Transcript

Kim Mills: In February, the Centers for Disease Control and Prevention released data showing that teen girls in the U.S. are engulfed in what they called “a wave of sadness and violence.” The numbers are startling. Nearly 1 in 3 teen girls has seriously considered suicide. Fifty-seven percent of teen girls said they felt persistently sad or hopeless, and 18% had experienced sexual violence in the prior year. The report also found extremely high levels of distress among LGBQ+ teens. More than 1 in 5 of them had attempted suicide in the prior year, and more than half reported poor mental health.

Today, we’re going to dig into those numbers. What is behind this crisis in teen mental health? Are we just seeing the effects of the pandemic? Is it social media, something else? Why are girls suffering so much more than boys? Which teens are more at risk? And what can parents, peers, schools, and communities do to help teens cope and stay safe and healthy in the face of such widespread distress?

Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I’m Kim Mills.

My guest today is Dr. Kathleen Ethier, director of the CDC’s Division of Adolescent and School Health, which put out the new report. She has been at the CDC for more than 20 years, leading research and policy work on health issues affecting youth and women. Before joining the CDC, she spent six years on the research faculty at Yale University working on studies of HIV, STDs, and unplanned pregnancy prevention. Dr. Ethier holds a PhD in social psychology from the Graduate Center of the City University of New York.?

Thank you for joining me today, Dr. Ethier.

Kathleen Ethier, PhD: Hi. So glad to be here.

Mills: Let’s start with the numbers I mentioned in the introduction. Almost one third of teen girls said they have considered suicide, almost 3 in 5 felt persistently sad and hopeless and 18% had experienced sexual violence. I think most members of the public who have heard these numbers were alarmed. And as someone who’s been working in the field for a long time, what about you? Were you surprised? Were you alarmed?

Ethier: Yeah, obviously, yes. The Youth Risk Behavior Survey, which is the report that we released is part, not all, but part of the data that’s contained in the Youth Risk Behavior Survey. The survey’s been around for more than 30 years, and as an adolescent health—my background is in adolescent health, I’ve been studying adolescent health for many, many years, and so we use the YRBS all the time. It’s a pretty standard way of understanding the health and wellbeing of young people in the country. Prior to the pandemic, we had been seeing mental health move in the wrong direction. We had seen that kind of centered around female students and LGBQ+ students. And then during the pandemic, we had additional confirmation that youth mental health was in crisis. That teenage girls seemed to be at higher risk.

So we saw some data from emergency room visits indicating that they were more likely to be showing up during the pandemic with having attempted suicide. So we had some inklings. I think we weren’t prepared, I would say, for the consistency across all of the different measures that we included in the report and then also some of the 10-year trends that we’ve been monitoring for the past number of years. And so we include these individual measures in this report around sexual behavior, substance use, experience of violence and mental health and suicide. Because for us in the division of adolescent school health, it speaks to the programmatic work. We know that these factors are interconnected. Most of these variables, this is the third time we’ve done this particular report. We include them every single time. We have some shifts to make sure we’re being relevant.

So we didn’t look at the data really before we decided that these were the set of variables we were going to include in this report. So when we put it all together and looked at the data and looked kind of across, we were not expecting that for all of the substance use measures that we include in the report. And it’s not every substance use measure that’s in the YRBS, but for the measures that we included in this report, for almost all of the experiences of violence except for being threatened or injured with a weapon and across all of the mental health and suicidal thoughts and behavior data we included in this report, that girls would be at such a significant increase compared to boys. And that was just really consistent. And I think we were not expecting that.

We’ve been monitoring kind of in these 10-year chunks, some of these variables like the proportion of youth who’d been forced to have sex. And so in 2017, when we looked at that 10-year trend in 2019, when we looked at that 10-year trend, there were no changes over those 10-year periods in that variable. When we looked at the 2011 to 2021 data, that was the first time we’d really seen an increase in that measure, that trend measure. And so that was really also very alarming to us. We’ve been saying for a while that out of every 10 teenage girls that at least one has been raped, and that has been consistent for the number of years that we’ve been looking at these 10-year trends. And that changed.

So yes, we were very alarmed. We look to our programmatic work to see how we can help, and we do have school-based strategies that address some of these issues, which I know we’ll talk about today. So I think you see the data, it is extremely alarming. It is our public health duty to get the data out and talked about and made accessible, which we’ve been trying to do. The next question, as you mentioned is why are we seeing this data? And then the next question after that is what do we do about it?

Mills: With girls in particular, and just the fact that these numbers are so alarming, do you have any way of knowing whether this is just a question of they’re more willing to tell the truth on polls than they had been in prior years? Might that be a factor that there’s more openness about this kind of conversation now?

Ethier: I think it’s very likely that we are doing a better job giving young people the language to describe their mental health. I don’t know that it’s less about telling the truth. This is an anonymous survey and it’s always been an anonymous survey. So I think perhaps there is less stigma about talking about mental health, but I also do think that we in a really positive way, have been giving young people the language to say what’s happening with them. What concerns me is that while we’re giving them the language to describe their mental health on an anonymous survey, what I worry about is that we aren’t giving them the pathways to tell adults, whether that’s their parents or their school counselors or their teachers or a mental health professional or their primary care doctor, I’m not sure. This data doesn’t tell us that we’ve given them the pathway to get help. And that worries me.

Mills: Before we get too further, too much further into this, I wanted to ask you about the cohort, the data, how you do this, how many kids are involved, how is it nationally representative, how do you pull it all together, and how are these youth basically approached and polled?

Ethier: So this is a school-based survey. So this is a survey of 9th through 12th graders, and this year the sample size was over 17,000 young people collected in schools across the country. Again, we’ve been doing this survey for more than 30 years. It is part of a system of surveys. So the data that I’m talking with you about that we released in this report is part of a national survey. There are also 47 state surveys and 28 local surveys. So across the country there are lots of individual youth risk behavior surveys that are conducted. And so we collect this data in conjunction with the states and locals as well. So we work with them so that we’re not overtaxing any individual school because they appear in either the national or the state sample. We use a sampling frame, and it’s probably somewhat complicated, but we use a sampling frame that allows us to use the demographics of the school, the individual school, to make sure that the data is nationally representative.

It doesn’t include data from every state, but it is nationally representative. And we do a lot of non-biased testing to make sure that if we get data from a school and then we have a different school that says, no, we really don’t want you to come in, that there isn’t kind of systematic differences between schools that agree to participate in schools that don’t. So there’s a lot of methodological and analytics support that we use in the sample to make sure that it is nationally representative—for all the data geeks who listen to your podcast.

Mills: And I’m sure there are some. So I have to ask you about social media because there’s been so much public and media attention recently to how social media can harm teens’ mental health. Do you think at least some of the blame for what we’re seeing in this survey lies there?

Ethier: I think it is more complicated than—honestly, it would be wonderful to have kind of a silver bullet that if we just fixed that one thing then this would all get better. I don’t think that that’s the case, although I think that social media does come with significant risks and the potential for significant harm, but it also comes with a lot of opportunity for connection and it comes with a lot of opportunity for young people to access information that they may not have any other way of accessing. And so it’s not the kind of thing that I think we want to throw out without really trying to figure out what should we keep, what’s important for young people to have and then how should we try to protect them. I think, and this is where social media probably plays in, I think a lot of what’s underlying this is social isolation.

We as humans, and I think the folks listening to your podcast who are either psychologists themselves or interested in psychology, I think we know, and as a social psychologist myself, I think we know that as humans, we are social beings. We require social interaction. And many of the things that we’re looking at in this report, both in terms of I think substance use and experience of violence and mental health and suicidality have some component of social isolation as a cause underneath. So I think that’s partially why the pandemic was so impactful was because we were separated from each other and young people lost the supports that they have in school. They lost their peer groups for periods of time, and I think that was really impactful.

And I think we on the opposite side, we see the power of connectedness in protecting the health and wellbeing of young people. And so where social media comes in, I think is that that can become a substitute connector and so can provide some connection. What I’m not sure about is whether it provides real connection in a way that protects health and wellbeing. And if not, how do we shift young people to connections that are more fulfilling and support them in ways that the connection that they’re getting through social media probably doesn’t?

Mills: Yeah. Some of the really shocking numbers that came out of this report were for girls and LGBQ+ teens, and I say LGBQ without the T because I know you didn’t ask about gender identity this time. Why do you think these two groups were faring so much worse than boys, or at least than straight boys? And how were boys doing?

Ethier: So, I mean, in many ways, especially around mental health and suicide, we saw increases across both boys and girls, across every racial and ethnic group that we included. And in this report, we actually included seven categories of race and ethnicity, which we hadn’t done before. And I think neither LGBQ+ youth or straight youth were doing particularly well in mental health. I mean, overall 40% of the students in the sample said that they felt so persistently sad and hopeless for at least two weeks in the last year that they couldn’t do the regular activities, which you will all recognize as depressive symptoms. And so I do want to say that it’s not like girls were doing terrible and boys were doing so much better. I mean that girls were doing significantly worse than boys and LGBQ+ students were doing significantly worse than heterosexual youth.

Almost consistently in the same way that we saw in this report for girls, LGBQ+ youth had already been doing significantly worse than straight youth prior to the pandemic. So we had really consistently been seeing that data since 2015, which is when we started asking about sexual identity. And we don’t have trends on this population for this year because we changed the question to be better reflective of sexual identity. And so we were less surprised because we had been seeing it, but nowhere less concerned that a quarter, for instance, a quarter of LGBQ+ students attempted suicide in the year prior to the survey. That’s really high to think about a quarter of those students attempted to not be here anymore. That is just really devastating.

I think as much as we’ve made significant strides in positive supports for LGBQ+ students, there’s still a long way to go. And I think the conversations, the public conversations over the last few years around, certainly around trans youth, which again, we include that question in this sample, but it affects all young people in that way. And so I think we would be na?ve to think that those conversations are not impacting them. I mean, we do have earlier studies that have shown that in states prior to marriage equality becoming available across the country, when we looked at states that supported marriage equality versus those that did not, we saw significant differences in suicidal thoughts and behaviors in LGBQ+ students. And so we know that the social environment when it is supportive has a positive impact on those young people. So this data doesn’t tell us, but if you’re asking me what impact do I think the current conversations are having, it’s impossible to suggest that they’re not having a negative impact.

Mills: Sure. And you probably can’t tell this from the data either, but how can we as a society get help to this particular group of teens when so many politicians and others are making it impossible for educators and other people to speak openly about LGBQ issues in schools?

Ethier: It’s certainly not my role from the federal perspective to advocate for or against any particular state law or policy. That’s not my role. But our research has shown that when you make schools, for instance, less toxic for LGBTQ+ students, so when you put policies and practices in place in schools to support those young people, not only do young people who identify as lesbian, gay, bisexual or say that they’re questioning do better in terms of their mental health and suicidal thoughts and behavior. But straight youth in those schools, the youth who identify as heterosexual in those same schools also have better mental health and less suicidal thoughts and behaviors.

And so what we see is that when you make schools less toxic for the most vulnerable youth, you make schools less toxic and more supportive for everyone. And so of course, when you have a group of young people who are faring significantly worse than others, you want to talk about all the ways in which they can be supported and the ways in which you can try to turn that around. But interestingly, supporting those young people also helps everybody. And in an environment that we’re seeing in our data where no one’s doing particularly well, to make such important environments more toxic for any group of young people, understanding the way that it affects everyone, I think it worries me.

Mills: Now, I want to stress that the recent report on youth risk behavior was not all bad news. I mean, there were some areas where youth did better than on prior surveys. Can you talk about those and some of the possible reasons for those improvements?

Ethier: Yeah. So we’ve been consistently over the last three waves of this data, when we’ve looked at these 10-year trends, we’ve been seeing sexual behaviors move in the right direction for a while. And interestingly, so we looked at 2007 to 2017 and then 2009 to 2019, and now we’re looking at 2011 to 2021. At the beginning of that time period, that 2011 time period, there were significant differences by race/ethnicity in the proportion of youth who had ever had sex, who had multiple sex partners, who were currently sexually active. Not only has everybody improved, but those differences, those disparities have closed. And now there aren’t significant differences between those groups in the ways that we used to see. We don’t know exactly why that’s occurring. I think we’ve spent a lot of time educating young people about the positive behaviors that we think will be healthy for them, and so they listen.

And we’ve been seeing the same thing across substance use as well. So even though we see this disparity between girls and boys in general, substance use has been going down across all of the measures that we included in this report. And again, they’re not all of the measures contained in YRBS, but across this set that we’ve been looking at for a while, they’ve all moved in the right direction. So I think that those are positive things in the sense that when you give young people information about their health and skills to make those changes, they’re able to do that. The areas that we’re seeing that are not positive are the things that are happening to them, like the experience of violence and then the resulting mental health impact of those experiences.

Mills: Now your division at the CDC works on resources for schools to help address violence and mental health. Can you tell us more about how schools can help teens and what exactly it is that the CDC is doing in this area?

Ethier: Sure. So specifically about schools. So again, my division’s the division of adolescent and school health. We have a program called What Works in Schools. And what that program does is it works to improve health education. So making sure that schools are putting in place quality health education programs. It works to help connect young people in their schools to needed health services. And then it does a collection of what we call safe and supportive environment work. And that is everything from making sure teachers have the training and the skills that they need to help manage the mental and behavioral health issues that they’re seeing in their classrooms, that they’re telling us all the time that they’re dealing with, especially since the pandemic, making sure that there are youth development programs in place, which are really effective in helping young people feel engaged and connected to important others in their schools and to important adults.

And then this set of things that I was just talking about in terms of making sure that schools are put in place policies and practices to support LGBTQ youth. When schools do all of that work, what we see is that in the same district, if you look at schools that put those programs in place versus schools that don’t, even in the same district, that the schools that put the program in place, we see decreases in sexual behavior, we see decreases in substance use, we see decreases in both forced sex and in the proportion of young people who say they didn’t go to school because they were worried about their safety. So it improves kind of the safety of the school environment, and particularly in the schools that put the LGBTQ inclusivity policies and practices in place, that’s really where we see the positive impact on mental health and decreases in suicidality for both LGBQ youth and heterosexual youth.

Mills: And the CDC makes these policies and practices available to what? All schools in America, all public schools, public and private? I mean, can any school—if a parent says, “where my kid goes, the school isn’t doing it”—how can they get it implemented?

Ethier: Sure. So we currently fund 28 large urban school districts to put the What Works in Schools program in place. We are very excited that What Works in Schools was included in the budget and brief that was released by the White House yesterday for expansion. So we’re really excited about that. It’s part of the Behavioral Health Transformation Initiative, and we’re just thrilled about that. But we put all of the ways in which we work with schools. So all of the things that we recommend that schools do are available on our website. What Works in Schools program is described on our website. We make our program guidance available to anybody who would like to use it. So that kind of gives you the play by play of all the things that we recommend that you do. And so we’re working on scaling it up because it is so effective in addressing some of the exact things that we’re concerned about in the data that we see, and we’re really excited about the possibility of being able to expand the program.

Mills: Now, what about training teens to help each other? There’s been a lot of reporting on peer to peer interventions that could help teens recognize the signs of depression or suicide in their fellow teens. And I’m just wondering if there’s a place in what you’re doing for these kinds of programs.

Ethier: Yeah, I mean, I really think that that’s a great technique. The division of violence prevention at CDC has some really wonderful bystander intervention programs that they’ve been working on for schools that I think can help support the safety and supportiveness of school environments. I think those are really great kinds of approaches. We are very much working on how to engage young people more in their schools. So we currently have a project about how to help schools set up youth advisory boards. So I think both on the individual level in terms of helping young people recognize what’s going on with their peers and supporting them and helping provide that pathway to important support as well as engaging youth in hearing from them what they need in their schools are all really important approaches.

We just last week had some presentations from young people from a couple of different states who are actually on their state boards of education, and I just thought that was the most wonderful approach. And these young people were incredible. They were so smart and so able to talk about what their schools needed. And so I was imagining what a great resource that they must be for the adults who are on their state boards of education. And I hope that more states decide to do that kind of work, but engaging young people in developing the solutions for the problems that we’re seeing among them, right? They’re telling us they’re in crisis, we should be asking them what they need.

Mills: So for parents of teens who are concerned about what’s happening with their kids right now, what can they do at home to recognize the signs of trouble and get support? And does the CDC have resources that parents could use?

Ethier: So a couple of things. We have a lot of resources on some parenting approaches like parental monitoring, which is really a fancy name for know where your kids are, who they’re with and what they’re doing. And we know that that is really protective for young people. And what we also know about parental monitoring is that it involves parents really being engaged. They’re not going to know where their teens are and what they’re doing and who they’re with unless they are asking the questions and unless young people are telling them. And that requires that they’re be this kind of give and take in trust and relationship building.

The other thing, as we’ve been talking a lot about this data, I think one thing that parents can do, and this starts early, this is not about waiting till your child is a teenager and starting this conversation, but I think parents can be starting with their young children to talk about “how are you feeling?” and giving them language, “I feel happy, I feel sad, I feel angry, I feel frustrated.” And to then engage with, okay, well, so “What should we do about that? What do we do with the happiness? What do we do when you feel sad?” and normalizing that conversation so that you don’t get to the teenage years and need to be trying to figure out how to talk to your teenager about their mental health.

So I would really strongly encourage parents of young children to start those conversations early. I think that we know from kind of what we know about social and emotional learning, teaching children how to manage their emotions, how to negotiate through them, how to understand what they are and work with those emotions is really important and can have really long-term impact. I will say for parents of teenagers, you can make sure that you’re attending to changes in behavior, changes in appetite, changes in sleep patterns, anything that looks different in terms of the way that your teenager is acting. And to start those conversations if you haven’t already.

I think there are great resources across a whole variety of websites. And I would try to find out where services are in your community. I know that’s a huge problem for parents right now is finding services when they need them. So just know that. Talk to your primary care provider, hopefully they will have some ways for you to connect with local sources of services. So there’s a whole kind of array of things you can do. I will say that our research shows that, back to connectedness, that family connectedness, so that sense of bond, that sense of trust, that sense of closeness. Family connectedness has long-term implications for health and wellbeing, not just during adolescence, but well into adulthood. And so in the same way that we see that school connectedness has 20-year impacts on a whole wide variety of outcomes, family connectedness does as well.

So the degree to which young people in seventh through 12th grade said that they felt close to and connected to their family 20 years later, they have better mental health, they are less likely to be a suicidal, they have better physical, they’re less likely to use substances, all of those things. We see that similarly with school connectedness and a lot of what we do in terms of creating safe and supportive school environments is meant to increase school connectedness. Family connectedness is just as important. So it may seem for parents of teenagers that it’s hard to make that connection, but they do want it. They may seem like they’re pushing you away, but they do want to be connected to you. And those connections have long-term impact.

Mills: So keep trying.

Ethier: Keep trying. Just keep it up, keep trying. Easy for me to say, I don’t have kids.

Mills: So last question. What’s next for your division’s research and when will the results of the next youth risk behavior survey be available?

Ethier: So this report is one teeny tiny little piece of all of the data that we have available. And so because I think of the importance of it, we wanted to get it out as quickly as we could and we wanted it to be accessible and while scientifically sound, we wanted people to be able to look at it and read it and take it in. I think that’s happened. So we’re really excited about that. But then we release—there’ll be a set of morbidity and mortality weekly reports that will come out at the end of April that will detail other areas. Some of the same outcomes will be included in some of the reports, but I think that there’s nine papers. There’ll be a big overview paper if you’re interested in the methodology of the YRBS, as well as kind of additional individual papers that look more at the interrelationships between some of these variables.

And then right around that time, we will release all of the data. So both the national data and all of the state and local data will be available on youth online. That is the way that we make that data available. And so that will just open it up for anybody who’s really interested in digging further into the data will be able to do that. We have a number of papers that are in the works from this data, and I encourage anyone who really wants to dig in and look and do their own analysis, we have the way to provide public use data sets to folks who want them, and we’ll be happy to do that. There’s a link to so that you can request those data sets. So for again, all of your data oriented listeners, they’re there. And then we’ll collect—the 2023 survey is currently in the field, so that will be available probably in about a year and a half.

Mills: Okay. All right. Well that’s very interesting. Thanks. We’ll try to put some links in our show notes, especially we have a lot of students who listen and they may be interested in digging in into the numbers. So I want to thank you for joining us, Dr. Ethier. This has been really interesting.

Ethier: Thanks so much.

Mills: You can find previous episodes of Speaking of Psychology on our website at www.speakingofpsychology.org or on Apple, Stitcher, YouTube, or wherever you get your podcasts. And if you like what you’ve heard, please leave us a review. Also, another reminder, we’d like to hear from you about what you think of this podcast and what are the topics you’d like us to explore. So please go to speakingofpsychology.org and look for the link to our listener survey. If you have comments or ideas for future podcasts, you can email us at speakingofpsychology@apa.org. Speaking of Psychology is produced by Lea Winerman. Our sound editor is Chris Condayan.?

Thank you for listening. For the American Psychological Association, I’m Kim Mills.