The Teen Mental Health Crisis with Ethan Benore, Ph.D.

Podcast Transcript

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Kate Kaput: Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput, and I'll be your host. Today, we're talking to pediatric psychologist, Dr. Ethan Benore about the teen mental health crisis in the United States.

Recent news headlines tell of a national emergency when it comes to teen mental health in the U.S. Statistics show that teen depression and suicide are on the rise, exacerbated in the last two years by the effects of the pandemic, and in fact, suicide has become the second leading cause of death among American adolescents. What's at play here, and importantly, what can parents and other adults do to best support the teens in their lives? Dr. Benore is here to help us parse through the headlines and figure it all out.

Dr. Benore, thanks so much for being here with us today.

Dr. Ethan Benore: Thanks for having me, and thanks for giving time for this conversation.

Kate Kaput: Absolutely, it's such an important one. We really appreciate you being here with us. I like to start by having our guests tell us a little bit about themselves, so tell us a little bit about you and the work that you do here at Cleveland Clinic. What kind of patients do you typically work with?

Dr. Ethan Benore: Sure. As a pediatric psychologist in our chronic pain program, I work in a specialized medical rehabilitation program for children with chronic pain. Chronic pain affects approximately 25% of children; however, a smaller percentage are significantly impacted by the chronic pain. They're either missing school, losing friends, dropping out of sports or other recreational activities, and the whole family suffers, just given how long it persists. In many cases, there are comorbid psychological issues that are a large factor of their suffering and prove barriers to their recovery.

Also, as a Chair of our Center for Pediatric Behavioral Health, I lead a team of psychologists and mental health professionals who are truly skilled and dedicated to helping improve the lives of these children. They work to assess and treat a wide range of mental health concerns. Most prevalent are anxiety, depression, disruptive behaviors, but there's several other conditions that our team is especially trained to treat.

Kate Kaput: All right, so really important work. We've been hearing a lot in the news lately about the teen mental health crisis. Can you give us a sense of what this refers to and just what's been going on?

Dr. Ethan Benore: What we know from research is that mental health issues in children and teenagers has been steadily increasing over the last decade or so. However, in the last year or two, in part related to the pandemic, there has been a significant increase in difficulties that children are facing. There's more than 4 in 10 teens — in a recent study by the CDC —there's more than 4 out of 10 children that say that they're persistently sad or hopeless. One in five, or 20%, of these teenagers have contemplated suicide. This information is more recent, that was collected during that first full academic year after the pandemic started.

What we know is that children benefit from stability, structure, routine and the support of trusting adults. However, during the pandemic, we've seen instability in our nation, we've seen changing structures in school, school schedules, children struggling with academic progress due to this. We've seen parents who have stopped working or have been unable to get work. We've seen increased alcohol and drug use by adults, and we've seen less support and more abuse by adults on their children. In the same study that we were talking about, more than half of the children that were assessed reported experiencing emotional abuse, including swearing, insulting, and 11% had reported physical abuse by their parents.

Kate Kaput: Those are some really staggering statistics. In December 2021, the U.S. Surgeon General issued a rare public health advisory warning of a "devastating mental health crisis among American youth" that he said were made worse by the COVID-19 pandemic. Are there other ways that the pandemic has exacerbated things? Anything else that is particularly on the rise?

Dr. Ethan Benore: A couple of things. Other than the instability that was created at school and some of the economic hardships, there was lack of access to resources. There was a huge focus obviously on identifying vaccines and keeping individuals safe; however, children weren't at school, so we had less ability to effectively monitor children's wellbeing. If there was abuse or other emotional concerns, individuals outside of the family had a harder time recognizing that. We've also seen increased adult distress and burnout. We've also seen loss of parents during COVID. During the pandemic, there was 140,000 American kids who lost a primary caregiver. We've seen just an increased volume of children needing care and needing a higher level of care.

Kate Kaput: It's almost like there are just a lot more things to be going wrong during the pandemic, there's a lot more opportunity for teens to be struggling. Before we get into some of the external causes beyond the pandemic, what can you tell us about the role of puberty and hormones and how they play a role in teen mental health? Not just now, I suppose, but always. What's literally happening in teens' brains and bodies that can contribute to depression and anxiety and other mental health conditions?

Dr. Ethan Benore: Sure. A way that I like to explain it to the teenagers that I work with and their families is talking more about brain development. When the child becomes a teenager, lower portions of the brain that detect threat, that generate emotions and look at relationships have been fully developed. A child can be very good at detecting threat and generating emotions. However, these higher functions of the brain, higher portions of the brain, are still developing. Despite the fact that on the outside these kids are looking older and older, their brain still hasn't fully developed. These prefrontal cortex, or these higher functions or portions of the brain, are not going to fully develop until a child is in their early twenties.

What you have here is a child's ability to generate emotions and a child's ability to regulate and monitor these emotions that are still not fully developed, and then we kick in a bunch of hormones at varying levels and varying times that just makes it a very chaotic environment for children to modulate and monitor the emotional changes that they're going through. You add to this the chaotic environment that children have in terms of having multiple teachers, multiple bosses, having poor sleep habits, teenagers usually struggle with that because of school, excessive stimulation due to electronic devices and no real chance to recover, we also have some poor food choices, and you get the standard teen experience. Then again, more recently, when you add to this pandemic, unstable social environment, less access to good food, good transportation, an adult caregiver, and then increased violence or threat of violence in the community, as well as through social media, and that's where you get the current crisis that we're in.

Kate Kaput: Yeah. I think some of those are really good points, that teens can look like adults, they look like young adults, and you forget that they are still children mentally, that their brains are still developing. That puts them in a sensitive position to be really sensitive to all kinds of things going on in the world. I think, as adults, it's easy to forget just how stressful it can be to be a teenager.

Dr. Ethan Benore: Yeah, thanks for saying that. It's actually one of the key points that I try to hit home with parents, which is what is on the outside doesn't always match what's on the inside. They are physically developing, but they are not fully developed yet. Pay attention to how their brains are developing and how their emotional management skills are developing.

Kate Kaput: Right. It's like, as an adult, if you take a minute to really transport yourself back to when you were a teenager, it's a pretty tough time. What are some of the other key contributors to teen mental health and how have those contributors changed over the years? You talked a little bit about pressure to achieve, schoolwork, social media, let's go a little bit deeper into some of those things.

Dr. Ethan Benore: Sure. It is interesting to think about, and I think for parents, maybe to put themselves back into what the world was like when they were teenagers as well, the world is just different, the world is changed. There is multiple opportunities for children and teenagers to participate in activities and in sports, in different school clubs. There's also multiple opportunities to fail. Children often struggle due to all of these evaluative structures around them, in terms of worrying about how they look, how they appear and if they're going to be successful.

There's also huge access to social media and technology, which is a wonderful resource, but it's also very difficult to escape. Being able to turn it off, to get away from some of the pressures that are put on by what children may watch in social media, and being able to escape unsettling information or misinformation that's shared on social media is just very difficult.

Beyond that, there's the economic struggles that I think our country and our families are facing right now. Everyone fights about money, but there's also people who struggle because they don't have money right now. There's also clear social unrest in our country in various ways. There's violence in the schools, there are hate crimes. There's some distrust of whether it's government agencies or police or teachers that also makes children feel like they're in an unsafe world. It can be very fatiguing, it can be very overwhelming, and it can seem hopeless to a young person, a young teenager, who's just starting to understand this larger world.

Kate Kaput: Yeah, that makes a lot of sense. I think some of the things that plague mental health for all of us as adults are the same things that are stressing out our teens, but they have fewer skills to cope with them and they're younger, so they're kind of like, "What kind of world am I entering?" That makes a lot of sense and is heartbreaking to think about.

You talked about social media. Studies show that loneliness is a key predictor of teen depression and suicidal ideations, and that online connections don't always fill the void in that loneliness. In the same CDC study that you talked about earlier, teens who said that they felt "close to people at school" were much less likely to have considered suicide. How does human connection play a role in depression and suicidality?

Dr. Ethan Benore: No one who is depressed wants to feel depressed, but they do struggle modifying those emotions, as we just talked about, the varying levels of emotions that teenagers face, whether this is due to biological or chemical changes or whether it's due to their social environment. Personal connection allows for validation, it allows for compassion and it allows for appropriate levels of support. Validation is, "I see you and I understand that you're a suffering." Compassion is that sense of, "I want your suffering to end." It's very difficult to get that in the same way from technology and social media. The last, of support is the, "I'm here to help." So much of middle childhood is about kids being able to do things by themselves. It's difficult when they get into the teenage years as well to ask for help, and you're just not going to get it at the same level from the internet. Asking for help is hard. It is important for caring adults in the child's life and the teenager's life to be there and to offer help to them.

Kate Kaput: Talk about some of the other ways that social media can play a role in teen mental health, from the comparison game to the pressure to curate the perfect life, things that also stress out adults, but play a special role in the lives of teens. What can you tell us there?

Dr. Ethan Benore: I appreciate you saying things that stress out adults, it stresses out adults as well. I think the problem that some teenagers face is they don't really have the reference point, that this is the world that they're coming into. They don't know that it hasn't always been this way or it will be better at other times, they just don't have that reference points. These unfair comparisons that get put up have a lot of weight, how you feel at school or what's going to happen this week at school means an awful lot to the teenager when they can't put it in perspective that a month from now no one else is really going to care and I'm going to be okay.

The focus on image, on how you look, you mentioned that. There's a lot of false expectations, because there's a lot of editing and airbrushing and ways that you can present yourself favorably online that just don't fully represent who you are. Children really struggle and teenagers really struggle with that mismatch of what I see other people becoming and what I know or what I fear about myself. There's just a lot of misinformation. There is a lot of good information that's out there, but it is embedded with a lot of misinformation as well. This can scare children. This can lead them down some very unhealthy ways of managing stress in their own life.

Kate Kaput: We talked about loneliness, but as we're talking about the pressures of keeping up appearances on social media, it's also important to note that sometimes teens who seem to have it all, whether on social media or in real life, can still be struggling with mental health challenges. We've seen some recent headlines about teen beauty queens and pageant participants, in particular who have died by suicide. Online, you might say that their lives looked "perfect." I think that's a really tragic reminder that it's not always the visibly sad, lonely kids who are facing mental health concerns.

Dr. Ethan Benore: It's wonderful that you say that. We've made some progress, I think, with some individuals who are in the spotlight who have also mentioned their own mental health struggles. Simone Biles in the Olympics was a really good example. It's important to know that it happens to all of us and it doesn't just happen to those who excel at the Olympic level. It happens to everyone, and everyone needs to address these issues directly so that they can learn the appropriate methods to deal with it, so that they can reach out and get the support from others, and so that they can move closer to the future that they want to create for themselves.

Kate Kaput: I want to move into talking a little bit about intersectionality and how teens identities can play a role in their mental health. Studies show that LGBTQ teens' risk of mental health issues goes up when the adults in their lives are unsupportive of their sexual orientation or their gender identity. What can you tell us about the role that parental support in particular plays in mental health for this demographic?

Dr. Ethan Benore: Certainly. We were talking about depression and suicide earlier. Yes, there have been studies where about 45% of LGBTQ teens are seriously considering suicide, and about up to 20% of transgender or non-binary youth have attempted suicide. This is worse for individuals of color. However, like you had mentioned, it is significantly buffered or improved if they live in a household, attend a school or live in a community that is affirming and supportive. No one wants to pretend to be someone else in order to fit in, to fit into their class, to fit into their school, to fit into their family. They want to be loved for who they are and how they see themselves. Children often see their parents as offering unconditional love and support, and in many respects, some children see their teachers the same way. If your parent cannot see you and love and respect you, it's difficult for teens to believe they have a chance with other individuals. It's critical that parents listen to their child, respect them for who they are and who they're becoming, and help them feel the love that they deserve as they're growing up.

Kate Kaput: You mentioned teen mental health in teens of color. In recent years, lawmakers in the Congressional Black Caucus' Emergency Task Force on Black Youth Suicide and Mental Health issued a report that shows that suicide rates among Black teens nearly doubled from 2007 to 2017, which makes it the fastest rising suicide rate of any racial or ethnic group. What are some of the reasons for an increase among this particular population?

Dr. Ethan Benore: There's two big ones that I can think about. One is social determinants of health, and the other is structural racism. These are important factors that people should study so they have a better understanding of truly what these concepts are. Structural determinants of health talks about where we live and how this influences our own wellbeing. Economic stability of your community, if you live in an impoverished community, the quality of education where you live and your ability to access that education, or the quality of healthcare, can you find a good doctor in your area, your own safety of your neighborhood, can you walk down the street without fear of becoming a victim of any type of violent act, the culture of the community around you. We don't choose the neighborhood that we're born into, but it does shape our mental health as we develop.

The other is structural racism. Black children are less likely to receive mental healthcare. Due to some of the factors related to social determinants of health, they do struggle with access to quality care. There is a stigma of healthcare and even a mistrust of healthcare professionals by some members of the Black community. I want to say it's not unfounded to some respect, there are people that are not offering support. When you think about it, we talk about unconscious bias a lot. I do think it's important for people to be honest with themselves. Symptoms of depression may include a child being loud, disruptive, argumentative. Symptoms of a child who is anxious, a child might yell, might fight back if you're trying to force them to do something that they're frightened to do. I think it's important for individuals to ask them how they would respond if that is a white child acting that way or if that is a Black child acting that way. Do you see the suffering that child is going through and can you reach out and provide the level of support that child needs.

How to help these kids? One is paying attention — pay attention to concepts of privilege, pay attention to concepts of bias and unconscious bias. Reach out to help the child, instead of worrying about trying to protect yourself or other people from the child. Offer hope — offer hope and a road to healing for some of these Black and Brown children who are suffering out there. Work to strengthen the community so the community raises these children and supports these children.

Kate Kaput: All of that is so important, I feel like we could do a podcast just on some of these intersections alone. The last one that I want to talk about is rates of teen mental health between girls and boys. Data shows that girls are twice as likely to report mental health struggles as boys, a CDC study showed that more than a quarter of teen girls seriously contemplated attempting suicide during the pandemic. Why might that be?

Dr. Ethan Benore: Well, I think there are several factors. I want to say, as a white man, I may not have all of the answers to this part, but some of the factors that are important to pay attention to is just the pressure that appears unique to young girls. There is significant pressure for how young girls look, how young girls develop physically or develop sexually, a lot of that happens in the open, out on social media, the social aggression that affects girls differently than how it affects young boys, and how it happens to young girls differently, and risk of safety. We still have 1 in 9 girls who are victims of sexual assault before the age of 18.

Then to add to that, I'm going to go back. I'm going to go back to bias and I'm going to go back to inequality. Just because we have now elected a woman as vice president of our country does not mean we have reached a level of gender equality in this country. Young girls see this, young girls recognize this and girls and women talk about this. The world is still harder for them. There are also symptoms of mental health disorders that I think go unrecognized in girls, and this may suggest bias as well. For example, young girls who have ADHD may be overlooked because if they're not acting up in class in the same way that a young boy is, a teacher just might not identify it or a parent might not identify it and seek the resources as needed.

Kate Kaput: I think it's so important, you've mentioned a couple of the ways that some of these mental health issues can manifest outwardly, from teens being loud or angry to teachers not recognizing ADHD. I want to talk about some of the ways that these mental health issues present, from warning signs, what parents should be looking for and then what parents can do. What are some of the warning signs that a teen is struggling with mental health issues, what should parents be on the lookout for, and talk us through the spectrum of some of those signs, because they're not all just, "Oh, my teen is really quiet and seems sad and never leaves their room."

Dr. Ethan Benore: Yeah. A couple of things that I would encourage families to do, the first is look for a change in behavior, so my child is more sullen, more quiet, more irritable. Look for behaviors beyond just mood, look for how are they sleeping, how are they eating, what are they eating? Are they doing anything less or more, they're not going out with their friends as much, they're not texting their friends as much, they're not playing sports as much. Any change in behavior should at least, maybe not raise a red flag, but should signal that you should pay closer attention.

The other thing that I encourage parents to do is ask, have an ongoing conversation with your child. We think about when you should start taking a look at child's mental health, I would say as early as age 3. After your child is walking and talking and peeing and pooping appropriately, then you move on to social and emotional development. Starting to talk with your child about how they are developing and just making that an ongoing conversation piece makes it a lot easier when you start to notice something and you can just ask your child, "Hey, you're acting differently. What's up? It looks like you're sad. What am I missing?" Being open for them when they are ready to talk. Making that discussion more habitual, I think, is helpful.

Kate Kaput: I'm glad you mentioned age, because that was going to be one of my other questions. There are some really tragic news stories out there about parents who thought their kids were too young to be experiencing depression or considering suicide. As you said, it's not all just teens. Start looking for those signs earlier in your kids and normalize those conversations.

Dr. Ethan Benore: Well, often we see higher rates of anxiety and depression in teenagers, but in younger children we see higher rates of disruptive behavior. Parents are very aware of the behavior of younger children, but may not be aware of the developing emotional difficulties that children are facing. Thank you for saying that, it is much younger than teenagers that we need to start looking and listening to our kids.

Kate Kaput: Presumably, if you notice something in your child sooner and you're able to help them get treatment, then that helps put them in a healthier space as they enter their preteen and teenage years, it hasn't been going on for years and years that they've been depressed. Back to teenagers though, for a moment, teenagers are known for being a little bit moody and not always thrilled about talking to their parents. How can parents differentiate — parents and guardians, I should say — how can adults differentiate between normal teen angst and more serious signs that something is wrong?

Dr. Ethan Benore: For parents who are interested, I would say they should ask and they should read. Again, I want to go back to early childhood development and teenage development. When a family is often pregnant with a child, or the mother is pregnant, you read a book, like what to expect. Oftentimes, when we have a baby, we're reading infant or toddler books about how to help toilet train or how to help get them to walk, how to give an appropriate time out. It usually stops there. Once we send them off to school, a lot of parents stop thinking about what do I need to know to help my child.

This is the stage where children's social behaviors and emotional function is truly developing, so it's important to think about what are you reading, as the parent, to educate yourself about a teenager. It doesn't have to be one of those big books, it can easily be a TikTok or a YouTube video nowadays. There's some lot of good information out there, mostly starting with some credible sites, like the American Psychological Association and the American Academy of Pediatrics, even the CDC website has some wonderful links.

The other thing that I would suggest is when you're working with your child, as a parent, just like you're teaching them to walk or teaching them to play or to share toys, is think about how you are teaching them. In much of the same way that a coach might pull somebody off the sidelines, talk with them a little bit about what happened on the field and then send them back out there, parents and teachers should do the exact same thing with children, pull them aside, process the situation, the event, help them understand what's happening inside of them and then send them back out to try again.

Kate Kaput: I like that a lot. You mentioned earlier that once kids hit the age of 3, they hit the early childhood developmental milestones, it's like these are the next milestones, the mental health milestones. It's almost about continuing education for adults, for parents, in making sure that they know how to pay attention to those maybe less obvious milestones, those mental health milestones, those emotional milestones, along the way as their kids grow up.

Dr. Ethan Benore: Right.

Kate Kaput: What can you tell us about cutting and other forms of self-harm? How common are they? Are they always a sign of suicidal ideation? I think there's a lot of misunderstanding from an adult level around teen self-harm. What can you tell us there?

Dr. Ethan Benore: Sure. It is important, I think, for people to understand self-harm. There was a nice study out in 2018, looking at this across multiple countries. I think it was about half a billion people that they looked at in over 40 countries. They found a prevalence rate of almost 17%, so almost 17% of teenagers had engaged in self-harm behaviors. This was higher for girls, less than about a 2:1 ratio, but much more common in girls. The mean age of people doing this was about 13. Again, look for younger kids, but 13 was the average. For half of those kids, it was about one or two episodes of self-harm. Typically, superficial cutting with a sharp object, could be a knife, could be scissors, could be a pen or pencil, is the most common type. The most frequent reason for cutting was not to kill themselves, but was to provide some sort of relief from thoughts or feelings. Creating physical pain overrides, temporarily, emotional pain. For these children, at least in this study, about half sought help from this emotional pain. It just usually wasn't from the right individuals, it was usually from a friend.

You talked about suicidal ideation, it is higher for individuals who do self-harm and obviously higher for individuals who are involved in more frequent self-harm. It's important, when you see self-harm, it is not a direct indicator that they are actively suicidal, but it is a red flag that you should be paying attention and trying to provide your child the resources that they need to help manage that emotional pain they feel.

Kate Kaput: Are there any signs of self-harm to look out for that are not just ... teens can be a little bit crafty about how they cover it up, or make sure that the adults in their lives can't very obviously tell that they are self-harming. What can you tell us about what parents can be on the lookout for?

Dr. Ethan Benore: It's very important for parents, if you do have a concern, to take a look at your child and to examine them. It is not always a cut on the wrist, sometimes it's a cut on the upper thigh, sometimes it's a cut on the shin where the child can cover it up, sometimes it's a cut on a thicker body part. Some children will do drawings or writings that people have hit themselves. The important part is if you have a concern, do the full examination, talk to your primary care doctor about the concern and figure out what's the best way to fully assess your child to ensure that they're safe.

Kate Kaput: Perfect, thank you. Let's move it relatedly, if a parent suspects that their teen is depressed or struggling with some severe mental health issues, where do they start? What can they do to help? What resources are available to them and to their kids? Where can parents begin?

Dr. Ethan Benore: I would tell parents to always begin with your primary care doctor. Often, your primary care doctor has had a longer term relationship with you, understands you, understand your child and how they're developing. Your primary care doctor also has access to resources, knows where to go for the next step. Develop a good relationship with your primary care doctor and start with them.

I had mentioned this before, there are some very nice websites out there that you can get information from. Start with the credible websites, do not just go to Instagram or TikTok to get this information. You will get some very helpful information from sources like CDC or American Academy of Pediatrics or American Psychological Association that points you in the right direction. Sometimes 30 minutes of just web surfing from these credible sites can be helpful.

What I would say is I would not expect your child to figure it out alone. That, "I will just patiently wait and hope my child figures this out," I don't think is a good plan.

Kate Kaput: I think that sometimes parents worry about overstepping or being too intrusive if nothing is actually wrong. Like I said earlier, teens are a little angsty, even the happiest of teens can be a little bit angsty, they don't always want to engage with their parents. I think sometimes parents worry, "Oh, I don't want to pry too much, because if it turns out that they're fine, then my kid is just going to resent me, they're going to be mad at me and I'll have done all this for nothing." What is the line between being there for your kids and overstepping, or being overly intrusive? What is your guidance to parents who are like, "Oh, I don't know if I should."

Dr. Ethan Benore: Yeah, it's a great question. What's the line? I think the line is the parents' own concern or their own worry. I think the issue is not the if I should, but the how I should. I definitely wouldn't recommend just rooting through their phone or rooting through their room, they will definitely perceive that as an invasion of privacy, but mentioning your own thoughts or your own concerns is important.

Think about it like this. Teenagers are often keeping to themselves as they get older. Why? They're developing a sense of independence, that's a good thing. They're developing more reliance on social relationships, that's a good thing. They're historically, through school, taught to do more and more things by themselves, tie their shoes, put on their coat, do their chores. The part that we need to be sensitive to is they are incredibly sensitive to being evaluated negatively. By your teenage years, you spent at least five to 10 years of schooling where some adult has evaluated your performance.

How do you start these conversations or get in there? One is having these regular check-ins or huddles, where you're talking about ups and downs with your child, the good as well as the bad. It makes it a little bit easier when you start to mention a concern. And listening much more than you talk. It often doesn't happen in a nice 20-, 60-minute conversation with your child. It certainly doesn't happen in a 60-minute lecture to your child. Sometimes, it's two to five minutes here or there, but spending time to just be quiet, listen more than you talk, gives them an opportunity to process out loud what they're going through.

Kate Kaput: I love that. When I think about my own childhood, or as a teen, and the times that I was like, "Oh, Mom, leave me alone. Nothing's wrong, I'm fine." It was annoying at the time, but now as an adult, I'm like, "Hey, Mom, thanks for checking in," because then the times when I was having a harder time, I knew that my mom really cared and that she was paying attention and that I could go to her if I needed that. I think that's another thing, is for parents to remember that, down the road, better to have checked in and nothing's wrong and to have been a little bit annoying checking in and showing your kid that you care than to never have checked in at all.

Dr. Ethan Benore: Right.

Kate Kaput: Let's talk about therapy. When is therapy the right move for a teen or for a younger child who is dealing with depression and other mental health issues, and how can parents go about finding the right therapist for their child?

Dr. Ethan Benore: That last one's very interesting. I'm going to circle back to that one. When to help, there's a couple of times. I mean, one, your child is asking for help, "I want to see somebody, I need help with this." That doesn't happen as much, so two would be a sudden or a drastic change in behavior. We've talked a little bit about some of those behaviors. The third is probably the most common, which is your child isn't progressing the way that you would expect them to, something is off and it's not getting better. I usually have parents give themselves a time period, like, "This is bad, I'm not going to wait this out. I'm going to give this two weeks and if I don't see any improvement, then definitely we're making a call to the doctor."

The other option that I tell parents is when you feel like you are beyond your ability to effectively help them or to effectively keep them safe. If you feel that “I am not able to do this” on your own, just like kids just have a hard time asking for help, parents sometimes do, too — don't wait it out. It's OK for you to call and ask for help yourself for your child.

In terms of how to find the therapist to work with your child, it's a tough one. I think there's such a strong need for mental healthcare right now that access is an issue. Also, you want to try to connect with somebody that is going to work for your child. When we go to school, you usually don't get to pick your teacher. When you go to therapy, you do. It's OK to call somebody, it's OK to ask them a couple of questions, it's OK to do a little bit of research and background checks on your doctors and figure out whom you would like to sit down and talk to. It's OK if, in the beginning, the child needs to feel it out for a little bit so that they feel safe in that situation.

Kate Kaput: Can you actually speak more to that? I know you said the child might need to feel it out and feel safe in the situation. I think sometimes teens go to therapy and their parents have made them go to therapy, they really don't want to and they're resistant to it, or maybe they're resistant to going in the first place. What can parents do or what is the approach for parents whose teens are really just not interested in going, but the parent does feel like they need that extra help and the teen does need to see somebody?

Dr. Ethan Benore: Yeah, that's a great question. In a situation like that, I would usually have the parent bring the child in and this is, "I'm asking you to do this as a favor to me," the parent might say, "This is something that I need. Just like I need you to go to school, I need you to go to this doctor. I'm not going to tell you exactly what to do, we're going to work this out, but I want you to give it a try for me."

Oftentimes, when I have patients come and the child is resistant, we'll set a time limit. We'll say, "OK, you don't want to be here. I'm trying to figure out how to help you. Let's pick, what are we going to do? Four times, five times? Let's give it a shot, see if it looks like this could be a good fit for you. If so, great, then we'll move forward. If not, then it's okay, we'll cut our losses and I'll figure out other ways to help you guys as a family."

Kate Kaput: It can be difficult to get in to see a therapist or a counselor right now, given the volume of the mental health crisis. What can parents do in the meantime, while they are trying to get their kid in to see a specialist?

Dr. Ethan Benore: It's incredibly difficult to get in, both here and other places. Again, it has to do with the number of children who need help and it has to do with just the acuity, I mean the severity of mental health issues that children are struggling with. What you have is less helpers to see the children. So yes, to some extent parents have to step up, teachers have to step up, and they have to work together.

Getting some of that information, this is why I talk about study and teach your child, getting information from the websites. There are a number of good books out there that walk you through what do I do if I have a teenager who's struggling with mental health issues, what is it like to grow up as a girl in this world today, emotionally. There's wonderful books out there that try to guide parents through this, but parents should be educating themselves, working as a team amongst other parents or supportive caregivers, and then connecting with the teachers as well, to make sure that they're managing these children as best as they can. We're all going to have to lean in a little bit to help these kids right now.

Kate Kaput: What about parents who want to sit in on their child's therapy appointment? This is something that we hear a lot. What do you say to parents in that case?

Dr. Ethan Benore: Yeah, that is a very good question. As a psychologist, I would ask “Why?” Obviously, it depends on the child, depends on the reason that they're there. I can think of different situations. I want parents involved in treatment, I want parents to know in some way, general or specific, what we're doing in therapy and how they can support the carryover of therapy at home. That does not need to be sitting in there or getting a play-by-play of what happens. In many cases, it's beneficial for the child to process some things without the parent nearby because, again, there's that fear of immediate judgment or some immediate consequence when, as the child, I'm not really sure what's going on right now, this is what I'm thinking, this is what I'm feeling, I just need to process it first before I can put it out there. Therapy provides that very safe and secure location for a child to process those thoughts and emotions and then decide how best they want to move forward. I would caution parents against strong arming their way into every therapy appointment.

Kate Kaput: Great. Finally, I want to talk about parents serving as mental health role models. What can parents do to show their children, not just when the children are teenagers, but throughout the course of their lives, what can parents do to show their kids that they prioritize and value mental health, both in the kids and in themselves? Is it important for parents to serve as role models in this space?

Dr. Ethan Benore: I would say it's imperative for parents to serve as role models. I don't hear it as much now, but growing up there was that expression, "Parents who read have children who read," that children need to see you do it because your actions will speak as loud as whatever you say in a lecture to your child. What does that mean? Parents need to live healthy, they need to eat well, they need to exercise regularly, both have been shown to influence mental health. They need to be involved in something socially and have positive social relationships. They need to talk about their own thoughts and feelings and model how they get through that.

I think some parents miss this part — obviously, you need to do that in an appropriate manner. I certainly don't need to talk about all of my fears and all of my angers in front of my child because that creates an unsafe environment for my child, but to be able to let my child know that, yes, I also have some levels of frustration and I also process these emotions of fear or anger or sadness is very helpful for your child, gives them hope that they can learn to do the same things effectively.

Kate Kaput: I love that. I think normalizing conversations around mental health, we hear all the time about how important that is to getting rid of the stigma around mental health issues, and I think a really thoughtful answer on how parents can play a role there.

As we start to wrap up today, Dr. Benore, is there anything that we haven't discussed on this topic that you think is important for people to know or to understand about teen mental health in general, and right now in particular?

Dr. Ethan Benore: There's maybe a couple, but one thing that we don't talk about, or we haven't talked about today anyways, is the concept of resilience, this idea that children can survive — and children do, they survive a lot of terrible things — but there are scientists out there who are studying what helps children survive through these difficult times. Then parents, teachers, healthcare professionals need to talk about resilience more and need to talk about how to help children be more resilient. We've hit on some of the topics here, modeling good behavior, listening to children, helping them process this, but finding out what makes kids resilient and building them up because I don't think this world is easier right now and in the near future it's probably going to stay like this.

One of the things that we talked about earlier was the idea of a connection. When you look at resilience research, the single most common factor for children who develop resilience is at least one stable and committed relationship with someone, a supportive caregiver or adult. That original study, I think you had talked about, the one from the CDC, I think you had mentioned that youth who were connected to adults were significantly less likely to report those symptoms of sadness and suicidality.

Kate Kaput: Yeah. I think that really speaks to the role of not just parents, but teachers, coaches, mentors, big brothers, big sisters, things like that, in making sure that kids feel safe and that they have someone to go to, someone to talk to. I think, like you said, kids are so much more resilient than we sometimes give them credit for, so that's also really reassuring to hear.

Dr. Ethan Benore: If I could add one more thing. I think resilience is a factor and I think hope is the other thing that we need to highlight for children. I think a lot of what's been going on in the last two years, I talked about this at the very beginning, can make children feel a little hopeless. It is bad what we're going through right now; it is not hopeless. We will get through this period in our life. We can create a path to reduce the suffering that children are experiencing and children can reduce their own suffering and begin that new future for themselves.

Kate Kaput: I think that hope is a perfect note for us to end on today, thank you so much for that. Thank you in general for being here with us today and for speaking with us on this really critical topic.

Dr. Ethan Benore: Thanks for having me.

Kate Kaput: If you'd like to schedule an appointment with Cleveland Clinic Children's behavioral specialists, please call 216.448.6110. Thanks for tuning in today.

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