Kids in crisis

VCU’s lead child psychiatrist, Ekaterina Stepanova, M.D., Ph.D., has observed that today’s teenagers are reporting the same stressors that have been plaguing this age group for decades: school, social pressures, family conflict, feeling misunderstood. The difference now, she said, is the sheer number of severe cases she sees compared to 10 years ago.  

According to the CDC, adolescents in the U.S. are experiencing record levels of sadness, violence and suicide risk. A recent study revealed that nearly three in five teen girls reported feeling “persistently sad or hopeless” in 2021, double that of boys and representing a nearly 60% increase over the past decade. The report also found that 52% of LGBTQIA+ youth had recently experienced poor mental health, and 45% had “seriously considered suicide.”  

The encouraging news, Stepanova said, is that most of her patients want to get better.  

“In the past, I can remember having to convince kids to participate in their treatment, but I don’t have to do that so much anymore,” Stepanova said. “The overwhelming majority of my patients are taking it seriously.”  

Stepanova is one of many specialists at VCU School of Medicine on the front lines of this national crisis. We sat down with her and Stephanie Crewe, M.D., to learn more about teen mental health and what parents and caregivers can do to support kids through their teenage years.  

Stephanie Crewe, M.D.  

Stephanie Crewe, M.D., chief of the Division of Adolescent Medicine, specializes in the care of 13- to -22-year-olds. As a primary care physician who works with “a very challenging and vulnerable population,” Crewe is often the first point of contact for teens and young adults experiencing mental health challenges. She noted that mental health has become increasingly prevalent in her role as she sees more young people in crisis, and she has lost three patients to suicide over the past three years.  

“That really hit home for me,” Crewe said. “What are we going to do? We can’t lose our kids this way.”  

SOM: What are you seeing now that you didn’t see 10 years ago?  

SC: We always hear about the negatives, and I want to communicate that I’m also seeing positives in this generation of young people. The positives I see in this generation are resilience, adaptability and confidence. A lot of these kids are very transparent, and they open up to me as if nothing stands in the way. 

The negatives include impoverished environments and inequities, this generation has seen injustices. Social media can be a negative construct and the pandemic was very detrimental. All these things negatively impact mental health, especially in this population.  

How do you talk to patients and their families about sensitives topics?  

I do what I call sandwich communication. Mom or Dad will be in the room with the patient, I ask both the child and the parent what they would like to talk about, and we make a list of questions or concerns. That way both can feel that this is an opportunity to bring things up and get what they need out of the visit. So, if you’re scheduled for a regular check-up, but Mom and kid tell me they’re worried about depression, we’re not going to do your wellness visit, we’re going to talk about your mental health. 

I then ask the parent to step out of the room for the physical exam. This gives the kid the opportunity to advocate for themselves, and to ask those difficult questions if they don’t feel like they can engage in front of their parent. I want this to be a safe space. If something comes up that I think will be hurtful to the child or anyone else, Mom or Dad will be the first to know.  

Then the parent comes back in to finish the visit and discuss anything we feel we can tag-team. I've had parents break down in my office because they’re dealing with the same things. We have to work on those parent-teen bonds and strengthen them by any means necessary. 

How do you connect with your patients?  

It requires patience and compassion, and knowing that this is their season of discovery and uncertainty. It also requires flexibility in every imaginable way. They’re going to test the waters and try to figure out whether they can trust this person if they disclose whatever’s going on in their head. If you respond with rigidity and only one way of thought, that’s not going to work.  

It also requires a level of authenticity, so they feel like you’re a real person who breathes just like them, not someone on a high horse who doesn’t understand what they may be going through. When inner city kids look at me, they don’t know that I've been in their shoes. In their head they may be thinking “No way can she identify with me,” but I always try to figure out something we have in common. I’m going to find something that gives me a crack in the window, so they know I'm trustworthy and they don’t have to be guarded with me.  

Ekaterina Stepanova, M.D.  

Ekaterina Stepanova, M.D., Ph.D., chief of the Division of Child and Adolescent Psychiatry and Psychology, leads the inpatient unit at the Virginia Treatment Center for Children. Her patients are kids in crisis, who arrive with levels of depression, anxiety and suicidal ideation that warrant hospitalization. Stepanova said the CDC’s findings “are not surprising,” and she shared what has changed – and what hasn’t changed – in the more than 20 years she has been a pediatric psychiatrist.  

SOM: How have your patients, and the way you interact with them, changed over the years?   

ES: Awareness of mental health problems has increased significantly. Children and their families are often able to recognize symptoms of depression, anxiety and other problems much earlier than many years ago. Early recognition is often the first step towards success.  

Most of the kids want help when they get here, which is a difference from years ago. Now, kids are working really hard and trying to get help. In the past, I can remember trying to convince kids to participate in their treatment, but I don’t have to do that so much anymore. The overwhelming majority of my patients are taking it seriously. They want to learn those coping skills to be able to be successful when they leave.   

What stressors are your patients reporting now, compared to 10 years ago?  

The stressors that teenagers are reporting now are essentially the same as they were years ago: school, family conflict, feeling like they’re not understood. The pandemic may also have something to do with the higher volume of mental health issues, along with social media.  

Kids are taking social media very seriously these days. Comments on posts can sometimes be triggers for a suicide attempt. That's a major difference from a decade ago – conflict is not just between two people anymore, and if something occurs on social media, the whole world knows about it. 

What advice do you have for parents of teenagers?  

Any change in behavior can be a warning sign. If a child has never been isolated and suddenly locks themselves up in their room, or changes their friend group seemingly out of nowhere, it may be nothing, but it’s worth exploring and asking. A lot of schools are providing education around mental health, depression and suicide, and it’s really important to reinforce that at home. It’s important for parents to say, “Hey, what did you learn? What did you think about that? Can you relate to it?” Find out what the kid knows, and then ask what they think. 

As the parent of a teenager these days, I can relate to how difficult it is. Having family nights, spending time together talking about non-serious things and just maintaining that connection and that bond, is really important. It may not prevent mental health issues, but it may help parents discover them.    

And if there are any concerns at all, parents know their kids better than anyone. It’s important to ask for help when it’s needed.   

How are the VTCC and its partners trying to address the increasing need for treatment?  

It’s hard to judge the proportion of kids needing services versus what we’re offering, but subjectively, it feels like it’s not enough. We have been creative in offering more interventions with essentially the same resources that we had previously. For example, we now offer group therapy options on various topics for both children and their families. We are providing more targeted interventions that are based on the latest evidence to make sure that we help children faster. Despite these interventions, our wait lists are long, and we are not able to meet the demand of all families in need. We simply need more providers to be able to address the needs. 

Outpatient providers are willing to work with us quite a bit, and we increase the frequency of outpatient visits when needed. We want to make sure the provider the child is seeing is close enough for them to get to. We really try to reduce those barriers to seeing a psychiatrist when patients leave us.  

We can only do this together.  

Suicide Prevention  

If you’re thinking about suicide or are worried about a loved one, the Suicide & Crisis Lifeline provides free and confidential support 24/7.  

Call 988 or visit the 988 Suicide & Crisis Lifeline website here