"This program fit more sensibly and manageably into the school environment than any of us thought it would," says Vander Stoep. "We've been able to help a lot of kids in this process easily and very inexpensively."
Access is critical to the success of the Developmental Pathways Research Program, and it's also the major stumbling block to getting troubled kids the help they need. "There's a huge shortage of qualified health professionals to treat children and adolescents," says Dr. Wendla A. Schwartz, a child psychiatrist who runs Solutions Psychiatric Associates, in Los Gatos, California.
It's not only more labor intensive (and therefore expensive), she says, it's also just plain difficult. "Treating a child who is depressed is completely different from treating an adult, because children and adolescents who are depressed don't necessarily -- or even often -- look depressed; they don't necessarily look sad," Schwartz adds. "The flip side is, they could 'look' depressed, but they're actually bipolar, or schizophrenic. They've got totally different brain chemistries; they're little unfinished products."
Predictably, the strain accumulates most at the classroom level. With all the roles teachers -- and coaches and administrators -- have had to take on over the last few years, should we really be expecting them to act as counselors, too?
"It's not fair, it's not just, it's not right," says Bostic, a former high school teacher himself, "but in this day and age, when you have such a large number of kids who live in fragmented families and other stressful situations, teachers are having to take on yet another role they didn't sign up for. Some people say schools have no business doing mental-health-related stuff, and I appreciate that. But the reality is, whether you do something or nothing, you're affecting kids' mental health every day you're a teacher.
"So, if we don't go and tell teachers that what they do and say in the classroom affects kids' mental health, then they won't know any better," he adds. "In my opinion, anyone with a brain should realize that you want teachers to have the skills to cultivate good mental health and diminish the probability that someone will become anxious, depressed, or psychotic."
Schwartz disagrees. "It's not right to encourage or teach non-mental-health professionals to get involved in any kind of evaluation or counseling," she says. "Any time you ask a nonprofessional to make a medical judgment, it's dangerous. I've seen that kind of situation go very badly wrong lots of times."
One nationwide program that's drawn both praise and criticism is TeenScreen. Developed by researchers at Columbia University, the program has a specific aim of decreasing the rate of teen suicides by working mostly in the schools. It employs a screening process divided into two stages: a computer questionnaire with roughly fifteen to fifty questions, followed by a face-to-face discussion. Students volunteer for the screening, and parental consent is required.
Though many people applaud the effort, critics say there's just no evidence that this type of screening works. They point to a study by the U.S. Preventive Services Task Force that concluded there is insufficient evidence either for or against screening the public for suicide risk. Other experts think screening inevitably leads to affixing a label of mental illness to kids, without benefit of a complete evaluation.
"I feel like a lot of the criticism that TeenScreen is facing has to do with the fact that they're focused on making a psychiatric diagnosis," says McCauley. "And once there's been a diagnosis, we get back to the problem of access to care and, more specifically, access to care that's evidence based and useful."
"These are not easy diagnoses to make," she adds. "That's one reason I feel like our program is working. Our screening is kind of like a thermometer that takes the temperature of the child and gives you an indication that the child is distressed, as opposed to making a psychiatric diagnosis."
Bostic supports the TeenScreen mission but agrees with McCauley that the problem with the program is mainly one of -- once again -- access. "The quagmire they've found themselves in is due in part to the question of who's going to make sure the schools are equipped with both the personnel and the savvy to know what to do with the results of the screenings," he says.
Though Schwartz doesn't have an official opinion about TeenScreen, one thing she and Bostic do agree on is that teachers can play a role in helping students they think might be having problems.
"They're out there on the front lines dealing with kids all the time; it makes good sense to have them know what to look out for," she says. "In fact, probably 20 percent to 30 percent of the time a kid shows up at my office, it's been a teacher who played an instrumental role in getting him there. They're an important influence on kids, and a lot of times parents, even well-meaning parents, have trouble seeing psychiatric illnesses in their kids unless the kid does something really heinous. In the more common, less-severe circumstances, it often takes an outside source, like a teacher, to tell a parent that what's going on with their kid is really out of the box."
Bostic agrees and takes the concept one step further. "There's no reason a teacher can't teach basic cognitive behavioral strategies to their students," he says. "It's not complicated; it's not difficult. It's just a matter of learning what to do -- learning, for example, that the way they respond to a kid who does poorly on an assignment has the potential to make the kid less vulnerable to depression or anxiety.
"We can spend our time continuing to get kids very sophisticated at distinguishing between tangents and co-tangents, but unless they're going into engineering, when are they going to use that stuff?" Bostic adds. "But are they going to have days when they look in the mirror and think, 'Man, I feel like crap'? Of course they are. So we need to train teachers to equip their students with the tools they're going to need to get up in the morning. These are tools they'll use their whole lives."