Far too many youth are struggling with their mental health, and there is no shortage of theories for what might be behind this troubling trend. Taking a quick look at surveys as well as popular media articles and books, the most common suspects generally include the negative effects of social media use, a helicopter parenting style, and lingering effects from the COVID-19 pandemic.1,2
Evidence supports the idea that these factors are indeed playing a role and require our clinical attention when working with families.3 At the same time, it remains painfully evident that many of the more “traditional” and timeless influences that have been shaping child development continue to exert powerful influences on many of our most acute children and adolescents. Major forces such as genetics, the prenatal environment, and early experience, may not capture as many online headlines these days, but they cannot be ignored when it comes to their ability to influence future mental health, for better or for worse.
Most of my clinical career has been devoted to children and families with high needs and complexities. I have seen a large percentage of youth struggling across many domains while acting as the child psychiatrist to a Medicaid-funded residential treatment facility for boys, working at an academic center often sent some of the area’s most complex kids, and in my current position at a safety net community health center. There are often significant safety concerns both for themselves and others, and they are frequently doing very poorly at school, if they are going at all. Symptom areas commonly experienced include significant aggression, self-harm, attention problems, emotional outbursts, anxiety, as well as—increasingly it seems—psychotic or quasi-psychotic experiences.
When seen for an initial evaluation, these youth can present with a dizzying list of diagnoses that have either been established already or need to be actively considered, including bipolar disorder, oppositional defiant disorder, intermittent explosive disorder, complex post-traumatic stress disorder, disruptive mood dysregulation disorder, and many others. The medication list, often just as long, generally matches this list of potential diagnoses.
Yet despite the long differential and this apparent complexity, there is often a remarkable similarity in these cases, so much so that I’ve found that I can cut and paste the same summary sentence in an astonishing number of evaluations:
“xxx is a xx-year old child/adolescent who presents with severe dysregulation, aggression, and anxiety in the context of early adversity and trauma and a strong family history of mental health problems and substance use.”
Children and their histories differ in significant ways, but three components seem to come up over and over again for these most troubled individuals: 1) a history of significant mental illness and/or substance use in biological relatives, 2) a prenatal history significant for a mother who has struggled with severe stress and adversity that often includes domestic violence and exposure to substances, 3) an early childhood characterized by trauma, neglect, abandonment, socioeconomic challenges, and, at best, suboptimal parenting practices.
My declared task for these evaluations is usually to come up with a medication to address the effects of these major developmental influences, which I then try to convert into a more comprehensive treatment plan that might well include medication but also includes individual therapy, parental/caregiver support and treatment, health promotion, school supports, and addressing socioeconomic barriers. The health promotion component often includes guidance about screens and social media use, but while most of the world these days seems concerned about youth who spend too much time interacting with others online, I more commonly encounter kids who need help developing social communications of any type. When it comes to parenting, I find that it is more common among the folks I see that I have to encourage parents to be more involved rather than less, as has been noted about the stubbornly persistent rates of child neglect.4 Similarly, as chatter on the internet gets more and more upset about children being praised too much, I find myself still pushing many parents to replace the harsh criticism with kinder and more supportive language. As for lingering effects of COVID-19, it has been my clinical experience that the pandemic more often exacerbated, rather than initiated, mental health problems that already existed.
Part of the apparent dichotomy between the clinical experience many of us have in practice and sentiments circulating through the media may be due to socioeconomic differences between many online writers advocating for “trendier” causes of mental health problems compared to the status of the average family encountered in public mental health settings. But beyond differences in the observers of this phenomenon, it also seems quite possible that there exists at least two somewhat distinct populations of youth: the first being a large group of struggling but relatively functioning individuals who are indeed being affected by excessive social media use and over-intrusive parenting, and a second more highly affected group whose mental health struggles are still primarily being driven by genetic factors, a stressed prenatal environment, and an early environment characterized by trauma and, more frequently, primary parenting figures who tend to be absent rather than being overinvolved. There is not a lot of research looking into this question specifically, although there is some evidence suggesting that the genetic architecture underlying child behavioral problems (that is, the relative magnitude to which youth emotional–behavioral problems are driven by genetic versus environmental factors) change as a function of one’s socioeconomic status.5
The main point here is not that we should be disregarding real concerns that are being raised about the potential hazards of excessive screen use or fashionable parenting practices but rather that some of the age-old factors such as genetics, the prenatal environment, and early trauma and adversity are still exerting very large effects, particularly on many of the youth who are presenting with the most acute levels of emotional–behavioral problems. Responding effectively means staying current regarding some of the modern pitfalls of 21st-century child development while keeping our eyes on the ball when it comes to some of the fundamental underpinnings of childhood mental health disorders that continue to exercise major effects today.
About the Author
David C. Rettew, MD, Department of Psychiatry, Oregon Health and Science University, Eugene, Oregon, USA; Medical Director, Lane County Behavioral Health, Eugene, Oregon, USA
Correspondence to:
David C. Rettew, MD; email: David.Rettew@lanecountyor.gov, 541-682-3608.
Funding
Dr. Rettew has reported no funding for this work.
Disclosure
Dr. Rettew has reported no biomedical financial interests or potential conflicts of interest.
Author contributions
Writing – original draft: David Rettew (Lead).