Protecting the Mental Health of Teenagers

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(upbeat music) (bell ringing) (people chattering) (people chattering continues) - Hello and welcome to The City Club of Cleveland, where we are devoted to conversations of consequence that help democracy thrive.

It's Wednesday, April 5th, and I'm Dr. Julia Bruner, senior vice president for Behavioral Health and Correctional Medicine at Metro Health.

And I'm pleased to welcome everyone here for this very special City Club event.

I'm honored to introduce the United States Surgeon General, Dr. Vivek Murthy And for a live recording of his podcast, "House Calls."

He will be in a conversation with Northeast Ohio's own best-selling author and child psychologist, Dr. Lisa Damour.

Dr. Vivek Murthy is the Nation's 21st Surgeon General and a post he previously held under President Obama.

As the nation's doctor, he holds the rank of vice admiral of the US Public Health Services Commission's core commanding a uniform service of over 6,000 public health officers.

His podcast, "House Calls," launched in 2022 with a premise that is very much in step with what we do here at The City Club and that is we believe that conversations can heal.

In this episode, Dr. Murthy takes his guests off script and explores how they navigate the messiness and the uncertainties of life to find meaning and joy.

By sharing openly what's on our minds and in our hearts, we can find strength and healing through connection.

Joining the Surgeon General and Dr. Damour on this journey today is our audience made up of more than 200 parents and partners of teenagers across the Greater Cleveland area.

The City Club would like to thank you for nearly two, for our nearly two dozen community partners for their support in bringing our parents to this, to today's special event.

And it's important that parents are here and their partners in the care of their children, because we know that they understand how significant the issue of mental health on teens has become and that it's not just because of the pandemic that we've all endured.

Parents, mental health professionals, and policy makers are concerned about how teens are managing the impact of social media and the stress built into the high school experience.

In addition to larger issues shaping our uncertain future, the rise of gun violence, the lingering effects of the pandemic, climate change, and the threats to democracy and civil rights.

According to the National Alliance of Mental Illness, NAMI, one in six adolescents between the ages of 12 and 17 experienced a major depressive episode and 3 million had serious thoughts of suicide.

Those numbers are even higher for young people between the ages of 18 and 25.

For these reasons and more, Surgeon General Murthy has made mental health for our youth a priority in his office.

And in December of 2021, he issued a public advisory urging a response.

Joining the surgeon general on stage is Dr. Lisa Damour.

Many of you know her.

She's a clinical child psychologist and the author of three bestselling books covering teenage mental health and a senior advisor to the Schubert Center for Child Studies at Case Western Reserve University.

Dr. Lisa Damour frequently contributes to the New York Times and the Washington Post and is the executive director of Laurel's School Center for Research on Girls.

We are excited to have Laurel here with us today.

If you have questions for our guests, you can text the questions to 330-541-5794.

You can also tweet your question, @thecityclub, and The City Club staff will try to answer and work, or not, they won't answer it, sorry about that.

They'll try to work it into the Q&A portion of the program.

Members and friends of The City Club, please join me in welcoming the US Surgeon General, Dr. Murthy, and Dr. Lisa Damour.

(audience clapping) - Thank you.

(audience clapping) Well, thank you so much everyone for joining us today.

And I'm so glad to be doing this conversation with a friend and somebody I admired deeply, Dr. Lisa Damour.

I do wanted to also thank you for joining us for something we're doing for the very first time, which is a live recording of our podcast "House Calls."

And so, this should be fun.

It's something we do all the time with a a variety of guests, the podcast itself, but to record it in front of an audience is a special treat for us today and we're really looking forward to your questions afterward.

So without further ado, let me jump in and today we're gonna be talking about a topic that is on many people's minds and that is mental health, particularly the mental health of teenagers.

And I'm really fortunate to be having this conversation with Dr. Lisa Damour.

She's a writer, she's a clinician, she's a proud Cleveland resident, but she's also somebody who's looked to by so many people in the country for advice on teen and adolescent health.

And her work has helped parents around the country, both her books, but also the contributions that she makes to the New York Times and to CBS News.

But most importantly, and I think her most important qualification for doing this work, is that she is a mom herself of two wonderful children.

So Lisa, thank you so much for doing this and welcome to "House Calls."

- Well, thank you.

I'm honored to be with you.

I'm grateful to this audience for being here with us and I am so looking forward to this conversation.

- Well, me too.

And let's start with where we are as a country when it comes to teen mental health.

You talk to people all over the country to kids, to their parents.

What is the state of teen mental health and how much of an effect did the pandemic have on how our kids are doing?

- So, we're trying to wrap our hands around where we are now.

What we know is that prior to the pandemic, and I know you know this but this is important to lay out, we had started to see a rise in concerns about adolescent mental health.

Right around 2010, the numbers started to tick up in terms of depression and anxiety.

They were ticking up slowly and then along comes the pandemic.

And the way I think about it is we were on a road that was not going well, and then we were in a ditch for a year and a half to two years.

and we're now trying to figure out where we are.

What I can tell you is that a lot of teenagers are doing just fine.

That they are back to their old routines.

They're living their lives, they're thriving.

For them, the pandemic is very much in their rear view mirror.

But there are a lot of teens who suffered tremendously through the pandemic and continue to suffer in the aftermath of the pandemic.

I think another thing that's informing this moment is that it's a very frightening time to be the parent of a teenager.

That teenagers have been through so much.

We are doing a good job of documenting how hard it was for them to go through the pandemic.

And so, a lot of the adults I'm talking with now find themselves in a moment, where they're looking at a teenager who may or may not be having a regular bad day, but they're not all together sure.

Is this a regular bad day or is this a kid having an adolescent mental health crisis?

So, I think part of what we can do is to help people tease those two things apart, because typical adolescent development is a rich and spicy business.

And trying to help set that apart from the true adolescent mental health crisis that we're seeing is not altogether easy.

- Well, there's so much to dig into there and a lot of rich and spicy topics as you mentioned so much.

But I wanna actually step back and talk about the term mental health, because this means different things to different people.

And you, you've spoken about this, but how we perhaps are thinking about mental health in the wrong way.

So, how do you think about what mental health is?

- So to me and to psychologists, mental health isn't about feeling good, or calm, or relaxed, or happy.

We like those things, but those don't actually figure into how we assess mental health.

For us, the way I think about it, is that it comes down to two things.

The first is having feelings that fit their context, even if they are negative, and unpleasant, and unwanted.

And the second, and this is really where the rubber hits the road, managing the feelings well.

So if we think of a young person, maybe they have a best, best friend.

And then they get the news that their best, best friend is leaving town, moving away, what we would fully expect to see is a lot of sadness.

We expect to see that teenager be deeply upset.

On its own, that does not raise our concern that there's a mental health issue at play.

What we're gonna watch is what happens next.

So, does that teenager cry?

We know that crying brings relief.

It's a very calms the central nervous system.

If it's a teenager, they probably put on their sad playlist and listen to their sad playlist for a while to help catalyze the expression of those emotions.

They might get tired of that, and then go for a run to get some relief.

And then, they might make plans to see their friends.

So, that is exactly what we're looking for.

That is the picture of health.

Our concerns arise if they take a different path.

If they decide, "I'm so sad and this feels awful, the best solution will be to smoke a lot of marijuana until this feeling dies down," or "If I'm miserable, everybody's gonna be miserable and we're gonna be miserable for a week," or "I'm gonna turn this against myself and I'm not gonna take good care of myself."

That's where our concerns will center.

But on its own, distress does not alarm psychologists so often.

And I think this is such a different view, but it's something that is so central to our understanding.

So often, distress is evidence of mental health.

If a teenager has a huge test tomorrow and they have not started studying, we expect to see anxiety.

We would like to see some anxiety.

- [Dr. Vivek] Right.

- Right.

So psychologists are vastly more agnostic on the negative or positive nature of emotion than one might think we are.

- #*Hmm.

- Well, well that is very helpful and I think this notion that it's okay not to be happy all the time, that there is appropriate responses, sad responses to circumstances that maybe arises, is very helpful.

And it gets to something that, you know, I've been thinking about as a parent myself as I watched my two kids who are five and six evolve in terms of their emotions, which is as parents, how do we know when the emotions are appropriate?

Not just in terms of degree and context, but also in terms of the extent of how long they last.

Like how do we know when it's the important to intervene?

- So to use a medical example in your honor, one of the ways that we think about these things as psychologists is that healthy people get sick.

They get cold, right?

They feel lousy.

And part of how we know they're healthy is they get better.

There are also people who get sick and they don't get better.

They get more and more and more ill.

They're unable to fight off whatever has found them and that's grounds for concern.

So, there's no sort of perfect moment when we know you've crossed the line from one to the other.

But what I would say is if you use sort of the common cold model, we expect our kids to have the common cold of all sorts of distress and we expect them to find their way through it.

They'll feel crummy for a while.

And then, they'll feel better and we can help them feel better.

We don't expect kids to feel low or anxious and stay in that place for a long time.

And what we really don't expect to see or don't wanna see is if it starts to interfere with their life.

So, they're not going to school or they're not seeing their friends.

They're not doing the things they need to do.

- #*Hmm.

- So, that's really helpful because I think this question of when to worry as a parent is a common one.

And that is very helpful.

I think one of the things that's hard about parenting, and I wanna preface this by saying I think parenting is one of the hardest jobs in the world, one of the most undervalued jobs in the world, but also a job I think has gotten harder in the last few years in particular.

And not just 'cause the pandemic, but I just think so much is evolving in our world, particularly around technology.

And it's hard as a parent to keep up with all of this and to know what your kids are engaged with, what's okay, what's not okay, what are the risks.

This is a tough time to be a parent.

And I was wondering if you could help us think about adolescences now compared to prior periods of adolescence.

Like every generation has gone through adolescence, it's hard.

Middle school's rougher almost everyone, right?

Myself included.

But it feels like there's something different about what kids are going through now compared to prior generations.

So, how should we think about the adolescent experience now and what's different?

- So, I think there's some boiler plate stuff that just remains true about what it means to be a teenager.

And when I talk to parents of teenagers and as the parent of teenagers myself, there's a lot of stuff that feels familiar.

You know, that it's not all new.

But one of the ways I think about what feels really different in the teenagers I care for is that there's a huge amount more input into their day and into their lives.

They are fielding so much more information than we ever did.

And of course, a lot of that is coming to them through their phones.

They're deeply aware of all that's happening in their social worlds, all that's happening in the wider world, and they're getting that information all day long.

I also think for a subset of teenagers, we're looking for a lot more output.

When I think about what we're asking of very ambitious teenagers in terms of high school achievement, plans for the future, the demands on them are far higher than they were when you and I were teenagers.

And so, I think that that sort of accelerates everything.

And we also know they're not sleeping very much.

When we look at the data over time, we see worsening sleep going up at like a nearly 45 degree angle in the graphs that we have, which happens to map almost perfectly onto worsening mental health.

So, that is something that has changed over time.

- Why are a kids sleeping less?

- That's a great question.

For me, one of the languages we use in psychology is the idea of a final common pathway where sort of everything converges.

And I think sleep might be one where there's a lot of things that can undermine sleep.

So, sometimes it's because they have their phones in their bedrooms overnight.

And our phones are irresistible and they're designed to be, and that undermines sleep.

And we even have data showing that sleeping in a room with a phone in it will give you worse sleep.

You actually don't sleep as soundly.

And the reason we think that's true is that we are also Pavlovianly attached to our phones that when we are not engaging a nearby phone, a degree of our energy is resisting the impulse to engage it.

And that's true even while we are sleeping.

So, that's an issue.

There are also kids who have very, very heavy demands on their time, right?

When we look at what ambitious high schoolers are doing, it looks very different than it has in years past.

There are also kids who have two jobs that they are using to try to support their family.

And they are working long hours to try to keep the family afloat financially.

So when I think about how, you know, the various inroads we can make to the adolescent mental health crisis, thinking about sleep and thinking about what is interfering with any particular teenager's sleep feels to me like one of the most solid and reliable ways to try to make things better.

- Hmm.

- Well, that's very helpful.

And I can see as you're talking about sleep, that this is a, this can be a reinforcing circle.

And I think if it's a vicious cycle where you sleep less, it impacts your mental health, potentially increases your anxieties, which leads you to sleep less.

And then, around and round we go.

Breaking that cycle I think is challenging.

And thinking about the role of parents in this is something I wanna talk to you about, because right now kids potentially have a lot of resources available to them.

Not all kids, but some kids.

They may go online for advice.

They may look to their friends for advice.

As a parent in 2023, how should we think about what our role is in shaping the mental health and experience of our kids?

- As a parent, I can actually sum up our job in two words.

Easy to say, hard to do.

Our job is to try to be a steady presence for our kids.

So, that means both in the day-to-day to try to be present and try to be available and provide a world for our kids that is full of warmth and also structure.

We know that's sort of the magic combination.

And then when our kids are upset, and especially when our teenagers are upset, to especially then try to be a steady presence.

And that's the hardest time, because teenagers do get upset with or without a mental health concern.

Their emotions are enormously powerful.

By their nature, it's just a neurological phenomenon that they have very, very potent emotions.

And teenagers are watching the adults around them for information about how bad the situation really is.

So if a teenager's had a terrible day and a fight with their best friend and they come home and they express this to their parent, they're watching the parent.

And if the parent gets just as upset as the teenager about it, the teenagers will think, "Oh, I thought this was a 15-year-old size problem.

This is apparently a 52-year-old size problem.

Like this is quite a bit more concerning."

So, our job is to try to be a steady presence.

We can't do it all the time, but that is usually what teenagers need is for the adults to try to be sturdy and around.

Now, you know and I know one of the worst things about the pandemic for teenagers was not only that they were suffering so, but that all of the adults who cared for them, whether it's their family, or their schools, or their religious communities, those adults were suffering too.

And so, part of how we help adolescent mental health is to take really good care of the adults in their environment.

- And I think that is such a powerful point you just made.

The health of kids is impacted by the health of the adults around them.

And in my travels around the country, you know, over the last two years and when I do round tables with young people, I am so struck by how they said during the pandemic in particular, they really felt like they had to grow up and not be kids anymore, because the people they would normally talk to or expect would react to their stresses, namely their parents, were occupied with their own stresses and worries and they didn't want to add to their burdens.

And so, I was heartbroken when I heard that the first time and it continues to pay me each time I hear it, but it does feel like if we really wanna help kids, we also have to think about help, how to help parents- - Yeah.

- And how to support parents 'cause they're, they've taken on more, I think, than most people can humanly do and are trying to navigate forces that, including around technology which we'll get to, that we are still only at the edges of understanding fully.

And that's a tall order.

But speaking of parenting in tall orders, one of the, I was with a friend recently at their house and I loved actually talking to the kids of my friends, because I feel like I learn a lot from them.

They're my own sort of for focus groups, if you will.

And so, I was at the home of these two very dear friends and talking to their two children the other day.

And one of them toward the end when we were just about to leave, mentioned that his middle school classmate had talked about wanting to harm herself and had mentioned that she doesn't feel like she has a will to live anymore.

And there was, I remember pausing that moment and just thinking, "Oh my gosh.

To hear that as a middle schooler from one of your classmates is profoundly disturbing and is concerning."

But as a parent, when you hear that, like you know how to talk to your kid about that, many parents also wonder, "Is my child feeling that way?

If I bring it up with my child is that gonna introduce an idea like into their head?"

Which is something we used to think about even with adults clinically and until we realize, no, it doesn't put the idea in their head.

But a lot of parents are having this experience of seeing either actual self-harm take place or seeing children who are considering self-harm and they're not sure how to talk to their kids about this.

So, what advice would you have for how to broach the topic of self-harm?

- I'm so glad you're bringing this up, because my experience is this worry sits underneath all of it.

You know, there's so much concern about teenagers in general, but also with the many headlines about adolescents suicide, I think this is what's keeping parents up at night and of course it is.

So, I will confirm that what you know to be true about adults is also true about teenagers.

Raising the topic does not give them the idea and this is often what keeps people from asking.

And what we also know from the research is that if a teenager is thinking about suicide, they're glad you asked.

So, the way to do this, if a parent has a concern, my advice would be to say to a teenager, "Because of," and then you have to give them a reason.

You can't just sort of ask this out of the blue.

Because you have been in your room for a day and a half, or because you were so upset about that thing, or because you haven't seemed like yourself.

Like hang some, you know, some hook to hang it on.

I need to ask you a question.

Have you had any thoughts of harming yourself or ending your life?

Just ask.

And we do find that teenagers appreciate the question and it doesn't make things worse and it can make things much better.

The other thing we wanna prepare parents for is that it has always been the case that teenagers sometimes say things that parents don't know what to do with.

And it can be dramatic and scary things, like I feel like I could kill myself or I don't wanna be here anymore.

If a teenager does that, I find it's really helpful to respond by saying, "Okay, wait, I heard you.

Is that something you're really thinking about or is that how upset you are right now?"

And teenagers usually say, "Oh no, no, no, no, that's not what I'm thinking about."

And then you go down the road of dealing with how upset they are right then.

But I think all parents should have these two tools in their toolbox.

One, how to raise the question if something has made them concerned.

And two, how to respond if the teenager says something concerning.

- Okay, that's very helpful and reassuring.

One more question about this since this is now becoming my personal therapy session and- - Sure.

- Parental guidance tutelage.

But our kids sometimes, sometimes we want to talk to 'em about something difficult that's happening in their life and there's a point where that's important and helpful.

We're also trying to strike this balance, you know, between that and not prolonging their focus on an issue that may have happened in the past that upset them.

How do we find that right balance, so that we are being, you know, an avid, and open, and available listener for our children, but that we're not contributing to continuing or prolonging their focus on an issue that we want them ultimately to get beyond?

- Well, I think the general framing is that time works differently for teens than it does for adults.

I've always thought that teenagers are like dog years, like one year of life for us is like seven years for them, like so much growth and change happens.

And the way parents experience this in the day to day is that their kid is in the worst possible mood at 8:00 AM and then at 8:10, their kids in a great mood.

And you know, like things have changed completely.

So I think that especially with adolescence, you wanna track where they are and really work moment to moment with them in terms of their mood.

There are times however, where we need to bring something up, where there's just a topic that it feels wrong not to mention.

And if it's not something that teenagers bringing up and they don't seem to be in that place, I think it's really smart to give them sort of some fair warning to say, "You know, I was thinking about this article I read," or "I was thinking about that thing you said the other day and I do wanna touch base with you about it."

Get a read on how much they're in the mood to talk.

And if they're not chomping at the bit for that conversation, keep it short.

Say your piece, let them hear you out, and be ready to move on.

But I think so often adults have a very important thing to say and a lot they wanna say.

And they roll up on a teenager who is thinking about 400 other things and is surprised by the conversation.

And the conversation doesn't go well and the adult feels disappointed.

And I think, well, their lives are busy, they got a lot going on.

If we're gonna introduce something heavy, we need to give them a fair warning.

- That's really good advice and you're making me realize I've done this wrong.

(everybody laughing) - We all get it wrong.

I learned mostly from my parenting mistakes.

- Because I can remember I've got a five and six-year-old, but with my six-year-old in particular, he'll be upset about something.

10 minutes later, just like you said, he'll be fine.

And then, I'll revisit it just to make sure he's okay and then he'll get annoyed.

He'd be like, "What are you talking about?

I don't even remember what just happened."

But I'm very disturbed by something you said because my six-year-old's moods change every 10 minutes sometimes.

And I thought that was gonna change after a year or two, but it sounds like from what you're saying I'm in for another decade or more of this so.

- Actually, things should settle down a little while.

- Okay.

- The way that we measure development as psychologists is we think sort of zero to five, which is as all parents know, bananas, right?

And then, six to 10, we call latency, which means that all of those intense emotions sort of start to quiet.

So, he should quiet down a little bit.

He'll still have moods, but they may not be so vivid.

And then, here's something that everyone should know.

Adolescence begins at 11, way earlier than anybody thinks it begins.

This is largely driven by puberty.

And what we know is that the effects of puberty are underway neurologically often before they're outwardly visible.

And so, everyone should know that if they're fifth or sixth grader suddenly wants more privacy, wants to close their bedroom door, doesn't want you to call them cutie patootie anymore, nothing is wrong.

Adolescence has not struck early.

This is typical development.

And psychologists have always marked the onset of adolescents at 11.

The other thing, if you're thinking about what you are in for and what to expect, emotionality in teens actually peaks around ages 13 or 14.

A little bit more 13 for girls, a little bit more 14 for boys.

And it really is just a function of what's happening neurologically, the relative strength of their emotions versus their ability to control their emotions.

I wish I could have billboards that said adolescence begins at 11, emotionality peaks at 13, because I think so often people feel like, "Whoa, why is my little kid acting like a teenager?"

And then at 13 they think, "Holy moly, if this is how we are starting adolescences, like what is in store?"

And what I can promise you is that mostly your 15, 16, 17-year-olds are a lot more easygoing.

- Hmm.

- That's really helpful.

Okay, I'm gonna call my wife after this.

- Okay.

- To be update.#* - Brace for 13- - Yes.

- 11 and then 13.

- That's right, that's right.

Well, you know, Lisa, I know you're no stranger to the, to what people often say about this generation of kids who are growing up, which is that among the many other things they say this generation of kids who are growing up are more fragile and less resilient.

I wanted to get your take on that, number one, is that true?

And if it is true, what do we think might be contributing to either that or to the perception that that's a case?

- I don't wanna say it's true.

I have so much belief and faith in teenagers.

And I gotta tell you, the beauty of being a clinician is to have an inside look at people's lives and the strength in adolescence.

And I watch teenagers day after day become philosophical and broad-minded through conditions that would level any adult.

So I just, I don't, they do not strike me as fragile.

Now, what we are observing and we have observed this in the data collected by the American Psychological Association for a while, they're stressed and they are rightly stressed.

And when we ask adolescents about stress prior to the pandemic, they tell us concerns about climate change, concerns about gun violence, concerns about political polarization.

They are acutely aware of the realities that surround them.

They're acutely aware of what they are soon to inherit and they're having the right reaction.

And so for me, I would just tease it apart.

I think they're every bit of sturdy, if not vastly more sturdy than we ever were.

And yet, they are up against things that we as adults really need to own and acknowledge and do everything we can to bring back under control.

- I think that's really well said.

And I think the temptation for older generations to compare themselves, current generations to say, "I went through that too.

You know, adolescence was hard for me too."

I think it belies fact that the unique set of stressors on this generation are really unprecedented, right?

I didn't have to deal with social media growing up as a child.

I didn't have to deal with the information environment around me being 24/7 and coming at me from all different corners.

And with that, information often being quite negative, right?

Like there's just a lot that we were able, I think, to turn off and be protected from, you know, in prior generations when we were growing up.

And you know, I wanna talk a little bit about relationships here and about friendships, about romantic relationships as they pertain to adolescents.

And I've been concerned about this, because I, you know, have worried a lot about how lonely children feel and how much loneliness is impacting the country more broadly.

But we know that around one in two people in America are struggling with loneliness, but that the numbers are actually even higher among kids.

And I wanted to ask you a little bit about that.

Like are you seeing this challenge of loneliness as well in the children that you work with and what do you think might be driving it?

- I think I'm seeing it so much more post-pandemic.

The phrase I will hear from teenagers several times a week is, "The pandemic messed up my friendships."

Like that's how they say it.

And I think that's just such an elegant and to the core description of it, and how could it not?

How could it not?

You know, they were away from one another.

They were in better and worse ways using social media to try to stay connected, but they were losing all of that 3D in-person data that can only be gotten when you're at school with your friends.

And they were deeply sad.

And so, we are still trying to help sort out how kids socialize, how to help kids build good social skills, how to help kids manage when they are having a hard time with somebody.

We're also watching kids struggle with managing conflict well.

And so when I think about what we as adults can do, I think it's a huge amount of being attentive to whether or not a child has at least one friend.

One or two good friends goes very, very far for kids.

They don't need big groups.

If kids don't have a close friend, I always fall back on the rule that you don't make friends, you find friends.

And so, I always give advice to get that kid in new traffic patterns, right?

If they haven't found their people at school, get them into something after school, get them something on the weekend, so they can find the kid where the chemistry really works.

But we need to attend to it.

We need to support it and we need to take seriously that everybody needs friends.

- Absolutely.

And those friendships are critical.

And I'm curious in today's age where people have relationships online and offline, how should parents think about online friendships and where does the online option help our social connection versus hurt our ability to form deep relationships?

- So, what we know from the data is that it's not that there's your IRL friendships, and then your online friendships.

That they're actually the same world and whatever's happening in real life is amplified online.

So, kids who enjoy good sturdy friendships, get along well with their dear friends or small group, that just carries over to their online activity and they use their time online to deepen, and strengthen, and expand those connections.

Kids who are struggling socially, who are isolated or engaged in a lot of conflict, what we see is that is also reflected in their online world.

That they continue to have more trouble to be involved in more cyber bullying on either side, sometimes both.

And so, we wanna think in many ways of social media as an accelerator of what's already in place.

And it's a tough one 'cause this is one of those situations where the rich get richer and the poor get poorer very fast with the online environment.

- That's very helpful and it tracks with this notion of which we'll get to in a moment about social media being a double-edged sword for our children.

But before we go there, you mentioned earlier on some gender differences.

And when we think about mental health, and I wanna think about friendships in particular, what have you seen and learned about how kids based on their gender may approach, or experience, or form friendships differently?

- Hmm.

- So if we just go with traditional gender categories, what we see is that girls tend to center their friendships on talking, right?

Being able to be in communication about the things they care about.

Boys often center their friendships on shared activities, joint, you know, ventures, whether it's a beloved video game or playing sports together or after school "Lego League."

What we do also know, and this is important to say, boys friendships are every bit as deep as girls friendships.

People I think sometimes can be dismissive that boys are tough, or indifferent, or, you know, do well as a lone wolf.

That's not what we see in the research.

Boys are as desperate for connection as girls and do form profound relationships with their peers.

- Yeah.

And that is that last point you mentioned about boys needing relationships just as much as girls I think is so important, because I, when I think about my own son, I worry about the version of manhood that we have often taught, you know, so, which is a guy should be independent.

They should be on their own.

They should be self-sufficient.

They shouldn't need anyone else.

Showing emotion is not necessarily manly.

Like all of these things which can interfere with this notion that you actually need other people and you need friendships and relationships.

Do you see that shifting in broader culture?

And if not, what do we need to do to help boys and you know, in early stages of life and in adolescence, feel okay with expressing their emotions of reaching out and initiating friendship and with building the relationships that we all need?

- I don't see it shifting as fast as I wish it were.

And you are entirely right that we have a script for what is masculine.

It is often lone wolf, tough, and vulnerable.

And especially for boys say around middle school who are really working to consolidate this identity around masculinity, what many of them come to the conclusion is that talking about feelings is a girl thing.

And then if they happen to be in two parent heterosexual households where the only person who's bringing up feelings is their mom, which happens a lot, that woman who's doing such good work can actually unwittingly entrench exactly what she is trying to offend.

And so, what has become very clear to me as I do my work is that if we really want boys to talk about feelings and we really do want boys to talk about feelings and we want them to talk about feelings that go beyond anger and pleasure at someone else's expense, which are the two categories of emotion.

They are allowed in our culture.

The men in their lives have to be on the front lines of this.

The men need to be talking about their own feelings.

The men need to be asking boys about their feelings.

And this will continue to be a problem so long as we treat the discussion of emotion as women's work.

- Really well put, yeah.

(audience clapping) You mentioned the two emotions that are permissible.

- Yes.

- Can you repeat that and underscore- - Yes.

- That once more.

That's important.

- So, well, this was research I really dove into in my recent book and it was so fascinating.

So, here's what I was expecting to find and here's what I did find.

What I was expecting to find was that girls and women were allowed to feel sad, anxious, frustrated, angry.

They were allowed to sort of enjoy this wide range of emotions and that is largely true.

There's an asterisk on angry and we can come back to it.

And I expected to find that boys were allowed to only feel invulnerable, so either anger or pleasure at someone else's expense.

So, that was largely what I found.

The unexpected finding is around, so there's two things around anger.

One thing I did not expect to see and I thought was to be honest, quite amusing, is that girls actually do express anger when they are young, so elementary school age and younger.

Boys express more anger than girls.

That flips in adolescence, girls express more anger than boys in adolescence.

There is one form of anger, however, where girls outpace boys all the way through development and it's disdain, which I thought was really funny.

I thought that was really funny.

Now the asterisk, the asterisk on the expression of emotion and especially anger in girls, it is not safe to do if you are Black so.

(audience clapping) There are different rules for the expression of negative emotions in Black teenagers.

They are disproportionately treated with heavy disciplinary response by cultural institutions.

So as you start to tease apart the data, the story is not the same for everyone.

- That's such a good point.

It's such a good point.

And it's I think, to build on your point, it's not, it's also not only not acceptable for certain groups, and like you were saying for Black women to express that anger, but it can be unsafe as well.

- Very, very.

- And can subject people to consequences, physical consequences, legal consequences that others may not experience, which I think contributes even further to our disparities.

But also comes back to the importance, I think, of what you have articulated so beautifully, which is the importance of understanding.

That at the end of the day, we are all emotional creatures as well.

That it's part of who we are regardless of our gender, regardless of our race.

And understanding how those emotions play into how we interact with each other and how we interface with the world is just really important.

Because when I think about my kids also on something I want to ask you about, I want my kids not only to be able to manage their own emotions, but I also want them to be able to interpret and understand the emotions of others, right?

So that if somebody else is mad at them, to recognize it may not be about them, it might be about something else entirely.

And if they assume it's about them, they might lash out.

They might just feel really bad about themselves, like they did something wrong.

Whereas all the while they may have very little role to play at all like in the outbursts that they just witnessed or experienced.

But it sounds like, you know, in an ideal world, you know, children would get the emotional education that we all need at home.

The reality is that many children don't and I'm not faulting parents here.

A lot of times parents don't necessarily have that themselves or they may try but not be able to successfully, you know, instill that in their child.

What role do schools have here?

What role does broader society have in helping kids build a social and emotional learning and skills that they need to be able to manage both their emotions, but also interpret the emotions of others?

- So, schools can do a huge amount and are working so hard to do a huge amount in terms of building out SEL curriculum, helping kids become fluent in a language of emotions.

And what can seem small is actually tremendous, which is actually helping kids learn to label emotions, to come up with a word to describe the feeling that they're having.

And what we know from the research is that act alone, if I say to you, "Oh, Vivek, I'm feeling very anxious."

As soon as I say it, I actually feel less anxious.

Just the expression, regardless of the response I get, just the putting feelings into words brings them down to size.

That's just something we know to be true.

So, helping kids learn to label their feelings and helping kids learn to read other people.

And if families do have the wherewithal, so much of that can happen at home.

And I wanna go back on what I said about being a steady presence.

Being a steady presence doesn't mean adopting a zen attitude and being unruffled by your kid.

And I think there can be really powerful moments for a parent to say, "Okay, I need to let you know I'm getting pretty mad," or "I feel mad."

And it may either be, "I'm mad because of something you did," or "I'm mad about something else that happened," right?

So, the parent alone can give that kind of context.

And then again, back to our definition of mental health, what we wanna see is what does the parent do next?

- [Dr. Vivek] Yeah.

- So, I'm gonna go take a walk around the block, or I'm gonna go watch my favorite TV show, or I'm gonna go do something to handle this well and that we can all the time as adults around kids be labeling emotions and then modeling healthy coping.

And if we - Yes.

- Just do those two things as much as possible, we'll make things better.

- Good.

Lisa, I wanna use the last portion of our time to talk about technology.

We've touched on this a little bit already in terms of online versus offline friendships.

I find that one of the most vexing questions for parents is how to manage phones and social media for their kids.

There's no guidebook here.

This technology's evolving quickly.

What advice do you have for parents on how they should think about these two things in particular, phones and social media, as their kids are growing up?

- So, there's unsettle and subtle versions of this.

So, the unsettle truly is I don't think kids should have tech in their bedrooms if you could help it.

And certainly not at night.

Not at night.

We know that there's no reason for them to have tech at night.

That is a good reason.

Then, there's the subtle.

And one of the ways I think about it is social media can be very hard on kids.

Social isolation is also hard on kids.

And so for me, I think about it as an inflection point, which is basically delay, delay, delay, delay, right?

If your kid is still plugged in socially, getting along with other kids socially, or if texting alone is keeping them plugged in and kids can go a long time on texting, right?

They really can get very deep into development, without needing to be online social, in social media apps to stay connected.

I would push it as long as possible.

- And when you say push it, you mean delay?

- Delay- - The use of social media.

- Delay the use of social media as long as possible.

And you know, we have emerging research showing, something I'm not surprised by, you know, that 13-year-olds on social media is a very different scene than 17-year-olds on social media.

And the way this shows up in my clinical work is sometimes I'll go talk to a group of high school juniors about their social media use and they'll be like, "We're not the ones you need to talk to.

It's the seventh graders."

And I think high school juniors tend to be pretty accurate around these things.

And so when we talk about social media and we talk about teenagers, we have to be careful not to collapse things, right?

That there really is a very distinct difference and we're starting to see that in the research.

The other thing I would want parents to be really mindful of is the force of the algorithms.

So, algorithms are very large data sets that are constantly collecting information on how we use our technology, especially our social media technology and YouTube.

What we look at, what we like, what we comment on, what we even rest on for a little bit, those then decide what you see next.

And the game here is to show you something next that you cannot resist.

These algorithms are working with massive data sets.

They are incredibly good at knowing what we're not gonna be able to pull away from and they start to actually shape very specific online environments.

The way teenagers talk about these environments is as sides, like what side of TikTok are you on.

So, some kids are on the cute animal side of TikTok.

Some kids are on the goofy dance side of TikTok.

Okay.

Other kids are on the ultra fitness, ultra diet side of TikTok.

Other kids are on the white supremacy side of TikTok.

And the way we wanna think about this is that teenagers especially are vulnerable to norms.

Little kids are not so vulnerable, adults are not quite as vulnerable, but teenagers are very norm vulnerable.

And once they are into an algorithm, it is showing them the same thing over and over and over again, that can become a norm.

And so in the pandemic, for example, when a lot of kids had time on their hands and were trying to improve themselves somehow and started searching for diet, exercise, fitness, soon their feeds were flooded with image after image after image of someone who's very thin or very fit.

And if you look at 400 of those a day, that creates a norm that then transfers into real world behavior.

And we saw this enormous upshot, uptick in eating disorder behavior in the pandemic.

So, what I would say to parents is you wanna know what side of TikTok your kid is on.

- And how's the parents supposed to know that?

- It's a great question.

That is a really great question.

That is a really, that is the key question, isn't it?

So for TikTok, you can ask your kid what's on there For You page, right.

That's how it introduces.

I also think once you have an older teenager, you can ask.

I also think if you feel like you can't get an honest answer from your kid about what side of TikTok they're on, they probably should not be on TikTok.

- Yeah, that's really good advice.

And I would also note that one thing I've heard from a lot of kids and parents about the notion of delaying the age at which they start using social media is they say it's a lot easier if other kids are delaying as well.

And being the only one who's doing it makes it really tough both for the parent and the kid.

So the extent to which parents are able, in some cases partner work together to delay the age of use for their kids, would make the, helps to make their kids feel like they're not alone.

But I also think that this is a moment where parents in particular, I think their voices are so important in this broader cultural conversation we're having and policy conversation on social media and technology and how to protect our children.

And I think when they do speak up, whether it's, you know, in the town square, or whether it's the policymakers, or whether it's in their schools, I think it helps, because I think a lot of parents are dealing with this challenge and struggle around technology, but feeling like they might be the only one and feeling powerless at how to manage it.

And it's really not their fault.

We didn't grow up with these tools.

And I was talking to a mother the other day whose daughter struggled mightily with social media and it really crushed her self-esteem.

And she told her daughter that there's certain apps she could not be on and she actually had her daughter's password for her phone.

She would look at the phone every night to see what her daughter was utilizing.

But what she didn't realize is her daughter had actually created an account that she didn't know about on the platform that she had expressly forbidden and had hidden it under the other apps, which the mom just didn't know- - [Dr. Lisa] Yep.

- That you could do.

So, this is a bit of the wild west out there in terms of technology and unfortunately it's happening at the expense, in some cases, of children.

So, this is a really tough space.

You know, as we wrap, I want to, I wanna just reflect on the fact that we've been talking about some heavy things here, right?

And there's a lot that parents and kids are contending with.

You've provided some really beautiful and clear advice on how to navigate that.

As you look at the future on everything that's gonna come, as tech evolves, as new things come down the pipeline, as we figure out how to deal with climate change and other challenges that, as you mentioned, are on kids' minds, what gives you hope that the future may be better than what we're experiencing now?

- Well, two things.

One is we have studied and studied and studied what protects youth mental health.

And there's one thing that stands out above everything else and it's strong relationships with caring adults.

Couple that with the fact that we are now talking about teenage mental health.

And you have done such an extraordinary job of moving that conversation into the mainstream.

And so, I think the fact that we are talking about adolescent mental health and how critically important it is and that the thing that actually protects and cultivates it more than anything else is available to all of us, those two things give me hope.

- Oh, that's beautifully said.

And I think such a good thing for parents to remember as well.

That at those moments when you feel like you're failing, like you're not doing enough for your child, that you can't do everything they need to protect them from the challenges around them, just knowing that being a loving parent who is there for your child, that that does so much and perhaps is the most important thing to safeguard and protect them for the future.

That's something worth holding onto.

And so, I appreciate you sharing that with us.

We have a little bit of time for some questions from the audience.

(everybody clapping) The questions go ahead.

- So, the topic of mental health in some households isn't necessarily like welcomed and some parents are kind of against it.

So when a child or a teen is talking to their healthcare provider and they decide that they wanna tell their healthcare provider about their mental health issues and they ask the doctor to kind of keep it a secret, what do you think the doctor should do about it, so they're not putting the child potentially in danger?

- Wonderful question.

Okay, well, so there's secrets and their secrets.

We don't keep secrets about imminent safety concerns, right?

So luckily, any doctor knows what to do if that information comes about.

But it's interesting, one thing I've observed, again, sort of in my appointed rounds is something I think we should have seen coming, but I was sorry to see it happen, which is as we've raised the alarm about adolescent mental health, I've heard from some teenagers that their parents are actually quicker to say, "You're fine, you're fine."

And what I think is, oh, those are parents for whom the idea of adolescent distress is very upsetting.

And so hearing about it is actually causing a defensive response, which is, "No, you're fine."

Now, here's the thing about teenagers that is the greatest thing in the whole world.

They have their parents.

They are also surrounded by other phenomenal adults everywhere they go, their schools, they're after school activities, their places of worship.

And so, I always feel more comfortable and hopeful with a 15-year-old whose parents are maybe not seeing eye to eye with them than I do with a 12-year-old.

Because with a 15-year-old, I know they can go to school, get a fabulous counselor at school who can talk with them.

They can go to their church.

They can talk with a pastor there.

- Next question.

- Hi, Lisa.

You talked a lot about, you know, dealing with feelings and emotions, but what I'm experiencing in my professional and personal life is this apathetic feeling from teens, the lack of feelings or emotion.

And I just wanted you to talk a little bit about kids who don't seem to be motivated, who are not even motivated to be with their peers, kind of like recluse, wanna be, you know, home all day and trying to like, you know, circumvent that.

Thank you.

- Thank you, Candace.

Here's a story we're not telling about the pandemic is the rise of avoidance to manage anxiety.

So, one of the principles in psychology is that avoidance feeds anxiety.

The more you avoid something, the less inclined you feel to do it, the more anxious you feel about it.

We are seeing record levels of school refusal, or truancy, or chronic absenteeism.

It's called lots of things depending on the district you're looking at.

And so, I think that what has happened for a lot of kids is that something that may be made them a little anxious prior to the pandemic, maybe going to parties or going to school.

You then don't do it for a year and a half.

You have a year and a half of avoidance, and then the idea of returning to it becomes overwhelming.

And so then you think, "Well, maybe I will go to school," or "I will go to that party," and then you start to feel anxious.

And then you think, "Or I won't," and then your anxiety drains away.

It's a highly reinforcing experience.

Whatever you imagine to be true about school or that party goes unchallenged, however scary or worrisome you thought it would be, sealed in amber.

And so then, actually avoidance continues.

- Well, I wanna thank everyone for joining us for this live episode of "House Calls."

And most of all, Lisa, thank you so much for this incredible conversation.

Grateful for you.

(everybody clapping) And for all of those of you out there who might have been wondering, if you were wondering at all, why Lisa is a bestselling author and so well sought-after for her advice, now you understand why.

So, I'm just so grateful we had you with us today and thank you for all the incredible advice you provided to all of us and to me as well.

- You're welcome.

- I took notes and will be putting this into practice, so thank you.

- Thank you.

Thank you.

- Appreciate it.

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