Raising Parents with Emily Oster - Ep 4: Are We Overmedicating Kids?

Episode Date: October 9, 2024

Kids and teens today are more diagnosed than ever, across the board, whether it’s a disorder like ADHD or a mental health condition like obsessive-compulsive disorder. Say you’re 15 and you’re worried about that upcoming algebra test? Anxiety. You’re 12 and you weren’t invited to that birthday party? Depression. Scared to ride your bike again after that little fall last summer? PTSD. And with these diagnoses come a menu of medications that purport to fix your child.  Today: What’s behind the rise in diagnoses—both for ADHD, mostly among young boys, and for anxiety and depression, mostly among teen girls? Are they really the most distracted, anxious, and depressed generation ever to exist? Or are we, perhaps, pathologizing what used to be considered normal feelings and behaviors—and as a result, diagnosing and overmedicating kids for. . . acting like kids? And what are the long-term effects of having millions of boys on speed and millions of girls on SSRIs? Resources from this episode: Abigail Shrier Bad Therapy: Why the Kids Aren’t Growing Up (Bookshop) Jennifer Wallace Never Enough: When Achievement Culture Becomes Toxic—and What We Can Do About It (Bookshop) Sami Timimi Naughty Boys: Anti-Social Behaviour, ADHD and the Role of Culture (Bookshop) Erica Komisar Being There: Why Prioritizing Motherhood in the First Three Years Matters (Bookshop) If you liked what you heard in this episode, the best way to support us is to go to TheFP.com and become a Free Press subscriber today.

Hi, everyone. Emily here, and you're listening to Raising Parents, my new podcast in partnership with The Free Press, where we interrogate all of the big and pressing and confusing questions facing parents today. Before we get to the show, I'm so excited to tell you that this season is in partnership with Airbnb. If you know anything about me, you know how much I love Airbnb. I think I'm currently holding like six Airbnb reservations in my account. Airbnb has provided incredible experiences for me, my family, and our friends across the country and the world time and time again. More on that and how you too can use Airbnb on your next family trip later in the episode.

For now, on to the show. Let's play a game. Listen to a few experts describe symptoms of a medical condition and see how many describe you or someone you know. Explosive or emotional outbursts. They tend to struggle with tolerating frustration or being sensitive to rejection or criticism. It's really hard for them to concentrate on one show, one activity. But on the flip side, they could also kind of hyper focus or kind of obsess about something as well.

If you're late, you know, sometimes maybe only by 10 minutes, but it's a chronic pattern. Always moving, pacing, fidgeting, can't sit still. You feel like you need to yell just to get through to them or remind them about 50 times in order to get them to do something. If your book bag, your desk, your closet, your drawers, looks like a bomb went off, that's a sign. They might cut in line, grab toys, they don't want to take turns. Bedtimes might be really difficult for you as well.

They might have a sudden burst of energy. They might talk a lot or make noises. So if they aren't talking, they're making noises of some sort. It makes a lot of careless mistakes. Of course, the biggest one is hyperactivity. Do any of these very general symptoms apply to you or to your kids? Because these clips are all describing symptoms of ADHD. And the experts?

They're all from TikTok, where self-diagnosing influencers have garnered millions of views making content just like this. And that's kind of the point. To hear it from these videos, as many kids and teens do every day, you too could be convinced that if you're perpetually late, or you talk a lot, or simply if your mind wanders while trying to read through Tolkien's detailed descriptions of a single tree in The Lord of the Rings for your English class, you too could have attention deficit disorder. And it's not just ADHD. Kids and teens today are more diagnosed than ever across the board. Whether it's medical diagnoses like ADHD or a mental health condition like OCD. Say you're 15 and you're worried about that upcoming algebra test. Anxiety. You're 12 and

you weren't invited to that birthday party? Depressed. Scared to ride your bike again after that fall last summer? PTSD. And with all of these diagnoses come a menu of medications that purport to fix your child. So what's going on? Over the past two decades, ADHD diagnoses in kids 3 to 17 in the U.S. have roughly doubled, with much higher diagnosis rates in boys than girls. At this point, one in nine kids in America are diagnosed with ADHD. ADHD medication shortages have persisted since the peak of the pandemic, even though the DEA has raised production quotas for some drugs, such as Vyvanse, by 24 percent due to the continued high and unpredictable demand. A large share of kids after a diagnosis

will be prescribed medications, typically stimulants, to treat their symptoms. In general, prescriptions of these stimulants, mostly amphetamine-based, have increased by roughly 45% over the last two decades. Between 2016 and 2019, 7.8% of kids ages 3 to 17 have taken a medication for difficulties with emotions, concentration, or behavior over the past 12 months. The global market for ADHD therapeutics is projected to be valued at approximately $25 billion in 2024. Turning to mental health, from 2003 to 2012, the percentage of children aged 6 to 17 diagnosed with anxiety or depression increased from 5.4% to 8.4%. By 2022, anxiety rates among girls rose to 12%. In 2023, about 13% of teens aged 12 to 17 experienced at least one major depressive episode in the past year, up from 8% in 2007. This increase is

particularly notable among teenage girls, who are almost three times as likely as boys to experience depression. Lastly, the telehealth therapy market, encompassing telemedicine and virtual therapy services, was valued at approximately $120 billion in 2023. So today, what's behind the rise in diagnoses, both for ADHD, mostly among young boys, and anxiety and depression, mostly among teen girls? Are they really the most distracted, anxious, depressed generation to ever exist? Or are we perhaps pathologizing what used to be considered normal feelings and behaviors, and as a result, diagnosing and over-medicating kids for acting like kids? And what are the long-term effects of having millions of boys on speed and millions of girls on SSRIs.

I'm Emily Oster, and from the Free Press, this is Raising Parents. Emily Oster, an economist by trade, has gathered the data, crunched the numbers, and is now debunking some of the most controversial myths about parenthood. I think what everyone is most interested in, like pregnant women, they're like, can I drink? You know, you shouldn't have like a lot. Where is this data coming from? The fundamental answer is we get data on people by asking people about their behaviors and what they do and by collecting information on how their kids do. Oster doesn't shy away from other charged topics.

People are using your database as an example as to why schools should reopen. What kind of reaction did you get to that? I imagine that was a little controversial. It was a little controversial, yes. You're an economist. You're not a doctor. I mean, what do you think people are going to take away from what you've written in this book? All that I'm trying to do here is really show women,

here is what the evidence is, and why don't you think about some of these decisions for yourself? Episode four, are we over-medicating kids? Today, I want to talk about the rise in two separate but related phenomenons. The rise in ADD, ADHD diagnoses among children and medications for it, particularly among young boys. And also the rise in mental health diagnoses, anxiety, depression, etc. and medications for those issues, mostly among teen girls. I think the rise we are seeing on both sides are actually connected, which we'll get to at the end. But for clarity, I'm going to separate them out, starting with ADD. And then in the

second half of the episode, we'll get into the mental health diagnoses that are also rising at alarming rates. Our tendency towards pathologizing and seeing a problem in the behavior of children and young people, and particularotherapist based in the UK. He's also the author of several books on children's mental health, including Naughty Boys, Antisocial Behavior, ADHD, and the Role of Culture. A note, I spoke to many doctors and therapists for this episode. The three that you'll hear from, first Dr. Tamimi, then Dr. Carlson, and Erica Komisar, they represent the three broad positions on ADHD medication. Basically, it's okay, probably not okay, and we're definitely overprescribing. It doesn't have much room in our busy lives to let children develop in their kind

of idiosyncratic and often challenging ways that they do. It's almost as if society is looking for an excuse for behaviors that are, in fact, completely typical for kids. One of the things that I've been trying to bring out when I discuss this issue is that the problem with the labels that we've started using is that it assumes that there is some commonality that draws them together so that somebody who's diagnosed with ADHD refers to some particular type of causative agent or at least a syndrome that can be thought of as having similarity so that if you've got a diagnosis with ADHD, it's a particular type of problem for which a particular type of solution will work. Whereas what I'm saying is these are just behaviors,

and they tend to be behaviors that we've become more socially intolerant of. That last point Sammy made is the crux of the ADHD crisis in young kids. For over 200 years, these behaviors we now associate with ADHD, like trouble focusing, not being able to sit still, and fidgeting, they've mostly been linked to kids. In fact, a Scottish doctor in 1798 noted that while these behaviors show up early in life, they often get better with age. And for some, that's true. But for most, ADHD symptoms stick around into adulthood. Pediatricians have built an ADHD model that centers on kids, often driven by parents asking what they can do to deal with their child. We don't know what causes this condition.

We certainly have lots of imaging data these days where kids with ADHD are given tasks to do and people watch how their brain circuits work. This is Dr. Gabrielle Carlson, a child and adolescent psychiatrist and a decorated professor of psychiatry and pediatrics at Stony Brook University. We don't know why there are some kids that have this batch of symptoms as opposed to that batch of symptoms. We don't know exactly what's inherited. There's no genetic testing you can do that says, oh, this child needs blah, blah, blah drug. That's, you know, tea leaf reading. But it would certainly be nice to be able to do that rather than trial and error, rather than looking and saying, well, you look like an Adderall kid, or you look like a Ritalin kid. We don't have ways of being able to detect that in advance.

We certainly know a whole lot more now than we knew even when I was in training, but boy, we've got lots more to learn. Erica Komisar, a psychoanalyst and social worker specializing in parent guidance, agrees with the ambiguity surrounding the definition of ADHD. She's an author of several books on raising children and is also a mother of three. ADHD is a stress disorder. And what do I mean by that? It's not actually a disorder. It's actually a response or a symptom of the brain in a hypervigilant state in reaction to stress.

So instead of as a society thinking about what are we doing to stress out our kids, we medicate them, we silence their pain, because we don't really want to know that we're stressing out our kids, we medicate them. We silence their pain because we don't really want to know that we're stressing at our kids because then it would mean having to make real behavioral and societal changes. So ADHD, depression, anxiety, behavioral issues. Think of it as the response is the fight or flight response. That's an evolutionary response to stress. Either children are becoming excessively aggressive, developing behavioral problems at an early age, that's the fight, or the flight is ADHD, which is distraction is the

flight part of the stress reaction. It's important to note that standardized clinical guidelines for diagnosing ADHD don't exist. Even the CDC has labeled this lack of consistency a public health concern. Despite this inconsistency, over the past two decades, ADHD diagnoses among U.S. children aged 3 to 17 have roughly doubled. And to manage these symptoms, many kids are prescribed stimulants, mainly amphetamines. The prescription of these stimulants has significantly increased over the last 20 years as well. Do you think that medication for ADHD is overprescribed? The short answer is no, but I think if you were to say not overprescribed, but appropriately prescribed, that's probably a different question.

Dr. Gabrielle Carlson again. By the time, and this is not a good reflection on our mental health system, but by the time you get in to see a child psychiatrist these days, chances are you've got something fairly significant going on. And in my experience, one of the things that I see are kids who have not been appropriately prescribed medication. And in fact, you know, there are a lot of data that the famous multimodal treatment of ADHD study that went on between the late 90s and early 2000s. One of the take-home messages of that study was that kids in the community get medication kind of thrown at them. Here's your five milligrams of Ritalin, come back in six

months. And the chances are they didn't take it. Okay. It wasn't that they dutifully took it for six months and came back, you know, okay, can I have some more? What kind of a treatment is that? So lots of times what I will see are people who didn't get the kind of follow-up that they needed to have to find out if it was the right medication, the right dose, the right frequency, right preparation, et cetera, et cetera. So there are some side effects people will cite for the long-term use of these drugs. I'm just going to list them, and I want you to tell me what you think. Heart disease, high blood pressure, seizures, irregular heartbeat, skin discoloration, abuse, and addiction. Do we think that the data supports

that? It's just not good data. I think the data don't support most of those things. The addiction business, there's no data that says that people who've had treated ADHD and have been on stimulants are worse drug abusers. In my opinion, medication is a bridge. Think of it as a bridge. But the bridge is until the talk therapy or play therapy or family therapy can take hold. And then you wean them off the medication. It's meant just to be a short-term bridge. Erica Komisar again. We're using medication as a long-term fix. We're not getting to the origin of the stress. And that's, you know, we've become a very drug-oriented society. You know, kids are being medicated for ADHD and depression and anxiety. Oh God, it's such early ages. I've seen many families over the years

who've got hooked up with the idea that medication was meant to be the thing that would help them. Say me to Mimi again. And teachers may have got to the point where they think the child's behavior is all dependent on medication and they've stopped looking at things that they might be doing or particular difficulties. You might end up missing things that are going on from their history that are important. And you might have overlooked various approaches of all sorts to do with their social world, to do with parents who split up and to do with how parents are communicating, to do with history of domestic violence.

I've seen a whole variety of things that kind of go missing when we focus on an idea that these behaviors that they're presenting is one, they should be considered a problem. You know, if you look at the symptom list for things like ADHD, show me a kid, particularly a boy who doesn't show some of those, at least some of the time. So I tend to think these days that what we call psychiatric diagnoses like ADHD, they're actually not diagnoses. They are commercial brands. And the successful brands in terms of making money out of people's worries, the successful brands in psychology tend to be the behavior of children, which is mainly boys. I know that I'm on solid ground when I say these are not scientific concepts.

ADHD is not a medical condition. It is a description. It tells you nothing about the cause. It is a description, which is vague, easy to change, easy to manipulate, of behaviors that are fairly common. And there's also been big changes in the way we think about what it means to be, and I prefer to use the word ordinary rather than normal, what it means to be an ordinary child. So there has been a shift in our culture towards thinking more about how vulnerable children are. So starting from the point of view that growing up is an experience with a lot of vulnerabilities and risks and this has led to a number of things. One of the things that's often referred to is the concept that domestication of childhood.

So children have much more of their activities that are get as no longer just in the realm of the ordinary, but as having the potential to be part of some sort of problem, psychological or psychiatric problem. So we've never had a generation of young people who have been as labeled with psychiatric labels and as pathologized as having potentially something wrong in them as this generation. I love that phrase, domestication of childhood, as we expect a sort of certain set of things that kids are going to do that are organized by adults, it leaves maybe less room for heterogeneity, the differences that would happen if we were all just kids were running around a forest and not being watched. Our concept of what we think of as ordinary in terms of childhood experiences has got narrower and narrower. But at the same time, our concept of what we imagine what parents should do has got narrower and narrower. So we're much more likely to look towards what we consider to be expert opinions

to help us figure out whether what's going on is ordinary. So we've had a whole growth of professionalized approaches to parenting and to dealing with what are perceived to be problems in the children. And so those are very connected because then this creates a whole ecosystem, an economic ecosystem of professionals, of assessments, of diagnoses, of guidance, of books, of courses, and so on. Well, at least he didn't mention podcasts. But when you're faced with this problem as a parent, who are you supposed to turn to for support, if not an expert opinion? Aren't teachers and school psychologists supposed to lay out all

these options that could help parents in these tough situations? We heard from one parent about her young son's experience with this in a private school. Sometime around second grade, we started to have conversations with teachers, reaching out and mentioning a few things here and there. We just noticed that your son is kind of daydreaming a lot. He's looking out the window. He's having a hard time keeping up with this task. Just a lot of examples that I was very familiar with, but never attributed to anything like ADD or ADHD.

One of the teachers actually told me, like, have you checked his hearing? I don't think he can hear me. And I'm like, no, we checked his hearing. It's fine. And then just a few suggestions here and there and we kind of dismissed it. And we politely said, thanks for all the recommendations and we've noticed and moved on

because we didn't really want to engage further. The conversation shifted to them using language like, we don't think he's capable of doing this. And they started to use some of the medical terminology and kind of like making him very much of a victim. And then last year when he was in third grade is when we officially started to have conversations from administration and school psychologists got involved. And a speech pathologist who started to make official recommendations. You should get your kid tested. Now, mind you, it all kind of, I don't know if because I'm very involved in the school and I'm a very headstrong parent that they were very careful about the way they approached this.

But first they said, well, I think your son could benefit from working with a speech pathologist. So I said, great, that's fine. You can work together. She did a 40-minute evaluation on him. And after that, she wrote to me saying, I think your son is struggling with attention. Here are some of the questions that I've asked him. And here are some of the answers. And then sent a long list of recommendations for physicians for us to contact the psychologist, the therapist, the neurologist to see if he can get an official evaluation, which we politely declined and said,

no, thank you. And then we had a school psychologist who, without our permission, ended up observing him in class and send us another email shortly after saying, just if you need additional recommendation, I did observe your son and we noticed that he was off task. So we got a little bit frustrated. My approach has always been, you know, at first I was like, thank you so much for your suggestion. We'll think about it and kind of let it go because I didn't want to engage further. My husband and I both decide this is the best way to go about it. But then when it started to come from multiple sides, we kind of had to put our foot down and we finally said, we wish not to discuss,

not have any more conversations around further evaluations or testing on any of that. What we want to talk about instead is what strategies have each teacher and support person has used in order to work with him on whatever challenges he's had in the classroom. And that's the only thing we want to talk about. And, you know, the frustration was, why didn't we talk about that first? And then this will be the last step instead of after 15 minute or 45 minute observation, you send me a list of professionals to do an official diagnosis. My son is definitely a boy's boy. He, just like a lot of other boys,

he's doing fine because we're very engaged as a family. And, you know, I think he just gets different, slightly different messaging at home than he does at school. And that is, you know, look, I know it's hard for you to sit down and do this for an extended period of time, but you have to work twice as hard, twice as much just to accomplish this task. And that's just what it is. He definitely has the tensities of being distracted and looking around and daydreaming. He is that kid. And I was fine with that. Like, I just accept him as is, and we accommodate and work with it. And we're very strong and consistent. And he thrives in an environment where there's high expectations,

very clear expectations, and he's held accountable for any misbehavior. And he does really well with that. When I hear that story, I understand why this mom is upset. It's hard enough as a parent to make sure you're advocating for your kid in school and communicating with their teachers when everything is going well. To feel like a diagnosis is being pushed on your child before trying other strategies to help is incredibly frustrating. It's also clear to me listening to this story that many parents probably wouldn't have pushed back. This is a mom who is pretty headstrong, as she describes herself. But parents do have a crucial role here in figuring out what's going on with their children,

which is why we need parents to understand the evidence. While boys are being diagnosed with ADHD at alarming rates, girls in America are being diagnosed with something different, anxiety and depression. After the break, we'll discuss what's ailing our girls and what we as parents should be aware of before rushing to a diagnosis. We'll be right back. This show is supported by Airbnb. Every year, I meet a group of friends for a weekend to reconnect. Over time, the group has grown.

More spouses, more children. But we still want to stay in a single house so that we can make the most of our time together. Enter Airbnb. Every year, we've managed to find a new hidden gem through Airbnb. And best of all, we can specify ones with a crib. So whoever has a baby can travel a little later. It's not just when traveling that Airbnb has come in handy. Recently, my in-laws wanted to come visit us for a few weeks.

We were thrilled. We were also delighted to find them an Airbnb literally down the street. That way we could have family time and family harmony too. Because sometimes you just need a little more space. And here's the really cool thing. Your home could also become an Airbnb. Maybe you even have an in-law suite that isn't being used that often. You could Airbnb the extra space and make some extra money.

To learn more about how you can become a host on Airbnb, go to Airbnb.com slash host. Again, thanks so much to Airbnb for supporting Raising Parents. And now, back to the show. Like ADHD, anxiety and depression have seen a significant rise in diagnosis over the past two decades. Specifically, anxiety diagnoses have increased by around 27%, while depression diagnoses have risen by about 24% in recent years. Of those percentages, the overwhelming share is girls. A large share of those girls after their diagnosis

will be prescribed medications or therapy, in some cases both. From 2016 to 2022, the monthly antidepressant med dispensing rate increased by 66%. In some ways, and for some people, these diagnoses are a remarkable value for their kids by naming the issues. People are able to get treatment that helps their girls, have them be less depressed and less anxious, and improves the experience of parenting, as well as the experience for kids. On the other side, we're talking about treatments that may exist for a lifetime. There are people who say that therapy and medications are grossly overused, and the side effects are not nearly researched enough.

What happens when you put a 13-year-old girl on SSRIs? When is it appropriate to rely on pharmaceuticals for an 11-year-old? Are we altering the course of these kids' lives without sufficient evidence? A quick note. When examining the root cause of many mental health issues, factors like poverty, acute childhood trauma, and sexual abuse are critical. These issues significantly contribute to serious mental health problems, and they are more prevalent among economically disadvantaged individuals. This is an important aspect of the mental health crisis,

but it's not the focus of today's discussion. Today, we're talking about the fairly recent changes in mental health among kids who don't fit this acute childhood trauma. Dr. Gabrielle Carlson again. Can you talk a little bit about childhood depression and how that would be recognized? I was fondly taught as garlic symptoms and onion symptoms. Garlic symptoms are externalizing disorders. They are what bothers everybody else. So ADHD is kind of a garlic disorder. Being oppositional is a garlic disorder.

Onion disorders are what bother you. They don't feel good. And anxiety and depression are the two most common ones. They are very similar. They're not quite joined at the hip, but they're fairly similar. One of the major differences is that anxiety is one of those things where it's, at a certain point, normative. Kids don't want to be separated from their parents. They're shy. They don't want to go to the birthday party if they don't know anybody. So anxiety has a sort of a normative component to it. Depression is also a dimension. The dimension with depression isn't whether you're always depressed or not, but there are things that are depressing. And so if you respond to something that happens that's

bad or unfortunate or whatever, and you feel bad, that's a normal response. So then the question is, well, when does it become depression? And it becomes depression again when it's impairing, when it's not just in certain circumstances. And there's probably a couple of other dimensions that come along with it, which has to do with guilt and blaming yourself for stuff and seeing everything through what I call poop-colored glasses. When we talk about anxiety and depression, are we talking more girls, more boys, older kids, younger kids? Well, I think it's different answers for different things.

Anxiety is probably the most common psychiatric disorder in kids. There are a lot of different anxieties. Depression, the rates are lower in kids. By the time you get to adolescence, in fact, across the span of adolescence, the rates go up. So by the time you're at the end of adolescence, you basically have adult rates. And more common in girls than boys. Research shows that women and girls are more likely to internalize mental

health struggles, leading to anxiety and depression, while men and boys tend to express their distress outwardly through behaviors like aggression or impulsivity. Women often suppress emotions, resulting in withdrawal, while men are more likely to act out their frustrations. This might be one explanation as to why women and girls are disproportionately diagnosed with mental health conditions like anxiety as compared with boys and men. Our producer Tamar talked to one mom about her 15-year-old daughter's ongoing experience treating depression and anxiety and noted how it's a lot like building the parachute as you're falling. Does mental health seem like something that gets talked about a lot by teens today? In my experience, yeah. I mean, I feel like there's at least the kids that I'm around,

it feels like with one another, they're kind of like, oh, that's what you're dealing with? This is what I'm dealing with. You know. And I think in a way, that's a really good thing. I think also they are actively diagnosing each other all the time and treating each other. You know, like we adults are accused of Googling everything, you know, and listening to that over our doctors. And I think the kids are taking care of each other in really good and also unhelpful ways. I think it puts a lot of pressure on each other. And yet they see the gaps in what their parents know and understand and also how sort of slow and not always helpful the medical system is, even though I believe in it, in theory.

What kinds of symptoms were you seeing? I would say when she was younger, I had been a little bit more worried about her being down. But she hit freshman year of high school. And so she actually came to us. She basically said she needed help. And it was her friends who they basically reported her to the counselor at school because they were worried about her. And then the school called us in and she shared a little bit. But really, one of the main things she shared was that she has a hard time talking to us, but she wanted to feel better and wanted to find someone to talk to. And so we started that process, which ended up with her diagnosis, which may not be the forever correct diagnosis, but they really felt like

even though she presented with concerns around depression, that it was anxiety that was sort of depression related to unmanaged anxiety. We were caught kind of flat footed in a way by it, partly because of my daughter's age. I found out 14 is the age, at least in the state I'm in, I don't know if it's a federal or state thing, where I don't automatically have access to my daughter's health information. Like she has to sign my right to have access to medical records and things like that in a way that I hadn't been aware of. And she has been happy to do that. But when you have a 14 year old, a 15 year old, the conversations with their doctors are different than when your kids are three or four. They share a lot, but your 14-year-old's therapist doesn't tell you every detail. The thing that feels the most frustrating to me is it feels

like there's just a lot of disconnects. There's a psychiatrist who can prescribe who doesn't really know her very well. And then there's a counselor. And then it's been very frustrating to figure out how to give that person access to her medical records from her initial diagnosis. And I think depending on what she brings to the conversation, I think she's getting less of the strategy stuff now than I had thought she was. I think in her initial treatment, she was getting less of the strategy stuff now than I had thought she was. I think in her initial treatment, she was getting more of that. I think what she's getting now is a little bit more.

How are you feeling? What are you thinking about? I don't think you can just learn strategies and expect to be able to like suddenly do these things if trauma and pain, you know, and all these things aren't being addressed. But I'm not as confident that there are a lot of ways where we know how to address anxiety and depression. It feels like we're still really, really, really, really figuring it out. I'm open to medicine, but also the field of medicine. But there just aren't as many answers as we'd like to think. I think the hope as a parent is,

okay, we've identified this. And it's not the same as being, okay, we identified a bone break, and we took it to the expert, and it's being fixed now. It feels much, much, much more nebulous than that. We're like building the parachute as we're falling. I'm really glad that she came to us. And I'm really glad that we have a team in place for her. But I think one of the things that she's struggling with now is, oh, okay, well, I did the big thing. I told somebody how I was feeling. Like I asked for help and huh, like I was still struggling with these things. For me as a parent, that's trying to guide and support a kid with anxiety that caused depression that needed to be intervened with and stuff. I'm just not sure we have the pieces in place. And that's hard.

Very generally, what are you seeing happening to kids in this generation, in the current coming up generation? Where do you think the problems are stemming from? I think the problems are stemming from multiple sources. I wish it was just one. This is Jennifer Wallace. She's a journalist and the author of Never Enough, When Achievement Culture Becomes Toxic and What We Can Do About It. She's also the parent of three teenagers. But I believe that there is this excessive pressure to achieve,

that the expectations are rising, causing high levels of perfectionism in young people. These are socially prescribed expectations. I also think there are issues of almost like an existential crisis happening, that this Gen Z is really the first generation to be raised primarily without religion. And young people, young adults, really, it's developmental that they grapple with, why am I here? What is my purpose? But we don't really offer kids a place to grapple with those real big life questions that are developmentally appropriate. You know, they're achieving, but they don't know what they're achieving for.

And then you add on things like social media, which I believe is not the root of it. I believe it is an accelerant. I think it is a magnifier of issues that young people are feeling in real life. So if you have a young adult that's struggling with feeling like they're never enough, struggling with social comparison, struggling with feelings of envy that they don't have the tools to manage and regulate, that you could be pretty assured that they're turning to social media and using it in ways that are not beneficial to themselves. I want to dive into many of those pieces. Let's start with this idea of toxic achievement culture. When I say achievement culture, what is that and why is it a problem? You know, when I was growing up in the 70s and early 80s, achievement mattered. My parents wanted me to be successful.

They wanted me to do well in school and do well in my sports. But it didn't define my childhood the way it is doing to so many young people today. So when I was growing up in the 70s and early 80s, life was generally more affordable. Housing, health care, higher education was more affordable. There was more slack in the system. So a student like me could, you know, their parents could be assured that even with some setbacks, even with a B minus in AP calculus, which I got senior year, that most likely I'd be able to replicate my own childhood as an adult,

if not do even better than my own parents did. That's the American dream, to not only do as well as your parents, but to do better. But we are seeing the first generation, the millennials, who are not doing as well on average as their parents. And we are feeling this steep competition that's been ushered in with globalization. I think that parents today are contenting with forces that are bigger than any one family, any one school, any one community, and young people are feeling it, and they are feeling the pressure. Can you paint a little bit more of a picture about what the effects of that culture are

at the level of kids? I surveyed 6,500 parents, and I also surveyed 500 young adults ages 18 to 30. And I wanted to find out what they felt around achievement and their value growing up. I have yet to meet a parent that does not love their child unconditionally, either their adolescent, their young child, or they're an adult child. But our children often don't feel our love as unconditional. They very much feel it, from what I heard in my interviews, as conditional. So of the 500 young adults I surveyed, more than 70% reported that they thought their parents, quote, valued and appreciated them more when they

were successful in work and in school. More than 50 percent went so far as to say they thought their parents loved them more when they were successful, with 25 percent of students saying they believed this a lot. One in four of the students in my survey believed that achievement, not who they are as people, is what mattered most to their parents. This is not to blame parents. Modern parents today, the parents of the population you're talking about, the parents of even younger kids today, parents are parenting in extraordinary circumstances. When we talk about the helicoptering and the intensive parenting, what we are really talking about are parents who feel like they have to weave individualized safety nets for each one of their children. Modern parents

today are feeling fewer and fewer guarantees. And so parents are absorbing these macroeconomic, macro social pressures and sensing that there is no safety net in our country and that they have to be the safety net for their kids. And then you talk about the impact on mental health, that that pressure coming out of parents into their kids, as well-meaning as it may be, then has some impacts on their mental health. Can you draw that through line a bit? Yeah. So in 2019, I wrote an article for the Washington Post that was covering two national policy reports that were naming who were the kids who are most at risk for negative health outcomes. They named children living in poverty, kids with incarcerated parents, children of recent

immigrants, children living in foster care, and then a new at-risk group was named, children attending what the researchers were calling high-achieving schools. Those are public and private schools around the country where the kids go on to competitive four-year colleges. These are generally well-resourced schools. And these kids, the researchers were finding, were two to six times more likely to suffer from clinical levels of anxiety and depression and two to three times more likely to suffer from substance abuse disorder than the average American teen.

The psychologists that were writing this report estimated that as many as one in three teens are at risk because of this, what they call an excessive pressure to achieve. Jennifer's pressure to achieve theory is one. Another explanation is that these very wealthy and resourced kids have access to therapists to diagnose them and parents who take even small mental health hiccups very seriously. The mental health industry has absolutely made a lot of hay out of it and made a lot of money off of it too. We're talking kids into trauma over everything and who is benefiting, the treatment providers. And unfortunately, we're creating, I believe, a generation of basically hypochondriacs.

This is journalist Abigail Schreier, the author of Bad Therapy, Why the Kids Aren't Growing Up. Abigail takes a more critical perspective on the rise in anxiety, depression, and other mental health issues affecting young people today. Which doesn't mean they're not in distress. It means that they are applying hyper-focus to the natural emotional hurts we all feel. And they're creating an organizing principle of life around it until they become sort of trapped in their emotional state. They're tyrannized by their feelings and they're tyrannizing each other. So your book is called Bad Therapy, Why the Kids Aren't Growing Up. Can you give me just an overview of why are they not growing up? So the kids who are awash in therapy, which this generation is through schools

with the wellness techniques and the social emotional learning, through their parents who are practicing all these therapeutic techniques from actual therapists. These kids who are awash in therapy have internalized the message. And the message is this, you have some form of disability. You have mental illness of some sort, even the ones who don't. You are not up to the challenges of life. You're not strong enough to bear them. And therefore they're opting out. They are basically taking a sick day off of life. You're not strong enough to bear them. And therefore they're opting out. They are basically taking a sick day off of adulthood. They are not showing up for work on time. They are not working hard at their jobs. They're not striving. They're not taking risks in relationship and asking someone out or trying to form a new friendship. They are absenting themselves from all the

wonderful challenges of adulthood that will ultimately bring them the most pleasure and satisfaction in life. And here's the worst part. The risks you take to become an adult, that's the cure for most adolescent angst. So they need to be able to know they can take those risks. They will overcome a little bit of hurt. We need to tell

them that. We need to believe in them. One of the things you talk about is the idea that less than half of Gen Zers believe that their mental health is good. I find that very surprising. It's upsetting because it means that they're so laser focused on the mental health. They've so bought into the idea that my mental health is something that I need constant tending and upkeeping of, whereas it's not true. Unless you have a mental health problem, like a disorder, like a real, you know, something really interfering with your ability to function in life and thrive, unless you have that, mental health is best achieved by leading a great life, which doesn't mean no distress. It doesn't mean no disappointment and no challenge and no failure.

No, it means surrounding yourself with loved ones, relationships that have meaning in the world, not these so-called online communities, which is no community at all, but real, real community in the world, a sense of efficacy, doing things for others, exercise, eating well, getting sleep, all the things that we know, building community, just doing for others, all these things we know makes for a happy life. Today, publicly admitting a mental health diagnosis is often praised, glorified even. Dude, guess what I was diagnosed with today what maladaptive daydreaming disorder this goes out to all my bipolar baddies

you're real you're valid you're not dangerous you're not crazy i am so ad. Never thought of me. Keep you on your toes. I feel like people overestimate narcissists like me a lot. Hey, mental health warriors. How you doing today? I wanted to tell you that if no one tells you today, I'm proud of you. Always changing. I'm an unpredictable baby. Don't think, just do it.

I'm a surprise party daily. So I asked Abigail to explain the potential downsides of this, especially when it comes to over-labeling or over-diagnosing every quirk in a child's developing personality. They think it's the most important thing about them. If a child needs it, then of course you have to give a kid a diagnosis. If they have anorexia, gosh, you need to identify that problem. Absolutely. And you need to involve a mental health professional.

But if they don't need it, if they might just be a little to one side of this wonderful bell curve of humanity, right? This wonderful human variation that we have, which honestly is an asset for any society. You don't go around diagnosing a kid because he may come to think, as the rising generation does, I'm going to put that in my social media profile because it's the most important thing about me. And also it limits me. So when did this adolescent mental health decline start? So I think most people date it to around the 1950s, where we started to see a very sharp rise in adolescent suicide. Between 1950 and 1988, the percentage of adolescent suicide quadrupled. But it's been in steady decline, and I do believe certain things have made it worse. So I do think, you know, social media has absolutely played a big role in making a lot of things worse. I think the lockdowns were terrible for kids,

forced isolation. So I think a lot of things in kids' environment, in their lives, their lives have gotten worse. Being away from family, they don't live around grandparents anymore. So a lot of the conditions of their lives haven't been as good. I mean, I have such a hard time with these time trends, Abigail, because we sort of think about trying to attribute that decline, which is quite real in the time trend, to anything in particular. You know, causality is so hard. And you draw on sort of therapy as something you think has a potentially causal component. And I'm curious, how do you think about developing that causality, even in your mind, when what we have is, you know has a potentially causal component. And I'm curious, how do you think about developing that causality,

even in your mind when what we have is, you know, a time trend? So why do I think that it's no accident that the mental health interventions, that the most showered in mental health intervention, the rising generation, the most diagnosed, the most therapized, you know, the kids who've gotten the most therapy and the most diagnosis, most psychiatric medication? Why do I think it's no accident that they have the worst mental health? Why do I think there's actually a causal arrow? A few reasons. First of all, their problems are precisely what the psychological research predicts are the known iatrogenic harms of therapy. So there is this

body of research. It shows what are the typical harms? What are the most common harms, risks of therapy? And of course, let me say again, if you need the therapy, it's worth the risk. Just like if you need the surgery, it's worth the risk. But if you don't need it, what are the harms that you would expect to see? You would expect to see more anxiety, more depression, more external locus of control, meaning more sense that they don't have efficacy in their lives. They don't have the power to improve their own lives. You would see more alienation from parents. You would see exactly what we're seeing, more demoralization about their mental illness or their diagnosis, exactly what we're seeing in this generation. But there's something else too. I think it's very significant that when you ask them what's wrong, you can answer that question a lot of ways. You know, how are you feeling? They always answer in the language of

psychopathology. They just see each other and themselves through the lens of therapy. That's no accident. We put these glasses on them and that's how they see the world. So they don't see the world in terms of disappointment. They see it in terms of trauma. And that seems to be playing an outsized role in their own minds for what's going on. It's not one size fits all. Most adolescents come into therapy with me and they want to talk.

They want to talk about their feelings. They want to talk about the relationship with their parents. So there's different kinds of therapy for different strokes for different folks. Erica Komisar again. No child should be medicated without being in talk therapy or play therapy. And having said that, we're over-medicating our children. And it's very distressing to me as a therapist because when I start to treat an adolescent

or a child or a family, within a very short period of time of understanding the organic nature of the origins of a problem, they should come to this play-based therapy. And then we sort of figure out, you know, how much is what your parents are doing, how much is, and then we kind of sort that out. So medication is unnecessary. Unless a child is suicidal. So first of all, let me say to everybody listening to you right now, if a child is suicidal, if your child is thinking about how they'll do it, you rush them to the emergency room. That's what emergency rooms are for. Don't even hesitate. Otherwise, you want to find a really good talk therapist. Sometimes we put them on antidepressants, but again, think bridge. Think bridge. It should be a bridge. It shouldn't be a long-term fix. So I'm a psychiatrist and a

psychotherapist. So I can look at things from those different perspectives, you know, from the medical as well as the psychological. Sammy to Mimi again. And what I have come to the conclusion is one of the most overlooked drivers of what we're thinking of these days as a kind of epidemic of mental health problems, of an epidemic of behavior problems, and so on, might actually be our professions. I'm sure you've experienced times of insomnia. All of us have. If you've been struggling with insomnia for a while, after a while, the thing that keeps you up at night is the fact that you can't sleep. So it's actually noticing this problem that feeds into the problem itself. Either it improves but comes back again or it doesn't improve. It convinces you even further that this is a serious problem, more serious than I first thought. And the further you go down that route and then, you know, you read an article about how important sleep is, which makes it even worse to feel about.

Oh, my God, this is really serious. It's going to shorten my life. I could die. You could die from lack of sleep. Yes. Exactly. All of these things. So the further you go down that route, the further away you've got from the idea that insomnia is an ordinary experience that all of us have. And the more desperate you become. They need to be told you're fine. You'll live. Remember we used to say that to kids? You'll live. Now, of course, there's the problem. What if the kid is really sick? Or what if they have a real problem? Have I accidentally sent a kid with a

fever to school? Yes, I have. It feels terrible. Okay? It's horrible. You beat yourself up. But there has to be some triage because right now we're doing the opposite. We're so affirming every minor injury, we're making them hop into a wheelchair and their muscles are atrophying. They're emotional muscles. And so I think we absolutely need to do the reverse. And the way to do that is before you do any accommodation for your kid, any mental health intervention, any sort of letting your kid off the hook, you need to ask yourself this, will this make my child stronger? Because a strong kid is a happy kid. Erica Komisar has a very different idea of what makes a resilient kid. If we think about where resilience comes from, you have to have a base of attachment security to have a foundation to cope with adversity in the future.

So we know that attachment security long term is the foundation for future resilience to stress because that's what resilience means, right? It means resilience to stress and adversity. So zero to three is a very important period where your presence physically and emotionally as much as possible lays down the foundation. Children are born not resilient, which is what we tell mothers they are. They're born neurologically fragile and emotionally fragile and in need of a sense of security and safety from the moment they're born. And mothers have a great deal to do with providing that sense of safety and security and trust in the environment that is necessary for future mental health. What are the primary outcomes that you think of as being influenced by this emotional availability?

Well, the primary outcomes are, we think of mothers providing a few things biologically to children. Stress regulation, stress buffering, emotional regulation, these are things that if we don't take care of business in the first three years, the consequences are great. Children are developing disorders of emotional regulation or stress disorders. Depression and anxiety are disorders of emotional regulation where children and then later adults can't regulate their emotions or keep them from going

too high or too low, right? So that's why we have anxiety is excessive fear. Depression is excessive distress and sadness. Basically, children aren't able to regulate their emotions. And so the claim is that if there's not an emotionally available caregiver in the first three years, that that causes ADHD and depression and anxiety, and that we see that in the data somehow. Yeah. So we see attachment disorders. So if you do not develop secure attachment in the first three years, the longitudinal studies say that 80% of kids 20 years later will still have attachment disorders. And those attachment disorders then correlate with all kinds of mental illness and stress disorders. So I work full time. I have since my kids were born, basically. Part of my

pushback here is my read of the data, I think is quite different from yours. And I think part of my pushback is it feels like you're saying that I messed up my kids or that the choice to work is something that makes you a bad parent. No. Now, you may not be the primary attachment figure. Maybe your husband. I don't know. It might be your mother. The primary attachment figure is the person who soothes the baby when they're in distress from moment to moment throughout the day and is soothing the baby when they're in distress the majority of the time. That's the primary attachment figure. To surface my personal feelings on this matter, I disagree with Erica's interpretation of

the data. I tried to get into a debate about the studies with her, but she wasn't excited to talk details. But in my work, I've spent a lot of time analyzing this data, and I strongly believe that both parents choosing to work does not harm your children. My view is that the weight of the evidence suggests the net effect of working on childhood development are small or zero. Depending on your household configuration, these effects could be a little positive or a little negative, but this isn't the decision

that's going to make or break your child's future success, if there's any decision that would at all. I want to be clear. There is data showing that adverse experiences for children between the ages of zero to three do matter. Kids need a stable place to live, enough to eat, people who love them and provide consistent support. And when kids don't have this when they're young, they suffer. But there are a lot of ways to deliver those needs, including stay-at-home parents, working parents, child care centers, nannies, grandparents, and more. My personal experience shouldn't matter for others, but for what it's worth, as I told Erica, I worked from when my children were very small. We had a nanny when the kids were little, and they were in group child care when they

got a bit older. My own parents had me in a home-based child care center from a kids were little, and they were in group child care when they got a bit older. My own parents had me in a home-based child care center from a few weeks old, and Tanta, as I called her, was a formative part of my early life. I will fully admit that this conversation with Erica made me feel a bit judged, especially when she told me I could only partly make up my parenting errors now that my kids are older. But I went back and read the data, and I felt better. Here's Sammy to Mimi again. Can I ask you, do you ever tell parents, listen, your kid's fine. The problem is you. I mean, I assume you would say it in a nicer way than that.

No, I wouldn't. I wouldn't say that because I don't think that is the issue. The thing that I find with all parents, you're going to worry you're being too harsh or you're being too soft or you should have done this or you should do that or you should try this or you shouldn't have tried that. So I see it from the other way around. I see a lot of this as being driven by an idea that it's almost like we're all under a kind of performance-related microscope. Our kids are under some sort of performance-related microscope from very early on in their life, but then so are the parents. You're battling that constant sense of being judged. And this is where sometimes it appears like a diagnosis helps you out as a parent, because you go from feeling like you're a failed parent being judged

for your child's outrageous behavior or whatever it's perceived to be, to actually being almost a heroic parent struggling with a child with a disability of some sort, with a condition of some sort. So there is a perception actually, which is a totally understandable one, that that might help take away some of that awful guilt that parents feel. What's the downside then? Once you go down a tunneled pathway, not only are you creating a potential identity that might follow that young person for life, that might limit what you see, might limit, for example, your ability to see their strengths, their abilities, things that make them great. But also the child will start to internalize an idea that there's something in them.

So where does this leave us? We know that the boys and girls are not all right for different reasons. Boys are being told that their inability to sit still during math or focus on the 17th powerpoint slide during science class, often before they're even developmentally ready to be sitting still for that long, is a medical problem. And they're being prescribed basically speed to fix it. Meanwhile, girls are being told that a bit of sadness could be a condition called depression, and feeling nervous might be clinical anxiety.

And they're being offered all kinds of antidepressants, mostly SSRIs, to fix it. But maybe, as Sammy Tamimi says, the problem isn't them. The problem's us. I don't mean parents. I mean a culture that's telling us our kids are sick when they're not. Yes, it's possible that diagnoses have increased because there are more kids today with ADHD and depression than there were 30 years ago. But the more likely reason is that there has been a change in diagnosis. This doesn't necessarily mean over-diagnosis.

Greater awareness could lead to more diagnosis because a condition was previously under-diagnosed. But over-diagnosis is definitely a possible explanation here too. We need more data and studies over time to come to a definitive answer. There is nothing harder in parenting than being told there is something of concern with our child. A health concern, a developmental concern, a socio-emotional concern, and of course our natural inclination is to fix it. We know what to do when our kids are sick with the flu, but these are not normal childhood illnesses and the fixing it part doesn't exactly have a script. And unfortunately, there

isn't an obvious data-oriented path. Instead, the right path requires a thoughtful, probably slow approach to figuring out what works for your family. It shouldn't always involve medication. Advocate for your kid, stand up for them, trust your gut. Finally, as parents, we need to be comfortable with our kids being uncomfortable sometimes. Whether it's because they're distracted and fidgety and need help staying on task, or whether they're nervous about the first day of school tomorrow, or afraid of the dark. Those are normal feelings and experiences. It is hard to see your kid struggling. In fact, it's probably the hardest thing as a parent. When you see your kids struggle, your first instinct is, I must end their pain. But that is not always what's best for them. And in fact, that challenge they're going through,

that's going to make them a whole lot stronger. There is one thing I can predict about your child, and I can predict that with certainty. And that one thing is that they will change. I just don't know in what way they will change, but I can tell you in five, ten years' time, their interests will be different. Possibly some of their friendships will be different the music they like their body would have changed the things that make them feel good would have changed

the things that they hate would have changed etc etc but you've got to give that an opportunity to happen for that to happen if you fix a child too early in their life you're limiting the possibilities for them discovering the only thing I can advise to parents is stand up for your own rights and for the rights of your children not to be labeled sometimes it is just about sticking with it, muddling through, and believing your kids will find a way through. And they do. When we do that, they do. Thanks for listening. Raising Parents is a production in partnership with The Free Press. It was produced by Liz Smith and Sabine Jansen. Thanks to producer Tamar Avishai. The executive producer is Candace Kahn.

Last, thanks to my guests today, Sammy Tamimi, Gabrielle Carlson, Erica Komisar, Jennifer Wallace, and Abigail Schreier. I'm Emily Oster. See you next time on Raising Parents.