Physical: During early adolescence, the body undergoes more development than at any other time, except the first two years of life. Developmental growth includes significant increases in height, weight, and internal organ size as well as changes in skeletal and muscular systems, and the onset of puberty.
Physical growth is often rapid and uneven, causing many adolescents to lack coordination and literally have growing pains.

Intellectual: During early adolescence, youth are most interested in real-life experiences and authentic learning opportunities; they are often less interested in conventional academic subjects. They are deeply curious about the world around them but may lose interest quickly if information is not presented dynamically with plenty of interaction and peer-to-peer involvement. Young adolescents develop the capacity for abstract thinking, and they are able to think about their future, anticipate needs, and develop personal goals.

Moral/ethical: Young adolescents tend to be idealistic and possess a strong sense of fairness. They are moving from being self-centered to considering the rights and feelings of others. They begin to realize that moral issues are not strictly black and white. They are able to consider ethical and moral questions but lack experience and reasoning skills to make sound moral and ethical choices, which can put them at risk.

Social: Young adolescents have a strong need to belong to a group. Peer approval becomes more important and they are likely to turn to friends first when experiencing a problem. As they mature socially, they often have opposing loyalties to peer group and family. Though young adolescents may be rebellious toward parents and adults, they still depend on them and desire their approval. They tend to test limits and challenge adult authority figures (Adapted from Caskey & Anfara, 2007) Emotional and psychological: Young adolescents begin to seek independence and to develop a strong sense of individuality and uniqueness. At the same time, they are highly sensitive to criticism, want to fit in with their peers, and are likely to have low self-esteem. They may be moody, restless, self-conscious,and unpredictable as they experience intense emotions and stress.

Normal behavior:

• Emotional up and downs—teens experience more intense feelings and become easily irritable
• Some withdrawal from family (i.e. spending more time with friends, staying in the room to play video/computer games, etc)
• Some risk taking behaviors: drugs, alcohol, sexually active

Abnormal behavior:

• Decrease in enjoyment and time spent with friends and family
• Big changes in energy levels, eating, sleeping patterns, or other behaviors
• Physical symptoms (stomach aches, headaches, backaches)
• Intense emotions such as feelings of hopelessness, sadness, anxiety, rage relative to the person’s history
• Excessive neglect of personal appearance or hygiene
• Substance abuse
• Dangerous or illegal thrill-seeking behavior
• Is overly suspicious of others
• Sees or hears things that others do not
• Unexplained weight gain or loss

Depression is a medical condition that is treatable with professional help. Although it’s normal for everyone to feel sad or depressed once in a while, struggling with clinical depression is not a typical rite of passage for teens. Clinical depression is an illness of the brain that includes imbalanced levels of neurotransmitters and pervasive changes in mood, thoughts, and physical functioning. Depression can be incapacitating and deadly if not treated. It is not a sign of weakness or an inability to “cope”. It can happen to anyone at any time, even without an identifiable reason. A depressed person will feel down for at least two weeks and experience some of the other symptoms. These feelings will interfere with the ability to function normally. If all of this is present then probably a person has gone from just being sad to being depressed. If this is the case, it’s important to reach out to a trusted adult and get the help needed to recover and get back to feeling normal. Depression can be incredibly frustrating and the sense of hopelessness and helplessness that it imbues people with can make it difficult for them to get help without the encouragement and support of the people who care about them.

It is important to distinguish grief from depression. It is normal for feelings of sadness or grief to develop in response to loss and/or change. The American psychiatric Association states: The “death of a loved one, loss of a job, or the ending of a relationship are difficult experiences for a person to endure”. Grief, therefore, is an emotional response to an incident of loss or change whereas depression is a pervasive disorder that stems from a combination of factors listed in the “biopsychosocial model.”

Clinical depression is a medical illness that involves abnormal functioning of the brain’s chemicals. Clinical depression often runs in families, which suggests that its origins may be genetic as well as learned; it can be accompanied by—and even aggravated by—other illnesses (e.g., substance abuse,learning disabilities, attention-deficit hyperactivity disorder, anxiety, sexual and emotional abuse). Children of parents with a history of depression are twice as likely as other children to develop depression. It is important to note that despite the presence of such a risk, a child may not develop depression. Clinical depression results from a combination of genetic, psychological, and social risk factors. Although people who have experienced a major loss/stressor or have a family history of depression are at a higher risk of developing the disorder than others, sometimes an individual can develop depression for no discernible reason.

Depression can result from an interaction of factors that include a biological component, social factors, and psychosocial factors.

• Biological: genetics, brain chemistry, other medical disorders
• Social: thought patterns, coping skills, self-esteem
  • Psychosocial: family, school, neighborhood, peers

Unfortunately, depression does not always have a clear cut cause that can be pointed to, sometimes people develop depression out of nowhere without a specific reason. Clinical depression, at it’s root, is a medical illness of the brain resulting from abnormal functioning of the brain’s chemicals, and, although we’re always learning more, we can’t always predict or explain the way our brain works. Depression is more common in people whose relatives also have depression but it is not a genetic disorder. A family history of depression increases the risk of developing depression, but it’s no guarantee that you will develop depression.

Due to the fact that depression can be experienced in so many ways, it’s not always easy to identify. In general, there will be changes from a persons normal self that have lasted for at least two weeks. Determining whether someone has depression depends on the number and severity of the symptoms experienced. To be diagnosed as major depression, symptoms need to be present consistently for at least two weeks. On average, episodes of depression in teens tend to last between six and nine months, though they can certainly persist much longer.

Symptoms can include:

• Feelings of sadness
• Loss of interest or pleasure in normal activities
• Irritability, frustration, or feelings of anger, even over small matters
• Insomnia or excessive sleeping
• Changes in appetite (decreased or increased)
• Agitation or restlessness (pacing, hand-wringing, inability to sit still)
• Slowed thinking, speaking, or body movements
• Fatigue, tiredness, loss of energy—even small tasks seem to require a lot of effort
• Feelings of worthlessness or guilt, fixation on past failures/mistakes or self-blame when
  things are not going right, worrying
• Trouble thinking, concentrating, making decisions, and/or remembering things
• Frequent thoughts of death, dying, or suicide
• Crying spells for no apparent reason
• Unexplained physical problems (especially pain-related), such as stomachaches, back pain
  or headaches
• Negative and/or abusive self-talk
• Struggling academically, drop in grades
• Isolation/withdrawal from friends and family
• Forgetful or easily distracted
• Substance use or abuse
• Lack of motivation to do anything

If multiple symptoms are present consistently, then there’s a good chance that a mental health condition like depression is the cause. Other conditions with similar symptoms include other mood disorders (e.g., dysthymic disorder or bipolar disorder), other mental health diagnoses (e.g., anxiety disorders, substance abuse/dependency, conduct disorder, eating disorders, PTSD), anemia or hypothyroidism. It is important that someone with symptoms see a doctor for a correct diagnosis and treatment.In addition physical pain frequently occurs with depression. This pain is real. It is not “all in the head”. For instance stomachaches commonly occur. One thought about why this happens is that stomachaches result from dysfunction in pain pathways regulated by serotonin and norepinephrine, two of the neurotransmitters that are out of balance in depression. Here’s an article from Psychology Today that talks about the symptom of somatic pain in depression:

http://www.psychologytoday.com/articles/200308/when-depression-hurts

Treatment entirely depends upon the individual. The best way to treat depression (in that it gives you the best chance of symptom relief) is a combination of talk therapy, antidepressant medication (if needed), and a set of healthy self-care practices (adequate sleep, healthy food, exercise, etc). Symptoms will differ from person to person and range along a spectrum of mild, moderate and severe. The following describe the severity of depressive symptoms and the type/length of treatment often recommended for each.

Mild Depression:
Type of Treatment/Length of Treatment:

• Individual outpatient therapy—Brief, 8 weeks, to long term intervention
• Group outpatient therapy—8 to 12 sessions

Moderate Depression:
Type of Treatment/Length of treatment:

• Individual outpatient therapy—6 months to years
• Medication—At least 1 year

Severe Depression:
Type of Treatment/Length of Treatment:

• Inpatient psychiatric hospitalization—5 to 7 days
• Day treatment—1 to 2 weeks
• Residential treatment—Months or years

It is important to remember, depression is a medical illness which requires medical help in the form of therapy and/or medication. It is important to get treatment as soon as possible from a medical doctor, psychiatrist or therapist.

The treatment used depends upon the individual. Sometimes a depressed teen can start feeling better just by going to therapy. In other cases, the symptoms of depression don’t respond fully to therapy; if teens still aren’t feeling better with therapy alone, then a psychiatrist might consider prescribing an antidepressant to help correct the chemical imbalance that underlies depression.

If you feel like you are not improving in spite of therapy, medication and taking care of yourself, then you might want to talk to your psychiatrist about trying different options. It could mean taking a different antidepressant or seeing a different therapist. Treatment does take time and it’s important to be patient, but if you feel like things are not working, talk to your care provider about your concerns and your desire to discuss other treatment options. The most important goal of treatment is making sure that you feel better and sometimes that requires more than what’s attempted on the first try.

In addition to medical treatment there are a number of things you can do to take care of yourself: get enough sleep, eat healthfully, manage stress, mindfulness, yoga, journaling, use friends and family as a social support system, if you have a faith, religious organizations and formal affiliation can be comforting in times of challenge and distress.

Whether or not someone experiences a return of depressive symptoms later in life depends on a number of different factors: family history, other mental health diagnoses, stressors, prior
number/frequency/severity of depressive episodes and treatment history. Not everyone who experiences a period of depression when they are young will become depressed in adulthood. There is a greater likelihood that depression will NOT become a chronic condition if help is sought early in adolescence, at the first sign that symptoms appear. Research also shows the longer period of time one is depressed the more the brain changes indicating the importance of seeking treatment early.

Depression isn’t necessarily something that can be cured, but almost everyone can experience significant, if not complete, symptom relief with treatment. Treatment does take time and it is important to be patient. If you feel like things are not working, talk to your provider about your concerns and your desire to discuss other treatment options such as a different medication or another therapist. The most important goal of treatment is making sure that you feel better and sometimes that requires more than what is attempted on the first try.

Psychiatrists are medical doctors (MDs) and can prescribe medications. Some psychiatrists manage the medication aspect of treatment only, while others conduct therapy as well.

Psychologists can have Ph.D., Ed.D. or Psy.D. degree, which means that they attended graduate school and are trained and educated to perform psychological research, testing, and therapy. Psychologists cannot prescribe medication, but they are specifically trained to conduct therapy.

Social Workers attended graduate social work programs, and are trained to conduct therapy as well as work with systems and case management; they have master’s degrees in social work and are licensed mental health providers.

Antidepressants work to correct the imbalance of neurotransmitters/chemicals in the brain that influence the kind of symptoms experienced in depression (low energy, loss of pleasure/interest in activities, etc). These chemicals include serotonin, norepinephrine, and dopamine. These medicines need to be taken under the supervision of a doctor or nurse practitioner, and often need 6-8 weeks to be fully effective (many teens report feeling at least a bit better after 2 weeks, though). Studies have shown that the MOST effective treatment for teens with moderate-to-severe depression is a combination of therapy and antidepressant medication.

Although members of different cultures do sometimes report their experience of depression as being different, it is clear that depression does not discriminate: EVERYONE, including people of every culture, gender, and age, can experience depression and, at its root, biologically, within the brain, depression looks the same. That being said, “how” people describe the symptoms of depression can differ based on culture. In Western cultures, people frequently talk about their moods or feelings, so they may be more likely to describe the malaise they’re experiencing by saying, “Ugh. I don’t know what’s wrong—I’m feeling so hopeless and down, like I can’t even make myself care about stuff I know is important to me. It just does not feel that way anymore.” In many Eastern cultures, it’s not always common practice or socially acceptable to talk about one’s own feelings/moods, so they may be more likely to refer to more somatic symptoms, mentioning aches and pains that persist without cause; being tired, exhausted, bored, or dizzy; and/or experiencing an inner pressure or a general sense of discomfort.

Experiencing occasional anxiety is a normal part of life. However, people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations. Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks).

These feelings of anxiety and panic interfere with daily activities, are difficult to control, are out of proportion to the actual danger and can last a long time. You may avoid places or situations to prevent these feelings. Symptoms may start during childhood or the teen years and continue into adulthood.

Symptoms of anxiety include constant, chronic, unsubstantiated worry about things that you don’t necessarily have reason to be worried about. This overwhelming worry can interrupt a person’s ability to function normally in social situations or at school and is also accompanied by symptoms like:

• muscle tension
• feeling restless or tired
• difficulty sleeping
• irritability or edginess
• concentration problems
• stomach problems
• headaches
• racing thoughts
• being completely overwhelmed or afraid of the task at hand
• depressed immune system
• longer time to recover from any injuries or illnesses

Anxiety disorders respond well to treatment and/or medication (or a combination of both) often in a relatively short amount of time.

Panic attacks can occur when anxiety is present. If panic attacks become frequent or severe enough to cause extreme distress or get in the way of things you need to do, it is important to get help, whether from a medical doctor (to rule out somatic causes) or a therapist.

Symptoms of a panic attack are:

• “Racing” heart
• Feeling weak, faint, or dizzy
• Tingling or numbness in the hands and fingers
• Sense of terror, or impending doom or death
• Feeling sweaty or having chills
• Chest pains
• Breathing difficulties
• Feeling a loss of control

Things you can do to help control anxiety:

• get enough sleep
• exercise regularly
• eat healthfully and regularly
• practice relaxation techniques (progressive muscle relaxation)
• deep breathing
• meditation
• during an anxiety attack divert your thoughts to something that is positive
• focus on something that is not anxiety-inducing

Bipolar disorder, formerly called manic depression, causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts in the other direction, you may feel euphoric and full of energy. Mood shifts may occur only a few times a year or as often as several times a week.

Although bipolar disorder is a disruptive, long-term condition, you can keep your moods in check by following a treatment plan. In most cases, bipolar disorder can be controlled with medications and psychological counseling (psychotherapy).

Let your friend know that you care and are concerned about them; mention what you have noticed that’s made you concerned and ask them how they really are doing. Bring the topic up when you have your friend’s full attention or when it comes up in media. Be sure you are in a safe and private environment. Think about what you are going to say ahead of time. Acknowledge that the topic is uncomfortable but you are there to help. Listen to them and let them know when they need to talk you will listen without judgment or criticism. Encourage them to get help, give them the information needed to do so, and/or go with them to talk to a trusted adult or counselor about what they have been experiencing.

If your friend does not want help, you can try to talk to them about why they don’t want help (Do they not know what help is like? Do they think it will not make them feel better? Are they afraid of other people knowing? Do they not want to go on their own?). Be supportive and patient. Tell them about the many ways they can get help, such as the school nurse, a trusted coach or teacher, a counselor or their doctor. If your friend refuses to get help, talk to an adult you trust and tell them your concerns about your friend.

If they state they are feeling suicidal don’t overreact or under-react. Stay with them and walk with them to help immediately. This may be a trusted adult or counselor, but get them to help immediately.

If a family member has been diagnosed with depression, one of the ways you can be supportive is by learning about the signs and symptoms of depression that affect them. Now that they are diagnosed, encourage them to seek and continue with treatment so they can have the best chance of feeling better. Talk with your family member about what depression is like for them, what they are like when their depression is worse vs. better, anything that triggers their depression, and what is most helpful to them when/if their depression gets worse. Make sure they have a list of people they can reach out to during difficult times. Finally, you can provide support by letting them know how much you care about them and their recovery, encouraging them to stick with treatment, listening to how they are feeling without giving advice or being judgmental and taking care of yourself.

Start a conversation about suicide by telling him/her that you are worried and feeling concerned about them. Your friend’s life may be in jeopardy. If you are concerned about losing their friendship, remember that if they lose their life you will lose your friend. This may be a choice between life and friendship and living trumps friendship. Here are some very important things to remember:

• Take it seriously. All suicide threats and attempts must be taken seriously.
• Show interest and support; listen, be genuine and ask questions in a caring, direct and nonconfrontational
  way.

Here are some samples:

• “I’m concerned about you and how you feel. You are not alone I will help you get the help you
  need.”
• “Have you ever felt so low that you felt life is not worth living?”
• “Are you thinking about suicide?”
• “Are you thinking of killing yourself?”
• “When did you begin feeling like this?”
• “Do you have a plan?”

Using the word “suicide” will NOT increase the chances that someone will take their own life.

• Do not attempt to “argue” anyone out of suicide. instead let the person know you care and understand. Avoid saying things like “Why would you even think of such a stupid thing? You have so much to live for.”
• Do not promise to keep a secret about the suicidal thoughts. Your friend might ask you to not say anything, or he/she may threaten to end your friendship if you do not keep the secret. This is definitely a difficult situation to be in, and can be very stressful. However, if your friend is suicidal, you must tell
  someone about it. Never do this work on your own. You can call your parents and ask for help, you can call 911, you can call your friend’s parents, or talk to an adult in your school. The key is to find someone to help you right away!
• Seek help for yourself. Hearing about your friend’s sadness and pain can be stressful for you, as well. You may experience many feelings related to your friend’s thoughts of suicide. You may feel angry, betrayed, confused, or saddened by your friend’s thoughts. It is important for you to find help for
  yourself, so that you have the opportunity to process all the feelings you may be experiencing. Recognize that you are not responsible for another person’s choice to end his/her life.*excerpts from “Break Free From Depression” discussion questions for student debriefing

There’s no single cause for suicide. Suicide most often occurs when stressors exceed current coping abilities of someone suffering from a mental health condition. Depression is the most common condition associated with suicide, and it is often undiagnosed or untreated. Conditions like depression, anxiety and substance problems, especially when unaddressed, increase risk for suicide. Yet it’s important to note that most people who actively manage their mental health conditions lead fulfilling lives.

There is no single risk factor for suicide. Suicide may be precipitated due to a combination of factors. Below are some of the risk factors:

Health Factors

• Mental health conditions
  • Depression
  • Bipolar (manic-depressive) disorder
  • Schizophrenia
  • Borderline or antisocial personality disorder
  • Conduct disorder
  • Psychotic disorders, or psychotic symptoms in the context of any disorder
  • Anxiety disorders
• Substance abuse disorders
• Serious or chronic health condition (including sleep deprivation) and/or pain

Environmental Factors

• Stressful life events which may include a death, divorce, or job loss
• Prolonged stress factors which may include harassment, bullying, relationship problems, and
  unemployment
• Access to lethal means including firearms and drugs
• Exposure to another person’s suicide, or to graphic or sensationalized accounts of suicide

Historical Factors

• Previous suicide attempts
• Family history of suicide attempts

Something to look out for when concerned that a person may be suicidal is a change in behavior or the presence of entirely new behaviors. This is of sharpest concern if the new or changed behavior is related to a painful event, loss, or change. Most people who take their lives exhibit one or more warning signs, either through what they say or what they do.

Talk
If a person talks about:

• Being a burden to others
• Feeling trapped
• Experiencing unbearable pain
• Having no reason to live
• Killing themselves

Behavior
Specific things to look out for include:

• Increased use of alcohol or drugs
• Looking for a way to kill themselves, such as searching online for materials or means
• Acting recklessly
• Withdrawing from activities
• Isolating from family and friends
• Sleeping too much or too little
• Visiting or calling people to say goodbye
• Giving away prized possessions
• Aggression

Mood
People who are considering suicide often display one or more of the following moods:

• Depression
• Loss of interest
• Rage
• Irritability
• Humiliation
• Anxiety

From AFSP, https://afsp.org/risk-factors-and-warning-signs

When an adolescent is experiencing mental health distress/crisis emergency services services (911 or mobile crisis unit 1-877-412-7474) will be contacted to evaluate and possibly transport the youth to an emergency room. It is not recommended that a family member or friend attempt to transport the youth on their own. The law enforcement officer evaluating the situation may initiate a 72 hour hold (a “5150” described below). If an ambulance is called to transport the youth to the nearest ER, a family member may or may not be allowed in the ambulance. If not, determine which hospital emergency room the youth will be taken to and follow the ambulance there. Once there the adolescent, if agitated, may not be given medication to calm them in order not to mask symptoms. For the child’s safety a guard may be placed by their door. You may be able to sit with your child while in the ER; however, at times, you may be asked to leave in order for the physician to speak with your child privately. Once an assessment is complete the adolescent may be admitted, released or transported to an in-patient psychiatric facility.

It is recommended that you take notes about the recommendations for a child’s care. This is vital due to the stress family members are experiencing and the quantity of new information. Do not hesitate to ask questions. If the adolescent is released following the emergency be sure to follow up immediately as advised in a discharge plan to ensure continuing care for the youth.

The term “5150” or 72-hour hold, is a means by which someone who is in serious need of mental health treatment can be transported to a designated emergency department or psychiatric inpatient facility for evaluation and treatment for up to 72-hours (even if against their will), because there is an immediate safety threat toward self or toward others. The 5150 status may be placed upon a person by a professional who is certified by the county behavioral health department to do so (and may include a police officer, school counselor, or other trained professional). The 5150 does not automatically mean the student/adult will be admitted to the hospital, but gets them to the emergency department for a formalized evaluation by a psychiatrist. If a parent or teacher is concerned that a student may need a 5150 evaluation, the parent/teacher should call either 911 and ask for a CIT (Crisis Intervention Team) officer or, in Santa Clara County, the Mobile Crisis Unit at 1-877-412-7474.

“Inpatient” treatment usually refers to the therapeutic support, structure, talk therapy, and medication management that occurs on an adolescent psychiatric unit. These units may be part of a larger hospital center (For example: Mills-Peninsula Hospital, St. Mary’s Hospital (SF), Fremont Hospital, or Pavilion (Concord), or can be a short stay evaluation center such as Uplift Family Services (http://upliftfs.org ):
San Jose, Campbell, and other locations.

“Intensive Outpatient”, (IOP) programs, such as those offered by BACA (Bay Area Children’s Association), Kaiser Permanente, Mills-Peninsula, and El Camino Hospital (the ASPIRE program) are 2-4 month, afterschool (3p-7p) programs designed for teens who may be leaving a hospital setting as a transition back to the community, or may be used to try and prevent hospitalization for teens in sub-acute crises (for example, a teen who is cutting regularly because of multiple and severe stressors, but who is not expressing the wish to die, nor in imminent danger of dying by suicide).

* Students and parents should understand that 5150 Status, IOP, or outpatient treatment does not appear on a student’s transcript*

Prior to returning to school, a re-entry meeting is held with the student, parent(s), and designated school staff (usually the counselor, school psychologist, and on-site therapist (if engaged in ongoing treatment at school). The purpose of this meeting is to create a safety plan and identify specific academic and socialemotional supports that can be put in place to promote student wellness and safety (including naming specific friends and teachers who can be leaned on during stressful times), initially during the first two weeks back at school, but with an open-ended end-date for accommodations based on how the student is doing. The counselor will coordinate with teachers to make sure that any missed academic work or new assignments, quizzes, tests, etc. is manageable during a time when the student should primarily be focused on feeling better and readjusting to the school environment/schedule.

In general, the specific content that is shared by a teen to his/her therapist in psychological treatment and therapeutic support services is confidential, and specific information is available to parents only if a teen agrees to have this information shared. Exceptions occur when a student’s safety is at issue–even then, clinicians strive to share “only as needed” information. When a student is undergoing treatment outside the school setting (for instance in the community, privately, via a team member from the LPCH/Stanford School Mental Health Team, or via Uplift Family Services), the medical information is restricted via the HIPAA (Health Insurance Portability and Accountability Act) law, which specifies conditions under which information can be shared. More information on this law is at https://www.cdc.gov/phlp/publications/topic/hipaa.html

FERPA (Family Educational Rights and Privacy Act) is a different federal law that protects the privacy of a student’s educational record, but allows parents to have access to all portions of the school record (including mental health records) upon request, until the student turns 18. Practically, this means that any mental health record that is recorded by a school mental health professional (ACS or other contracted agency by PAUSD) and is kept onsite at the school may be requested by the parent. By contrast however, the records kept by the LPCH/Stanford team are classified under the HIPAA Law, and not the FERPA Law, and are kept offsite (electronically) as part of hospital records. Thus, a parent may request the mental health record, but the specific content to be released first has to be approved by the treating clinician (thus, sensitive information that the teen and clinician do not want shared may be redacted from any released material). For more information on FERPA, see

http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html