It’s been a few weeks, or months, or years, since your teenager began treatment with an SSRI, and she can’t–or won’t—describe what difference she senses, if any. She still feels debilitating anxiety at times, or has tough days when obsessive thoughts dog her. Yet you believe she’s better. Isn’t she? How does a parent evaluate from the outside looking in? This post shares my own experience, as well as perspectives from a couple of clinicians with expertise in treating adolescents.
Our eighteen-year-old, Grace, began taking an SSRI (Fluoxetine) for her unmanageable anxiety the summer after she graduated from high school, two months before she would leave for college across the country. She’d been in treatment for ten months, and she and her therapist hoped medication would alleviate an increasing tendency towards panic attacks. Summer was the ideal time to introduce and monitor a medication: Grace would have two months to relax at home, running a small dog-sitting business that she loved, with time for knitting, singing, and hanging out with friends. Initially, her dad and I had reservations –- had we really exhausted all the other avenues for helping her feel calmer and less stressed…meditation, yoga, managing allergies? We didn’t like giving her the message at such a young age: you need a drug to cope with being you. But she insisted; her therapist agreed; we supported them both. If a medication might give Grace the breathing room to develop skill in dealing with her anxiety, it was worth a try.
Several weeks into the process of tapering her onto the SSRI, we had an experience that her dad and I felt demonstrated it was having a positive effect: It was a sweltering 4th of July, and we decided to walk our two dogs, along with Grace and the two golden doodles she was pet sitting, about a mile up the road to the old-fashioned parade that’s a tradition in our tiny New England town. Before the parade, a local “Minuteman” reads the Declaration of Independence, and then a foursome of Colonial re-enactors fires off a few rounds with revolutionary-era muskets in a field across from the Town Hall. The unexpected “boom” of gunpowder spooked one of the dogs, and she bolted on the leash, dragging Grace behind her with a violent yank. All four dogs became frantic and we were engulfed in a frenzy of canine panic – barking, whining, jumping, pulling. We managed to wrangle them to a quiet field about 100 yards away from the parade route where we could calm them a bit. Grace plopped down on the ground in exhaustion—sitting right on top of a colony of fire ants. Dozens of stings added insult to injury. She was overwhelmed, in pain, crying. But it STOPPED THERE. She didn’t spiral into panic: sobbing, nauseous, hyper-ventilating, catastrophizing, out of control, as she had on several occasions over the past few months. Too often, I had looked on helplessly as she imploded, unable to hug her (she hates being comforted when she’s upset) or talk her down (that only jazzes her up), becoming increasingly frustrated by my own inability to protect her from such suffering. But this morning was different. She seemed to have more resources to deal with the out-of-control, over-stimulating situation—her central nervous system didn’t run amok as it would have just a few weeks before. She could breathe and get a little space from her initial sense of panic, even laughing when her dad arrived with the car and we loaded up the four golden pooches to deliver them from ground zero.
I mentioned this dog-mageddon to her a few days later when we discussed how things were going with the new drug. She said she didn’t think it was working yet—she still felt anxious, still woke up in the middle of the night with racing thoughts, still wrestled with self-loathing for being “such a head-case.” (Her words, not ours.) Her dad and I immediately countered with “Oh, but, we think it’s helping.” We could see that she had more resilience. It’s often the case: family members observe signs that an SSRI is alleviating symptoms before the patient does.
Over the last two years, Grace has continued her therapy while in college. There are four indicators I look to when I’m curious how things are going with her medication and whether it’s still helping:
- How is her sleep?
- Is her general energy level in balance? Or is she having feelings of lethargy/brain fog, or “speeding up”/ increasing her pace to distract from an inner sense of urgency and fear? How does her body feel?
- Is she practicing self-care? Exercising, eating (at least some) healthy food, seeing her therapist, saying no to excessive commitments, and taking time for pleasurable activities like knitting and visiting the local animal shelter are some ways she cares for herself.
For me, these three realms provide a good window into my daughter’s well-being. But the fourth and most important indicator is what Grace thinks. It’s been 21 months since she first started taking Fluoxetine, and she has adjusted the dosage once. Here’s what she says:
I take stock of how clear-minded I feel. Before medication, I felt shrouded in this cloudy, obsessive mind space. Obviously, I still have anxiety. What’s changed is the extent to which I can cope with it. I’ve stayed on medication so I can learn how to take care of myself as a person with anxiety. I don’t intend to spend my whole life medicated, but before I stop, I want to feel like I have tools and a strong sense of self to take care of my own mental health.
Since I am not a professional, I reached out to a couple of clinicians with extensive experience in treating adolescents: Daisy Hackett, LICSW, of Willa Family Counseling in Newburyport, MA, and Robyn Maltz, LICSW, of Newton, MA, for their clinical benchmarks.
Hackett reinforces three essentials:
- Professional monitoring: No meds without regular therapy! “Your teen should be in regular treatment with a therapist – at least every other week. The therapist will be talking regularly with your child about his symptoms,” and has the best lens for determining if the choice and dosage of a medication is optimal. Ideally, your child’s therapist should be in communication with the prescriber, if these are not the same individual. If it’s time to re-evaluate a med, either because your child expresses readiness to make an adjustment, or because there is a concern about effectiveness, the involvement of your teen’s therapist is critical.
- Trust and respect your child’s boundaries. If your teen doesn’t want to share her anxiety or depression treatment and recovery experience with you, that’s developmentally appropriate for an adolescent. An older or more independent teen may want your support while also needing you to keep your distance. Just make sure she’s going to therapy, for the benefits of #1, above! “Teens need to develop relationship skills beyond their parents for understanding and communicating about their difficult feelings. Their therapist is a safe place to practice.”
- Basic functioning: Sleep, energy, and appetite are three key areas where you can observe improvement or change. With SSRI’s prescribed for depression, look for “brightening,” more energy, and a decrease in irritability or sadness. (Hackett notes that depression in teens often presents with irritability in lieu of sadness.) If prescribed for anxiety, your child’s sense of stress should ease; he will be able to meet challenges with more calm.
Robyn Maltz suggests parents, kids, and therapists jointly develop a clear list of bullet points detailing areas of functioning they want to improve. Generally, these will involve coping at school, at home and with friendships. “What were the areas of dysfunction prior to the medication? It’s so important to know what you’re trying to medicate. If those things are improving, then it’s working.” She adds that an SSRI is typically going to bring relief when there is a biochemical component to the anxiety or depression and cautions that this is not always the case.
Extreme anxiety in kids in the year 2018, Maltz points out, is an appropriate response to a hyped-up culture of social media and outsized performance expectations. She emphasizes the imperative of helping kids develop tools for working with their difficult feelings, rather than exclusively relying on medicating those feelings away. “An SSRI typically relieves about 30%” of a patient’s suffering, she notes, so “it should be used as a single element in a comprehensive treatment plan” including multiple modalities ranging from psychotherapy to CBT and more. Maltz suggests that in her decades-long practice, she has viewed medication for teens as a last resort rather than a first step, particularly with those younger than 16 years old.
Hackett offers this reassurance for concerned parents: “You know your kid. You knew to steer them into treatment! Don’t worry, you’ll notice if a drug isn’t helping the way it once did, or if a new med isn’t causing improvement. Parents’ worry only increases their child’s anxiety, so trust your judgement.”
Note: Call your doctor or therapist immediately if you see signs of increased hopelessness or suicidality in a child on a new medication. This article does not deal with medications for such diagnoses as ADHD, bipolar disorder, or OCD. Ask a therapist if you’re concerned. If you can’t talk to your teenager’s therapist because of privacy regulations, then seek out your own counselor for a consult.
By: Holly Kania, Anxiety In Teens Contributor