Teen mental health: a parent's guide

In November 2024 the Eanes Independent School District's counseling department asked me to spend an evening with parents on one question: what should you know about your pre-teen or teenager's mental health before you need to? The district recorded it, and it is embedded at the bottom of this page. This is the written version, updated and organized so you can find the part you came for. It covers how clinicians decide whether something is a concern, the four most common conditions and what treats them, the suicide warning signs I would want every parent to know, and the conversations parents ask me about most: death, sex, suicide, self-injury, and self-esteem.

A note on the source. I spent most of my career in pediatric psychology at Children's Wisconsin and the Medical College of Wisconsin, working with children from prenatal diagnosis to about age 27, and helped build the hospital's universal suicide screening program. Everything below comes from the research literature rather than my personal values; what you do with it is your family's call. I am a PhD, not an MD, so where medication comes up I am reporting what the evidence says, and your prescriber decides.

How a mental health concern is diagnosed

Parents often ask whether what they are seeing is a phase. Clinicians answer with four questions. First, is there more emotional distress than the situation would explain? Second, is there impairment: are school, friendships, or family life suffering? Third, is the behavior atypical for the child's age and culture? A three-year-old's tantrum is normal; the same tantrum from a seven-year-old is worth a closer look, because what we care about is whether behavior fits where a child is developmentally. Fourth, is it explained by something else? Depressive symptoms in a teen with a family history of hypothyroidism, or a sudden onset of obsessive-compulsive symptoms after a strep infection, are medical questions before they are psychological ones, and substance use and other diagnoses need ruling out too.

If the answer to the first three is yes and the fourth is no, it is time to talk to someone.

The four most common conditions, and how much they overlap

In U.S. data from 2016 to 2019, the most common pediatric mental health conditions were ADHD, anxiety, behavior problems, and depression. ADHD is one of the few diagnoses more common in boys; anxiety and depression run somewhat higher in girls. Behavior problems are on the list even though they are not a diagnosis, because they are so often the reason a family first calls.

What matters most for parents is how much these overlap. A child with major depression has about a one in three chance of also meeting criteria for ADHD, and a similar chance of meeting criteria for oppositional defiant disorder. Among children with the long, low-grade form of depression called persistent depressive disorder, the ADHD overlap is higher still. In practice this means that when a child is referred for behavior or for attention, I am always checking whether depression or anxiety is underneath, because the treatment is different.

ADHD

What was called ADD in the 1980s and 1990s is now the inattentive subtype of ADHD: trouble following instructions, difficulty staying organized, the homework that never makes it home. The hyperactive subtype is the fidgeting, the talking, the interrupting. Many children have the combined type. ADHD is unusual among pediatric diagnoses in that for roughly half of children it resolves by adulthood, whether through better coping skills, maturation, or landing in work that fits their strengths. For the other half it is more hardwired.

For mild ADHD I start with therapy: social skills training, because impulsivity costs friendships, and parent training with behavior modification. One example from my own caseload is a daily report card, where the teacher marks whether a child stayed seated for a set number of minutes and the parent applies a small, consistent consequence at home, such as fifteen minutes more or less screen time. Applied every day, that shapes behavior. For moderate to severe ADHD, medication belongs in the plan alongside therapy; the two classes are stimulants and non-stimulants, and for a child with a complex medical condition such as a serious congenital heart defect, choosing between them is a conversation between the prescriber and the specialist. Given the long waits for child psychiatry in Texas, a pediatrician who keeps up with the literature is often the right place to start.

One treatment I would add to every ADHD plan: physical activity, ideally in the morning, and if not in the morning then whenever it will actually happen.

Anxiety

Anxiety is a family of conditions, and they behave differently. A specific phobia usually follows an event, like a dog bite. Social anxiety tends to be temperament, shows up early, and worsens over time unless the child is steadily exposed to social situations. Separation anxiety is a healthy sign of attachment at eighteen months to three years and a concern if it is still running the household at six or eight. Panic disorder brings the racing heart and closing throat that send well-meaning parents to the emergency room for a cardiac workup; agoraphobia is what happens when the child starts avoiding wherever the panic struck, which at school can look like refusing to go. And generalized anxiety disorder describes the natural-born worriers: perfectionistic, hard on themselves, often high achievers precisely because they worry, which is why I think of it as a double-edged trait rather than a defect.

The most effective treatment across all of these is cognitive behavioral therapy, and its engine is exposure. Exposure means facing the feared thing in graded steps, over and over, until the body stops sounding the alarm. For a child bitten by a dog, that might be practicing breathing while talking about dogs, then while looking at pictures, then from twenty feet outside a dog park, then closer the next week. It is counterintuitive, because it asks parents to let a child be distressed on purpose. The alternative is worse. Accommodating avoidance, such as never walking down the street where the dog lives, is the single most reliable way to make anxiety grow.

For moderate to severe anxiety, an SSRI alongside therapy is standard; fluoxetine and sertraline are the two with FDA approval for pediatric anxiety. And regular physical activity is not a nice extra. For anxiety and depression in both children and adults, the research puts cognitive behavioral therapy, an SSRI, and regular exercise in the same league, with the combination stronger than any one. If a family will not consider medication, therapy plus exercise is a real plan. If a teenage boy will not consider therapy, medication plus exercise is a real plan.

Behavior problems are usually a symptom

I put quotation marks around "behavioral disorders" when I teach this, because the behavior is almost always a symptom of something else. A child acting out to get sent home from school is often anxious. A child whose irritability has spiked is often depressed; in children and adolescents, depression can present as irritability instead of sadness, and in boys it often does. A child who has stopped trying in class and started disrupting it may have an untreated learning disability or ADHD and has decided that acting out beats looking stupid. Oppositional defiant disorder and conduct disorder are real diagnoses, and they are the ones I reach for last.

The family environment matters here more than parents want to hear. High expressed emotion at home, meaning yelling, loud voices, dramatic exits and entrances, is a risk factor for acting out. So is parent stress. In studies of families of children with congenital heart disease, a mother's stress level during pregnancy predicted the child's emotional adjustment at ages one through four better than the severity of the heart condition did. I have watched a child waiting for a heart transplant cope better than a child with a minor murmur, and the difference was how the parents were doing. Taking care of your own mental health is one of the most effective things you can do for your child's.

On discipline: the research is clear that corporal punishment, even when it falls well short of abuse, is associated with more aggressive behavior in children, not less, compared with time-outs and other consequences. Whatever a family's tradition, on effectiveness alone it is one of the worst tools available. What works, especially in the youngest years, is consistent time-outs, more positive reinforcement than negative, and the structured parenting programs with the strongest evidence: parent management training (useful from about age three to eighteen, and the first-line treatment for ADHD under age five), Parent-Child Interaction Therapy, and the Triple P Positive Parenting Program. If a therapist offering parenting help does not base their work on one of those, keep looking.

Depression

The core picture is a low or irritable mood most of the day, nearly every day, for at least two weeks, with loss of interest in things the child used to enjoy: the friends they stop seeing, the soccer practice they stop wanting to attend. Around it cluster changes in appetite, weight, sleep, and energy, fatigue, feelings of worthlessness or excessive guilt, trouble concentrating or deciding, and, as a classic symptom rather than a separate problem, thoughts about death. If a child is referred to me for ADHD, I check that the concentration problem is not depression first, because the symptoms mimic each other.

Treatment starts with cognitive behavioral therapy, which does two things: cognitive restructuring, teaching a young person to catch the automatic negative thought and test it against reality, and behavioral activation, getting them back on a schedule of activities that are both valued and enjoyable. I see a lot of moods drop in summer for exactly this reason; kids who do well during the school year lose the structure and the sense of accomplishment, and sleep until noon. Interpersonal therapy is a different framework with strong evidence for adolescent depression and is worth knowing about. For severe depression, an SSRI alongside therapy is the standard of care, with exercise as the third leg.

A word about the black box warning, because parents raised in the 1990s remember it. The warning came from a small number of cases in which a young person started an SSRI and later attempted suicide. With decades of data since, many researchers now believe the likelier explanation is that the medication restored energy before it lifted mood in a few already-suicidal patients, and that fear of the warning kept far more depressed young people off effective treatment than it protected. There is an active debate in the field about whether the warning should be removed. Every family decides for itself; the point is that the decision should rest on current evidence rather than a headline from thirty years ago.

One more pattern worth naming. If your child's mood drops every October or November, with more sleep and more carbohydrates, and lifts every March, that is a seasonal pattern, and morning light is a legitimate treatment: early time outdoors, or a 10,000-lux lamp for twenty minutes a day. Light therapy does not help ordinary depression, but it does help the seasonal kind.

Suicide: the warning signs that matter most

Suicidal thinking is common enough in adolescence that every parent should be prepared for it. In the CDC's 2019 Youth Risk Behavior Survey, about 19 percent of U.S. high school students said they had seriously considered suicide in the past year, about 16 percent had made a plan, about 9 percent had attempted, and 2.5 percent had made an attempt serious enough to need medical treatment. Those numbers rose further after the pandemic.

The standard warning-sign lists include threats, plans, and giving away possessions, and they matter. The signs I would ask parents to watch hardest are quieter. A sudden change in appearance or hygiene that is new for that particular child: the one who has stopped showering or wearing deodorant, when they used to care. Sleep, especially trouble falling asleep or waking early and lying there. And above all, the language of hopelessness, helplessness, and being a burden. Hopelessness is such a strong predictor that specialists measure it on its own, and when I hear a young person say there is no point, or that everyone would be better off, that is the moment I lean forward.

If you are in a crisis, three things. Stay calm and stay with your child; no one who has just said they feel suicidal should be left alone until there is a plan. Restrict access to lethal means: lock away prescription and over-the-counter medications, including acetaminophen and ibuprofen, and firearms and sharp objects. The image I use is a household where someone struggles with alcohol; you do not keep beer in the fridge. The point is to put time and obstacles between an impulse and an action, because the impulse usually passes. Third, if you cannot reach the pediatrician or therapist and you are worried about safety right now, call or text 988, go to the emergency room, or call 911. An evaluation is how you find out whether this is a thought, a plan, or an emergency, and most of the time it is a thought, which is treatable.

Talking about suicide before it is urgent

Start earlier than feels comfortable, around fifth or sixth grade: what suicide is, what to do if a friend says they are thinking about it, what to do if the thought shows up in your own head. Use openers when they come. When a celebrity or a peer dies by suicide, the risk of contagion among young people who identified with them is real, and that is a week to watch more closely and to talk.

The framing I use with patients, and recommend to parents, is a continuum. Almost everyone, when stressed enough, has had a dark thought somewhere on the range from "I wouldn't mind not waking up tomorrow" to "I want to kill myself." So the question is not the yes-or-no "are you suicidal," which invites a no. It is "where on that range have you ever been?" With younger kids I sometimes draw it as a thermometer. Asking that way normalizes the thought as a symptom, which is what it is, a symptom of depression or trauma or overload, not evidence that a child is broken. Kids who hear that answer honestly. For a fuller version of this conversation, see how to talk to your teen about suicide.

Self-injury

Self-injury has risen sharply, especially among adolescent girls, and parents understandably assume it is a suicide attempt. Usually it is not. It is most often a coping strategy in a young person who turns distress inward rather than acting out: the physical pain briefly crowds out the emotional pain, and that relief is exactly what makes it hard to stop. The two overlap, though; young people who self-injure are at higher risk of suicidal thoughts, so it should never be waved off. If you notice injuries, ask directly and without leading whether it was an attempt to die or a way to get through a bad feeling. Treat the answer as a symptom, not a character flaw, and get a professional evaluation, both because the risk is real and because it can go further than intended.

Death, sex, and the other conversations

Death. With school-age kids, use plain words and real details. "His heart stopped beating and he died" serves a child better than "he got sick and went to heaven," whatever your family's beliefs about what follows, because children take language literally: if being sick means dying, every cold becomes a threat. Say clearly that nothing they did or did not do caused it, because magical thinking at this age is powerful. If they will attend a funeral, describe ahead of time what they will see, including the casket and adults crying, so nothing ambushes them. Afterward, leave the door open without forcing it through: "This reminded me of Grandpa. What do you think?" and then let it go. A memory activity, such as looking at photos together, gives the loss somewhere to live.

Sex. The research on what prevents very early or unsafe sexual activity points to three things: accurate information, early and ongoing conversation, and trust that teenagers can hold two messages at once. "I do not think you should be having sex at this age, and if you do, here is how to be safe" is not a contradiction to a teenager; it is a complex message, and they understand it. Talking about sex does not increase risky behavior; more conversations decrease it. Waiting for a milestone like a first period is late, because by then the information has come from friends, cousins, and screens. Use openers: the awkward scene in the movie you watched as a family is a fine reason to bring it up at breakfast the next day. And do not underestimate what a pre-teen already knows; earlier is better than later.

Alcohol. A parent asked about drinking as early as freshman year. What I want to know is the function. Is a teen drinking to fit in, or to escape feelings? The first calls for the same complex-message conversation as sex. The second is a sign of depression or anxiety that needs treatment, and the drinking is the symptom.

Self-esteem. Praise effort and steps, not outcomes: not "you were great at gymnastics" but "I saw you working harder on that." Help your child find one area of real mastery; the subject does not matter. And protect time for social skills and friendships, not only sports and academics, because peer connection is one of the strongest supports a young person has.

Where to start

Your pediatrician and your school counselor are the first calls; both know local resources and who is in network. Every Eanes ISD campus has counselors and licensed school-based therapists, and most Texas districts have something similar. When you read a therapist's website, look for the specific evidence-based treatments named on this page rather than a promise to treat everything. And model what you want your child to learn: good sleep, physical activity, and saying out loud, "I'm stressed, so I'm going for a run." Kids do what they see.

If you would like to talk it through, Little Dove Psychology sees kids, teens, and college students virtually across Texas and the other PSYPACT states, with evening and weekend appointments. If we are not the right fit, we will say so and point you toward someone who is.

Common questions

How do I know if my child's behavior is a mental health concern or just a phase?

Clinicians look at four things. Is there more distress than the situation would explain? Is there impairment, meaning school, friendships, or family life are suffering? Is the behavior atypical for the child's age (a tantrum at three is normal; a tantrum at seven is worth a look)? And is it explained by something else, such as a medical issue, substance use, or another condition? Distress, impairment, and a mismatch with development are what turn a phase into a concern.

What are the most common mental health conditions in children and teens?

In U.S. data from 2016 to 2019 the most common were ADHD, anxiety, behavior problems, and depression. They overlap a great deal: a child diagnosed with major depression has roughly a one in three chance of also meeting criteria for ADHD, and behavior problems are very often a symptom of anxiety or depression rather than a diagnosis of their own.

Does ADHD go away as a child gets older?

For about half of children diagnosed with ADHD, the symptoms no longer meet criteria by adulthood, whether through better coping skills, maturation, or finding work that fits their strengths. For the other half it is more hardwired. That is why treatment focuses on organizational and social skills that carry forward, with medication added for moderate to severe cases, and physical activity for everyone.

What is the most effective treatment for anxiety in kids?

Cognitive behavioral therapy, and within it, exposure: gradually and repeatedly facing the feared thing until the body's alarm quiets down. The single most unhelpful thing a loving parent can do is accommodate avoidance, such as skipping the street where the dog lives or letting a child stay home from the lunchroom, because avoidance feeds the anxiety. For moderate to severe anxiety, an SSRI alongside therapy is standard, and regular physical activity belongs in every plan.

My teen is irritable rather than sad. Could it still be depression?

Yes. In children and adolescents, depression can show up as irritability instead of a low mood, and boys in particular often present that way. A significant increase in irritability, together with loss of interest in friends or activities, changes in sleep, appetite, or energy, and trouble concentrating, should raise the question of depression before it is written off as attitude.

What are the warning signs of suicide in a teenager?

The standard lists include threats, plans, and giving things away, and those matter. The signs to watch hardest are quieter: a sudden change in appearance or hygiene that is new for that child, sleep problems, especially trouble falling asleep or waking early and not getting back to sleep, and any talk of feeling hopeless, helpless, or like a burden to others. Hopelessness is one of the strongest predictors of a suicide attempt in the research.

What should I do if my teen says they are having thoughts of suicide?

Stay calm, and stay with them. Do not leave a child alone until you have a plan for their safety. Lock up or remove anything that could be used impulsively: prescription and over-the-counter medications (including acetaminophen and ibuprofen), firearms, and sharp objects. If you cannot reach your pediatrician or therapist and you are worried about immediate safety, call or text 988, go to the emergency room, or call 911. A thought is not the same as a plan, but an evaluation is how you find out where your child is.

Is self-injury the same as a suicide attempt?

No, though they overlap. Self-injury is most often a way of coping with intense emotional distress; the physical pain briefly displaces the emotional pain, which is what makes it hard to stop. Young people who self-injure are at higher risk of suicidal thoughts, so it should never be ignored. Ask directly and without leading whether the injury was an attempt to die or a way to cope, treat it as a symptom rather than a character flaw, and get a professional evaluation.

How do I talk to my child about death?

Simply, plainly, and with the real words. "His heart stopped beating and he died" is kinder in the long run than "he got sick and went away," because younger kids and even early teens take language literally: if being sick means dying, every cold becomes frightening. Make clear that nothing they did caused it. If they will attend a funeral, describe ahead of time what they will see and that crying adults are normal. Afterward, leave room for questions without forcing them, and consider a memory activity such as looking at photos together.

How do I find a good therapist for my child?

Start with your pediatrician or your school counselor; both usually know who is in network and who is good. When you read a therapist's website, look for the specific evidence-based treatments named on this page: cognitive behavioral therapy and exposure for anxiety, CBT or interpersonal therapy for depression, parent management training for behavior concerns, and a willingness to coordinate with a prescriber when medication is part of the plan. Be wary of anyone who says they treat everything.

Watch the webinar

Recorded and published by Eanes Independent School District, November 2024 (1 hour 3 minutes). The practice was then named Little Dove Consulting; it is now Little Dove Psychology.

Sources cited on this page

• Kroll, K. (2024, November). What every parent should know about supporting their pre-teen/teenager's mental health [Webinar]. Eanes Independent School District. Watch on YouTube
• Ivey-Stephenson, A. Z., Demissie, Z., Crosby, A. E., et al. (2020). Suicidal ideation and behaviors among high school students: Youth Risk Behavior Survey, United States, 2019. MMWR Supplements, 69(1), 47–55. Read the report
• Gershoff, E. T., & Grogan-Kaylor, A. (2016). Spanking and child outcomes: Old controversies and new meta-analyses. Journal of Family Psychology, 30(4), 453–469. doi:10.1037/fam0000191
• 988 Suicide and Crisis Lifeline: 988lifeline.org. Texas Youth Helpline: dfps.texas.gov.

This page is general information for parents and is not a substitute for an evaluation of your own child. Medication decisions belong to you and your child's prescriber.