J.D. emerged from his parent's divorce in 2013 a different kid. He'd always been serious, but now he was moody and falling behind in school.
"His English teacher described him as a dark cloud of doom," said his mom, Marty Hoffmeister, who asked to be identified by her maiden name to protect her son.
Hoffmeister watched as J.D. suffered through adolescent angst: demanding classes, confusing interactions with girls and a mom who just wanted to know what was wrong. She reached out to the family doctor but was hesitant to put him on anything more than light antidepressants.
"I didn't know how much of (his behavior) was hormones or how much of it was him not eating what he should," Hoffmeister said. "It's really tough for parents to sort out what could be going on in their kid's life."
Young people like J.D. fall into a gray area somewhere between a formal diagnosis and clean bill of mental health. They can fail to show up on the radar of a health care system already struggling to treat children with serious mental illnesses, leaving parents of kids in the gray area to worry about underdiagnosis on one hand and overmedication on the other.
Increasingly, researchers and other health experts are focusing on this group of young people, working to address emotional issues before they lead to larger problems. Nearly 31 percent of child and teen participants in a new, multi-year study from JAMA Psychiatry (paywall) exhibited "subthreshold symptoms" of a mental illness, including aspects of anxiety, conduct or mood disorders, but did not qualify for a formal diagnosis.
Members of this subthreshold group are three times as likely as healthy peers to suffer from health, legal, financial or social problems later in life as young adults, and they need the support of physicians, school leaders and parents alike, said William Copeland, an associate professor of psychiatry and behavioral sciences at Duke University School of Medicine and the study's lead author.
"Physical illness is universal, and I believe mental illness is almost as universal," he said, but it's not seen as normal to get a child a mental health screening the way it is to get a physical exam.
The stakes
Copeland's study highlighted the large number of young people affected by mental illness. In addition to the 31 percent of participants in the gray area, 26 percent of the children met the criteria for a formal diagnosis. The study included more than 1,200 participants who were assessed multiple times between ages 9 and 26, but the research is not representative of all U.S. children because it oversampled American Indians.
"It's overwhelmingly clear that (emotional) problems are more common than we ever suspected," Copeland said. Rather than affecting a few people who are damaged or different, mental health issues are "part of the common experience of growing up."
Most young people struggling with their mental health, including nearly two thirds of the 26 percent of survey participants who met the criteria for a mental illness as well as all of the 31 percent who exhibited subthreshold symptoms, "aren't getting any help whatsoever," Copeland said.
This unmet need is problematic because the longer a mood or attention disorder goes untreated, the more likely it is to create consequences that extend beyond a child's mental health, noted Laurie Wakschlag, professor of human development and social policy at Northwestern University.
For example, parents likely limit their child's interactions with others if the child has an irritability problem. But this relative isolation compared to other children further stunts the child socially and emotionally.
"The problem gets more entrenched with each additional negative interaction," said Wakschlag, whose research focuses on identifying mental health issues in children as young as 3 and 4.
In response to growing awareness of how common mood or behavior disorders are in childhood, many school counselors now reach out to all students, rather than concentrating their efforts on the few students who are open about their mental health struggles.
"We have a strong bent now on preventive guidance counseling," said Teresa Klatka, school counselor at Eastside Elementary School in Rock Springs, Wyoming. She regularly visits classrooms throughout the year, offering lessons on issues like stress, bullying and coping with loss.
"If we can (intervene) before things get really bad and teach skills and coping strategies, students are better able to help themselves make better decisions," she said. "Once they get into trouble, it becomes a very difficult situation."
J.D.'s ongoing mental health issues came to a head one day last fall, when a stressful quarter at school culminated in him threatening one of his classmates.
"By the time I got to school, the police were there. It was the biggest nightmare," Hoffmeister said. J.D. was admitted to the hospital for a psychiatric evaluation and school administrators expelled him.
Already struggling with depression and attention issues, he now had to start over at a different high school. But the incident also put him on the path to a better mental health care plan, as well as a stronger relationship with his mom.
"What happened that day has so changed his life and changed my life, too," she said.
The risks
The goal of helping children in the gray area receive treatment is to prevent crises like Hoffmeister described. However, increased attention to childhood mental health also raises the risk of interfering irresponsibly and being too aggressive with treatment, said Daniel Klein, professor of clinical psychology at Stony Brook University in New York.
"We have false positives and false negatives both," he said. "How to find the balance is a very tough question."
Antipsychotic drug prescriptions are rising at a troubling rate in the United States. Between 2005 and 2009, almost one-third of young people diagnosed with a mood disorder (31.3 percent) received antipsychotic medication from their psychiatrist. Ten years earlier, from 1993 to 1998, only 9 percent of these patients received antipsychotics, according to a 2012 study on national trends.
Another analysis, released in July by JAMA Psychiatry (paywall) found that these prescriptions are routinely given to young people who haven't been diagnosed with a mental disorder or who struggle with ADHD or depression, for which the Food and Drug Administration does not recommend antipsychotics.
Overly aggressive treatments are likely prescribed by doctors who didn't specialize in childhood mental health or demanded by parents who are grasping for a quick fix to a difficult situation, Klein noted.
"Many people live in areas with few child psychiatrists and psychologists," he said. "Our mental health system is not a good one for children."
Treatment plans are also complicated by current diagnosis standards, which are often hard to apply to young people, Wakschlag said.
"For oppositional defiance disorder, listed symptoms are things like 'The child often loses his or her temper.' But what young child doesn't often lose his temper?," she said.
Wakschlag advocates for new standards that help parents and health care professionals place young people along a spectrum of normal behavior. Although more research is required to standardize this spectrum, she is hopeful that better diagnoses would result in better outcomes for hundreds of children.
"We have to guard against missing the boat and having children wait (for treatment) during a critical developmental period when help would improve the likelihood of their life following a healthy course," she said.
A path forward
Copeland's study has inspired calls for earlier intervention, as well as claims that expanding mental health care options for children would shrink the future population of adults who suffer. And yet researchers are still working to determine the most effective types of treatments, leaving parents to sort out what's best for their child in the meantime.
"Our knowledge of whether early intervention is going to help in the long term is still pretty limited," Klein said, noting that he does support educational initiatives around emotional health, like the coping mechanisms Klatka teaches her students.
Similarly, Copeland noted that proactive treatment cannot guarantee an anxiety, behavior or mood disorder will be the last mental health issue a person faces. But it can guard against harmful behaviors like drug use, disengagement with school or violence, which often stem from underlying mental health issues, he said.
"I wish there were more parents talking to their kids about emotional functioning (and) about what's going at home or school," Copeland said. "If (childhood mental health research) normalizes the experience of emotional and behavioral problems, that'd be a huge positive."
Parents should have regular conversations with their children about mental well-being, asking questions about friends or noting when a young person seems frustrated or upset, Klatka said.
Family doctors or school counselors should be brought into discussions if a troubling mood is affecting multiple domains of a child's life, she added. Aggression with a sibling might be natural, but it's concerning when anger issues also arise in the classroom and at community events.
"Work on your relationship with your child. Don't wait until there are problems," Klatka said. When an emotional situation arises, such as a death in the family or drama in a child's friend group, "use it as an opportunity to teach healthy ways to deal with problems and emotions."
J.D.'s experiences have led Hoffmeister to be open with her 12-year-old daughter about the kinds of stressors she'll face in junior high.
"We've talked about how girls can be really mean. I tell her to do what she thinks is right and not get caught up in other people's drama," she said.
Her relationship with J.D. has also changed, evolving into a more open dialogue as he gets settled into his senior year and continues to meet with a therapist.
"If J.D. feels depressed, he comes to me," Hoffmeister said. Then, they work together to figure out what's wrong and how to help him feel better.
It will be a stressful fall, with J.D.'s college search quickly picking up steam, but Hoffmeister is hopeful the family has turned a corner to brighter days.
"Last year, I was struggling just to get him up in the morning and get him to school," she said. "Now, he's moving forward."
"His English teacher described him as a dark cloud of doom," said his mom, Marty Hoffmeister, who asked to be identified by her maiden name to protect her son.
Hoffmeister watched as J.D. suffered through adolescent angst: demanding classes, confusing interactions with girls and a mom who just wanted to know what was wrong. She reached out to the family doctor but was hesitant to put him on anything more than light antidepressants.
"I didn't know how much of (his behavior) was hormones or how much of it was him not eating what he should," Hoffmeister said. "It's really tough for parents to sort out what could be going on in their kid's life."
Young people like J.D. fall into a gray area somewhere between a formal diagnosis and clean bill of mental health. They can fail to show up on the radar of a health care system already struggling to treat children with serious mental illnesses, leaving parents of kids in the gray area to worry about underdiagnosis on one hand and overmedication on the other.
Increasingly, researchers and other health experts are focusing on this group of young people, working to address emotional issues before they lead to larger problems. Nearly 31 percent of child and teen participants in a new, multi-year study from JAMA Psychiatry (paywall) exhibited "subthreshold symptoms" of a mental illness, including aspects of anxiety, conduct or mood disorders, but did not qualify for a formal diagnosis.
Members of this subthreshold group are three times as likely as healthy peers to suffer from health, legal, financial or social problems later in life as young adults, and they need the support of physicians, school leaders and parents alike, said William Copeland, an associate professor of psychiatry and behavioral sciences at Duke University School of Medicine and the study's lead author.
"Physical illness is universal, and I believe mental illness is almost as universal," he said, but it's not seen as normal to get a child a mental health screening the way it is to get a physical exam.
The stakes
Copeland's study highlighted the large number of young people affected by mental illness. In addition to the 31 percent of participants in the gray area, 26 percent of the children met the criteria for a formal diagnosis. The study included more than 1,200 participants who were assessed multiple times between ages 9 and 26, but the research is not representative of all U.S. children because it oversampled American Indians.
"It's overwhelmingly clear that (emotional) problems are more common than we ever suspected," Copeland said. Rather than affecting a few people who are damaged or different, mental health issues are "part of the common experience of growing up."
Most young people struggling with their mental health, including nearly two thirds of the 26 percent of survey participants who met the criteria for a mental illness as well as all of the 31 percent who exhibited subthreshold symptoms, "aren't getting any help whatsoever," Copeland said.
This unmet need is problematic because the longer a mood or attention disorder goes untreated, the more likely it is to create consequences that extend beyond a child's mental health, noted Laurie Wakschlag, professor of human development and social policy at Northwestern University.
For example, parents likely limit their child's interactions with others if the child has an irritability problem. But this relative isolation compared to other children further stunts the child socially and emotionally.
"The problem gets more entrenched with each additional negative interaction," said Wakschlag, whose research focuses on identifying mental health issues in children as young as 3 and 4.
In response to growing awareness of how common mood or behavior disorders are in childhood, many school counselors now reach out to all students, rather than concentrating their efforts on the few students who are open about their mental health struggles.
"We have a strong bent now on preventive guidance counseling," said Teresa Klatka, school counselor at Eastside Elementary School in Rock Springs, Wyoming. She regularly visits classrooms throughout the year, offering lessons on issues like stress, bullying and coping with loss.
"If we can (intervene) before things get really bad and teach skills and coping strategies, students are better able to help themselves make better decisions," she said. "Once they get into trouble, it becomes a very difficult situation."
J.D.'s ongoing mental health issues came to a head one day last fall, when a stressful quarter at school culminated in him threatening one of his classmates.
"By the time I got to school, the police were there. It was the biggest nightmare," Hoffmeister said. J.D. was admitted to the hospital for a psychiatric evaluation and school administrators expelled him.
Already struggling with depression and attention issues, he now had to start over at a different high school. But the incident also put him on the path to a better mental health care plan, as well as a stronger relationship with his mom.
"What happened that day has so changed his life and changed my life, too," she said.
The risks
The goal of helping children in the gray area receive treatment is to prevent crises like Hoffmeister described. However, increased attention to childhood mental health also raises the risk of interfering irresponsibly and being too aggressive with treatment, said Daniel Klein, professor of clinical psychology at Stony Brook University in New York.
"We have false positives and false negatives both," he said. "How to find the balance is a very tough question."
Antipsychotic drug prescriptions are rising at a troubling rate in the United States. Between 2005 and 2009, almost one-third of young people diagnosed with a mood disorder (31.3 percent) received antipsychotic medication from their psychiatrist. Ten years earlier, from 1993 to 1998, only 9 percent of these patients received antipsychotics, according to a 2012 study on national trends.
Another analysis, released in July by JAMA Psychiatry (paywall) found that these prescriptions are routinely given to young people who haven't been diagnosed with a mental disorder or who struggle with ADHD or depression, for which the Food and Drug Administration does not recommend antipsychotics.
Overly aggressive treatments are likely prescribed by doctors who didn't specialize in childhood mental health or demanded by parents who are grasping for a quick fix to a difficult situation, Klein noted.
"Many people live in areas with few child psychiatrists and psychologists," he said. "Our mental health system is not a good one for children."
Treatment plans are also complicated by current diagnosis standards, which are often hard to apply to young people, Wakschlag said.
"For oppositional defiance disorder, listed symptoms are things like 'The child often loses his or her temper.' But what young child doesn't often lose his temper?," she said.
Wakschlag advocates for new standards that help parents and health care professionals place young people along a spectrum of normal behavior. Although more research is required to standardize this spectrum, she is hopeful that better diagnoses would result in better outcomes for hundreds of children.
"We have to guard against missing the boat and having children wait (for treatment) during a critical developmental period when help would improve the likelihood of their life following a healthy course," she said.
A path forward
Copeland's study has inspired calls for earlier intervention, as well as claims that expanding mental health care options for children would shrink the future population of adults who suffer. And yet researchers are still working to determine the most effective types of treatments, leaving parents to sort out what's best for their child in the meantime.
"Our knowledge of whether early intervention is going to help in the long term is still pretty limited," Klein said, noting that he does support educational initiatives around emotional health, like the coping mechanisms Klatka teaches her students.
Similarly, Copeland noted that proactive treatment cannot guarantee an anxiety, behavior or mood disorder will be the last mental health issue a person faces. But it can guard against harmful behaviors like drug use, disengagement with school or violence, which often stem from underlying mental health issues, he said.
"I wish there were more parents talking to their kids about emotional functioning (and) about what's going at home or school," Copeland said. "If (childhood mental health research) normalizes the experience of emotional and behavioral problems, that'd be a huge positive."
Parents should have regular conversations with their children about mental well-being, asking questions about friends or noting when a young person seems frustrated or upset, Klatka said.
Family doctors or school counselors should be brought into discussions if a troubling mood is affecting multiple domains of a child's life, she added. Aggression with a sibling might be natural, but it's concerning when anger issues also arise in the classroom and at community events.
"Work on your relationship with your child. Don't wait until there are problems," Klatka said. When an emotional situation arises, such as a death in the family or drama in a child's friend group, "use it as an opportunity to teach healthy ways to deal with problems and emotions."
J.D.'s experiences have led Hoffmeister to be open with her 12-year-old daughter about the kinds of stressors she'll face in junior high.
"We've talked about how girls can be really mean. I tell her to do what she thinks is right and not get caught up in other people's drama," she said.
Her relationship with J.D. has also changed, evolving into a more open dialogue as he gets settled into his senior year and continues to meet with a therapist.
"If J.D. feels depressed, he comes to me," Hoffmeister said. Then, they work together to figure out what's wrong and how to help him feel better.
It will be a stressful fall, with J.D.'s college search quickly picking up steam, but Hoffmeister is hopeful the family has turned a corner to brighter days.
"Last year, I was struggling just to get him up in the morning and get him to school," she said. "Now, he's moving forward."