Our Children, Stress, and Mental Health: When to Worry and How to Get Help

May 17

The Change Principle, Part 2

In the last blog post, I focused on when our stress becomes “too much,” and what to do about it. In the spirit of my parent-first parenting philosophy, I took on our stress and mental health as what we need to prioritize. However, I know many parents have some season of their parenthood when they worry about their child’s stress and mental health too. When is their stress too much, when do you worry, and what do you do about it?

Pandemic life added fuel to the already burning fire causing alarm in the field of child and adolescent mental health. It seems not a day goes by without some headline of despair about our depressed and anxious children. The finger of blame points in various directions, parents often self-blaming in addition to society’s blame. On a Twitter post about parents and yelling, I recently asked if we had more structural supports for families, would parents yell less? One respondent did not share my macro-view, and replied that parents are the reason children are a mess and “they all need therapy.”

Leaving the unnecessary parent-blaming out of it, I do agree that we need support, sometimes professional, to be better parents for our children. Any regular reader knows my drum beat: when parents are better, our children are better. I’m not going to delve into the complicated research on the link between parents and children’s mental health, but other aspects of modern childhood in our culture warrant discussion when it comes to taking on mental health for our children. (It’s not all our fault.)

Academic Stress

Did you know the CDC designated teenagers in “high-achieving schools” as an at-risk group? This alarming CDC designation derived from recent research finding that teens at high-achieving schools have 2-3 times the national average of anxiety, depression, substance abuse, and delinquent behaviors.

Although research on academic achievement has traditionally supported the push for good grades due to links with a range of positive outcomes in adulthood, recent research in the context of modern childhood includes some critical considerations:

Social competence is a stronger predictor of success in adulthood than GPA
Intrinsic motivation and failing are key components to overall academic competence
Parents valuing kindness over achievement have children with higher academic achievement

My high-achieving neuroses occurred in the 80s and 90s, which likely proved protective. These days, I take a more hands-off approach to my children’s academic lives than I ever thought I would, both due to the research and because of what I see in my therapy practice (Children and Teens Under Pressure: Academic Achievement).

Sports and Extra-curriculars: “Extra” Stress?

Do you remember the time you spent playing sports, or doing whatever other non-school activities you enjoyed? I played soccer and softball, and did dance, which never exceeded a few hours a week. I’m not sure “travel leagues” even existed. When I decided to return to dance at age 12 after some time away, I wasn’t too old. These days, it feels like if a child hasn’t started an activity by age 6, it’s too late. Not to mention the ballooned amount of time and money many activities involve compared to our childhoods, making extra-curriculars more and more elitist and exclusive over the years.

In addition to the higher pressure and greater resources required, it’s adding stress to parents, children, and the family unit. COVID may have helped reset what had invisibly become a norm: over-scheduled families with little family time, and children with almost no down time. Now that there’s an opportunity to start again post-pandemic (-ish), we can seize the moment to be more intentional and deliberate in balancing our child’s passions and their wellness, as well as our family’s well-being. Some tips:

Think carefully about what your child truly gets out of each activity
Consider what might change if they no longer had that activity
Make decisions as a family about how to pick a select few activities
Prioritize family time and down time; both reduce effects of stress and improve resilience

When done in moderation, children participating in extra-curricular activities can experience many important social and emotional benefits, but the key is “in moderation.”

“Suffering may be part of the human condition, but the beauty and power of parenthood is our children do not need to suffer alone if we observe and take action to help them make meaningful change.”

When is it too much?

I will never forget a young teen who showed up in my office with constant migraine headaches, seeking treatment for managing the chronic pain. We only met a couple of times because it was so difficult to fit therapy into her busy schedule of the homework required from all AP classes, debate team, and theater, all pressurized by the internal and environmental expectations of straight As. You don’t need my specialized degree to diagnose the problem. She didn’t need therapy for her headaches; she needed to slow down and pare down.

The stress signs for our children are similar to the ones I listed for us, but since we are not in their heads, we need to observe closely. Telltale signs include changes in daily functioning, such as:

Being more withdrawn
More “meltdowns” (how these look depend on the child’s age)
Increased irritability
Problems sleeping
Changes in eating (overeating, or reduced interest in eating)
Difficulty completing tasks due to problems focusing
Increased forgetfulness
When they simply tell you, “it’s too much.” Sometimes we don’t listen, but we need to.

What’s important is how the constellation of these changes may be occurring together. So, if your child is suddenly consuming double portions at dinner, but nothing else has changed, that one data point would likely suggest a growth spurt instead of stress overwhelm. Look at their daily functioning as a whole – how would you describe it most of the time, and is it different in a way that concerns you?

Children: Stress and Mental Health

Just like for us, chronic, high stress can push our children toward the “disease” end of the mental health continuum. Also, just like us, they are likely scooching around on that continuum to the left and the right of their individual average, but have vulnerabilities that can slide them into the danger zone when overwhelmed. If a child has always tended toward separation anxiety behaviors for example, chronic, high stress may manifest in extreme behaviors of wanting to never leave the house.

Risk factors include major life transitions, such as divorce, family move, or death of a loved one, or experiencing a traumatic event. The American Psychiatric Association defines trauma as experiencing or witnessing an event that involves “actual or threatened death, serious injury, or violence.” Trauma specialists, however, often consider a wider range of experiences as potentially traumatic, such as those that are “emotionally disturbing,” like unexplained separation from a loved one, or the pervasive experience of racism. Living through a global pandemic may also apply, depending on the degree of emotional impact and loss of feeling safe.

With child and adolescent mental health, however, stress may not always be to blame. The science is complex about genetic and biological factors, and how they interact with the child’s environment. For the sake of simplicity right now, I just want to be clear that even if your child is not overwhelmed by stress, you may develop concerns about their mental health. Stress can be a trigger, but not always.

When to Seek Help

When we worry about our children and wonder if they need professional support, it is often hard to discern when to take the next step. When is a tantrum no longer a normal toddler outburst? When are problems falling asleep more than “just a phase?” What kind of pre-teen emotional explosions are par for the developmental course, and what may signify a deeper problem?

A quick review of how we make diagnoses in mental health: first, we evaluate the intensity, frequency, and duration of symptoms. A 15-minute meltdown feels like an eternity, but a 2-hour one actually IS an eternity and not the norm. If your behavior of concern occurs 1-2 times a month, that likely has not reached a problematic frequency. However, characteristics of symptoms pair with the next consideration: impairment in functioning.

To what extent do the child’s symptoms get in the way of their daily life? In my intakes, I always ask about changes in grades, for example, or participation in social activities, both structured and unstructured. Maybe they hold it together at school, but their anger dysregulation at home is causing significant stress in family relationships. “Areas of functioning” include home/family relationships, school, social, physical health, and emotional health.

Since this blog post is not a substitute for a professional consultation, let’s talk about that next. You are your child’s parent, not their mental health professional. So, although you are an expert on your child, you are not supposed to be the expert on evaluating their mental health needs. If you are concerned, a pediatrician screening is often a good first step, and they usually have referrals for specialists. However, this step is not a necessity, and you can seek an evaluation independently.

Who Are All These People?

The landscape of child mental health specialists is rich . . . and confusing. I regularly explain that I am not a psychiatrist, for example, since I never went to medical school and do not prescribe medication (although some states allow this for psychologists who get the right training). Psychologists differ from other masters-level therapists because we have education and training in psychological assessment, in addition to therapy. However, these are often separate skill sets in the real world of practice, with some psychologists specializing in assessments, and others in therapy. Masters-level clinicians (LCSW, LCPC, LMFT, for example) all provide therapy; the most important qualification is their experience with children and adolescents.

To add another wrinkle, neuropsychologists further specialize in assessments of neurological and psychological abilities; these assessments have become the real standard of any complete psychological evaluation. I often make the recommendation for children I see in my therapy practice to receive a neuropsychological evaluation to assess potential ADHD, Autism, or Learning Disabilities, that may be contributing to the emotional symptoms I’m treating. Although I could give the family symptom questionnaires, those are just one data point, and a neuropsychological evaluation provides a much more comprehensive picture.

How Does It Work?

An intake for therapy is different from a neuropsychological evaluation. In a therapy intake (the first appointment to establish therapy treatment), we ask a million questions to gather information about current concerns, and important history of symptoms and functioning. The questions we ask inform the mental health diagnosis we form by the end of the appointment, which is required for submitting to insurance. (I think many parents may not be aware of this.) Sometimes we use standardized questionnaires as another data point, especially when assessing anxiety and depression.

A neuropsychological evaluation also includes an interview, but the heart of it involves a series of multiple questionnaires and hands-on tests with the child to assess a wide range of neurocognitive abilities in addition to emotional and behavioral symptoms. This usually requires 1-2 visits and a feedback session when you meet to discuss results and recommendations. Neuropsychologists often recommend therapy to address symptoms and diagnoses, but they do not usually provide the therapy.

When Children Need Change

There may be much to despair over when it comes to the state of child and adolescent mental health; however, I do celebrate the increased acceptance and reduced stigma associated with it, which I have observed change in the short span of my career. Based on personal and professional observations, as well as data, I expect you to have a mental health concern about your child at some point in your parenting. The concern may stay at what we call a “subclinical level,” meaning it doesn’t reach the threshold of a psychiatric diagnosis. Or it may not. And they will benefit not only from a professional evaluation and treatment, but more importantly, from your astute observations and support in getting them the help they need.

Suffering may be part of the human condition, but the beauty and power of parenthood is our children do not need to suffer alone if we observe and take action to help them make meaningful change.