Mental Health Information for Teens

Attention Deficit Hyperactivity Disorder 337 Children who have symptoms of hyper- activity may display these tendencies: ✤ It’s A Fact!! • Fidget and squirm in their seats • Talk nonstop ADHD Can Be Mistaken • Dash around, touching or play- For Other Problems ing with anything and every- Parents and teachers can thing in sight miss the fact that children with • Have trouble sitting still during symptoms of inattention have the dinner, school, and story time disorder because they are often quiet and less likely to act out. They • Be constantly in motion may sit quietly, seeming to work, but they are often not paying attention • Have difficulty doing quiet to what they are doing. They may get tasks or activities along well with other children, com- pared with those with the other sub- Children who have symptoms of types, who tend to have social impulsivity may display these ten- problems. But children with the dencies: inattentive kind of ADHD are not the only ones whose disorders • Be very impatient can be missed. For example, • Blurt out inappropriate comments, adults may think that children with the hyperactive and show their emotions without re- impulsive subtypes just straint, and act without regard for have emotional or consequences disciplinary problems. • Have difficulty waiting for things they want or waiting their turns in games • Often interrupt conversations or others’ activities What causes ADHD? Scientists are not sure what causes ADHD, although many studies sug- gest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain inju- ries, nutrition, and the social environment might contribute to ADHD.

338 Mental Health Information for Teens, Third Edition Genes: Inherited from our parents, genes are the “blueprints” for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder. Knowing the genes in- volved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments. ✤ It’s A Fact!! Children with ADHD who In their first few years of driving, carry a particular version of a cer- teens with ADHD are involved in tain gene have thinner brain tis- nearly four times as many car accidents sue in the areas of the brain as those who do not have ADHD.They associated with attention. This are also more likely to cause injury in National Institute of Mental accidents, and they get three times as Health (NIMH) research showed many speeding tickets as their peers. that the difference was not perma- nent, however, and as children with Most states now use a graduated this gene grew up, the brain de- licensing system, in which young driv- veloped to a normal level of thick- ers, both with and without ADHD, ness. Their ADHD symptoms also learn about progressively more chal- improved. lenging driving situations. Teens, espe- cially those with ADHD, need to Environmental Factors: Stud- understand and follow the rules of the ies suggest a potential link between road. Repeated driving practice under adult supervision is especially impor- tant for teens with ADHD. cigarette smoking and alcohol use during pregnancy and ADHD in children. In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old build- ings, may have a higher risk of developing ADHD. Brain Injuries: Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury. Sugar: The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In

Attention Deficit Hyperactivity Disorder 339 one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no dif- ferent behavior or learning capabilities than those who received the sugar substitute. Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results. Food Additives: Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity. Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity. How is ADHD diagnosed? Children mature at different rates and have different personalities, tem- peraments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD. ADHD symptoms usually appear early in life, often between the ages of three and six, and because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other chil- dren, or seems constantly “out of control.” Often, teachers notice the symp- toms first, when a child has trouble following rules, or frequently “spaces out” in the classroom or on the playground. No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment. A family may want to first talk with the child’s pediatrician. Some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in child- hood mental disorders such as ADHD. The pediatrician or mental health specialist will first try to rule out other possibilities for the symptoms. For example, certain situations, events, or health conditions may cause tempo- rary behaviors in a child that seem like ADHD. A specialist will also check school and medical records for clues, to see if the child’s home or school settings appear unusually stressful or disrupted, and gather information from the child’s parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted.

340 Mental Health Information for Teens, Third Edition The specialist would pay close attention to the child’s behavior during different situations, some highly structured, some less structured. Others would require the child to keep paying attention. Most children with ADHD are better able to control their behaviors in situations where they are getting individual attention and when they are free to focus on enjoyable activities. These types of situations are less important in the assessment. A child also may be evaluated to see how he or she acts in social situations and may be given tests of intellectual ability and academic achievement to see if he or she has a learning disability. If after gathering all this information the child meets the criteria for ADHD, he or she will be diagnosed with the disorder. How is ADHD treated? Currently available treatments focus on reducing the symptoms of ADHD and improving functioning. Treatments include medication, various types of psychotherapy, education or training, or a combination of treatments. Medications: The most common type of medication used for treating ADHD is called a “stimulant.” Although it may seem unusual to treat ADHD with a medication considered a stimulant, it actually has a calming effect on children with ADHD. Many types of stimulant medications are available. A few other ADHD medications are non-stimulants and work differently than stimulants. For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Medication also may improve physical coordination. However, a one-size-fits-all approach does not apply for all children with ADHD. What works for one child might not work for another. One child might have side effects with a certain medication, while another child may not. Sometimes several different medications or dosages must be tried before finding one that works for a particular child. Any child taking medications must be monitored closely and carefully by caregivers and doctors. Stimulant medications come in different forms, such as a pill, capsule, liquid, or skin patch. Some medications also come in short-acting, long- acting, or extended release varieties. In each of these varieties, the active

Attention Deficit Hyperactivity Disorder 341 ingredient is the same, but it is released differently in the body. The long- acting and extended release forms often allow a child to take the medication just once a day before school, so they don’t have to make a daily trip to the school nurse for another dose. Parents and doctors should decide together which medication is best for the child and whether the child needs medica- tion only for school hours or for evenings and weekends, too. ADHD can be diagnosed and medications prescribed by medical doctors (usually a psychiatrist) and in some states also by clinical psychologists, psy- chiatric nurse practitioners, and advanced psychiatric nurse specialists. What are the side effects of stimulant medications? The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomach- aches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered. Less common side effects include sudden, repetitive movements or sounds called tics and personality change, such as appearing “flat” or without emo- tion. Talk with your doctor if you experience any of these side effects. Do medications cure ADHD? Current medications do not cure ADHD. Rather, they control the symp- toms for as long as they are taken. Medications can help a child pay atten- tion and complete schoolwork. It is not clear, however, whether medications can help children learn or improve their academic skills. Adding behavioral therapy, counseling, and practical support can help children with ADHD and their families to better cope with everyday problems. Research funded by the National Institute of Mental Health (NIMH) has shown that medi- cation works best when treatment is regularly monitored by the prescribing doctor and the dose is adjusted based on the child’s needs. How is psychotherapy used to treat ADHD? Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working

342 Mental Health Information for Teens, Third Edition ✔ Quick Tip Here are some tips to help kids stay organized and follow directions. Schedule: Keep the same routine every day, from wake-up time to bedtime. Include time for homework, out- door play, and indoor activities. Keep the schedule on the refrig- erator or on a bulletin board in the kitchen. Write changes on the schedule as far in advance as possible. Organize Everyday Items: Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys. Use Homework And Notebook Organizers: Use orga- nizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home the necessary books. through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, and other structured routines can help a child control his or her behavior. Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expres- sions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

Chapter 46 Autism Spectrum Disorders Introduction All autism spectrum disorders (ASD) are characterized by varying de- grees of impairment in communication skills, social interactions, and re- stricted, repetitive and stereotyped patterns of behavior. The autism spectrum disorders can often be reliably detected by the age of three years and in some cases as early as 18 months. Studies suggest that many children eventually may be accurately identified by the age of one year or even younger. The appearance of any of the warning signs of ASD is reason to have a child evaluated by a professional specializing in these disorders. Parents are usually the first to notice unusual behaviors in their child. In some cases, the baby seemed different from birth, unresponsive to people or focusing intently on one item for long periods of time. The first signs of an ASD can also appear in children who seem to have been developing nor- mally. When an engaging, babbling toddler suddenly becomes silent, with- drawn, self-abusive, or indifferent to social overtures, something is wrong. The pervasive developmental disorders, or autism spectrum disorders, range from a severe form, called autistic disorder, to a milder form, Asperger About This Chapter: Text in this chapter is excerpted from “Autism Spectrum Disor- ders (Pervasive Developmental Disorders),” National Institute of Mental Health, Feb- ruary 5, 2009.

344 Mental Health Information for Teens, Third Edition syndrome. If a child has symptoms of ✤ It’s A Fact!! either of these disorders, but does not Is autism related meet the specific criteria for either, the to vaccinations? diagnosis is called pervasive develop- mental disorder not otherwise specified The Institute of Medicine (PDD-NOS). Other rare, very severe (IOM) conducted a thorough re- disorders that are included in the autism view on the issue of a link between spectrum disorders are Rett syndrome thimerosal (a mercury based pre- and childhood disintegrative disorder. servative that is no longer used in vaccinations) and autism. The fi- Rare Autism Spectrum Dis- nal report from IOM, “Immuni- orders zation Safety Review: Vaccines and Autism,” released in May Rett Syndrome: Rett syndrome is 2004, stated that the committee relatively rare, affecting almost exclu- did not find a link. sively females, one out of 10,000 to 15,000. After a period of normal de- Until 1999, vaccines given to velopment, sometime between six and infants to protect them against 18 months, autism-like symptoms be- diphtheria, tetanus, pertussis, gin to appear.The little girl’s mental and Haemophilus influenzae type b social development regresses—she no (Hib), and hepatitis B contained longer responds to her parents and pulls thimerosal as a preservative.Today, away from any social contact. If she has with the exception of some flu vac- been talking, she stops; she cannot con- cines, none of the vaccines used in trol her feet; she wrings her hands. the U.S. to protect preschool aged Some of the problems associated with children against 12 infectious dis- Rett syndrome can be treated. Physi- eases contain thimerosal as a preser- cal, occupational, and speech therapy vative.The MMR [measles,mumps, can help with problems of coordination, and rubella] vaccine does not and movement, and speech. never did contain thimerosal. Va- ricella (chickenpox), inactivated Childhood Disintegrative Disor- polio (IPV), and pneumococcal der: Very few children who have an au- conjugate vaccines have also never tism spectrum disorder (ASD) contained thimerosal. diagnosis meet the criteria for child- hood disintegrative disorder (CDD). A U.S. study looking at envi- ronmental factors including expo- sure to mercury, lead and other heavy metals is ongoing.

Autism Spectrum Disorders 345 Symptoms may appear by age two, but the average age of onset is between three and four years. Until this time, the child has age-appropriate skills in communication and social relationships. The long period of normal devel- opment before regression helps differentiate CDD from Rett syndrome. The loss of such skills as vocabulary are more dramatic in CDD than they are in classical autism. The diagnosis requires extensive and pronounced losses involving motor, language, and social skills. CDD is also accompanied by loss of bowel and bladder control and oftentimes seizures and a very low IQ. What Are The Autism Spectrum Disorders? All children with autism spectrum disorders (ASD) demonstrate deficits in social interaction, verbal and nonverbal communication, and repetitive behaviors or interests. In addition, they will often have unusual responses to sensory experiences, such as certain sounds or the way objects look. Each of these symptoms runs the gamut from mild to severe. They will present in each individual child differently. For instance, a child may have little trouble learning to read but exhibit extremely poor social interaction. Each child will display communication, social, and behavioral patterns that are indi- vidual but fit into the overall diagnosis of ASD. Children with ASD do not follow the typical patterns of child develop- ment. In some children, hints of future problems may be apparent from birth. In most cases, the problems in communication and social skills become more noticeable as the child lags further behind other children the same age. Some other children start off well enough. Oftentimes between 12 and 36 months old, the differences in the way they react to people and other unusual behav- iors become apparent. Some parents report the change as being sudden, and that their children start to reject people, act strangely, and lose language and social skills they had previously acquired. In other cases, there is a plateau, or leveling, of progress so that the difference between the child with autism and other children the same age becomes more noticeable. Social Symptoms From the start, typically developing infants are social beings. Early in life, they gaze at people, turn toward voices, grasp a finger, and even smile.

346 Mental Health Information for Teens, Third Edition In contrast, most children with ASD ☞ Remember!! seem to have tremendous difficulty learn- ing to engage in the give and take of every- Autism spectrum disorder day human interaction. Even in the first (ASD) is defined by a certain few months of life, many do not interact set of behaviors that can range and they avoid eye contact. They seem in- from the very mild to the se- different to other people, and often seem vere. The following possible in- to prefer being alone. They may resist at- dicators of ASD were identified tention or passively accept hugs and cud- on the Public Health Training dling. Later, they seldom seek comfort or Network Webcast, Autism respond to parents’ displays of anger or Among Us: affection in a typical way. • Does not babble, point, Children with ASD also are slower in or make meaningful ges- learning to interpret what others are tures by one year of age thinking and feeling. Subtle social cues— whether a smile, a wink, or a grimace— • Does not speak one may have little meaning. To a child who word by 16 months misses these cues, “Come here” always means the same thing, whether the • Does not combine two speaker is smiling and extending her arms words by two years for a hug or frowning and planting her fists on her hips. Without the ability to • Does not respond to interpret gestures and facial expressions, name the social world may seem bewildering. To compound the problem, people with • Loses language or social ASD have difficulty seeing things from skills another person’s perspective. Some other indicators include Although not universal, it is common the following: for people with ASD also to have diffi- culty regulating their emotions. This can • Poor eye contact take the form of “immature” behavior such as crying in class or verbal outbursts • Doesn’t seem to know that seem inappropriate to those around how to play with toys them. The individual with ASD might • Excessively lines up toys or other objects • Is attached to one par- ticular toy or object • Doesn’t smile • At times seems to be hearing impaired

Autism Spectrum Disorders 347 also be disruptive and physically aggressive at times, making social relation- ships still more difficult. They may at times break things, attack others, or hurt themselves. In their frustration, some bang their heads, pull their hair, or bite their arms. Communication Difficulties By age three, most children have passed predictable milestones on the path to learning language; one of the earliest is babbling. By the first birth- day, a typical toddler says words, turns when he hears his name, points when he wants a toy, and when offered something distasteful, makes it clear that the answer is “no.” Some children diagnosed with ASD remain mute throughout their lives. Some infants who later show signs of ASD coo and babble during the first few months of life, but they soon stop. Others may be delayed, developing language as late as age five to nine. Some children may learn to use commu- nication systems such as pictures or sign language. Those who do speak often use language in unusual ways. They seem un- able to combine words into meaningful sentences. Some speak only single words, while others repeat the same phrase over and over. Some ASD chil- dren parrot what they hear, a condition called echolalia. Although many children with no ASD go through a stage where they repeat what they hear, it normally passes by the time they are three. Some children only mildly affected may exhibit slight delays in language, or even seem to have precocious language and unusually large vocabularies, but have great difficulty in sustaining a conversation. Another difficulty is often the inability to understand body language, tone of voice, or “phrases of speech.” They might interpret a sarcastic expression such as “Oh, that’s just great” as meaning it really IS great. While it can be hard to understand what ASD children are saying, their body language is also difficult to understand. Facial expressions, movements, and gestures rarely match what they are saying. Also, their tone of voice fails to reflect their feelings. A high-pitched, sing-song, or flat, robot-like voice is

348 Mental Health Information for Teens, Third Edition ✤ It’s A Fact!! For every child eligible for special programs, each state guarantees special education and related ser- vices.The Individuals with Disabilities Education Act (IDEA) is a federally mandated program that assures a free and appropriate public education for children with diagnosed learning deficits. By law, the public schools must prepare and carry out a set of in- struction goals, or specific skills, for every child in a special edu- cation program. The list of skills is known as the child’s Individualized Education Program (IEP). The IEP is an agreement between the school and the family on the child’s goals. common. Some children with relatively good language skills speak like little adults, failing to pick up on the “kid-speak” that is common in their peers. Repetitive Behaviors Although children with ASD usually appear physically normal and have good muscle control, odd repetitive motions may set them off from other children. These behaviors might be extreme and highly apparent or more subtle. Some children and older individuals spend a lot of time repeatedly flapping their arms or walking on their toes. Some suddenly freeze in posi- tion. As children, they might spend hours lining up their cars and trains in a certain way, rather than using them for pretend play. If someone accidentally moves one of the toys, the child may be tremendously upset. ASD children need, and demand, absolute consistency in their environment. A slight change in any routine—in mealtimes, dressing, taking a bath, going to school at a certain time and by the same route—can be extremely disturbing. Repetitive behavior sometimes takes the form of a persistent, intense pre- occupation. For example, the child might be obsessed with learning all about

Autism Spectrum Disorders 349 vacuum cleaners, train schedules, or lighthouses. Often there is great interest in numbers, symbols, or science topics. Problems That May Accompany ASD Sensory Problems: When children’s perceptions are accurate, they can learn from what they see, feel, or hear. On the other hand, if sensory infor- mation is faulty, the child’s experiences of the world can be confusing. Many ASD children are highly attuned or even painfully sensitive to certain sounds, textures, tastes, and smells. In ASD, the brain seems unable to balance the senses appropriately. Some ASD children are oblivious to extreme cold or pain. An ASD child may fall and break an arm, yet never cry. Another may bash his head against a wall and not wince, but a light touch may make the child scream with alarm. Mental Retardation: Many children with ASD have some degree of mental impairment. When tested, some areas of ability may be normal, while others may be especially weak. Seizures: One in four children with ASD develops seizures, often starting either in early childhood or adolescence. Sometimes a contributing factor is a lack of sleep or a high fever. An EEG (electroencephalogram—recording of the electric currents developed in the brain by means of electrodes applied to the scalp) can help confirm the seizure’s presence. In most cases, seizures can be controlled by a number of medicines called “anticonvulsants.” The dosage of the medication is adjusted carefully so that the least possible amount of medication will be used to be effective. Fragile X Syndrome: This disorder is the most common inherited form of mental retardation. It was so named because one part of the X chromo- some has a defective piece that appears pinched and fragile when under a microscope. Fragile X syndrome affects about two to five percent of people with ASD. It is important to have a child with ASD checked for fragile X, especially if the parents are considering having another child. For an un- known reason, if a child with ASD also has fragile X, there is a one-in-two chance that boys born to the same parents will have the syndrome.

350 Mental Health Information for Teens, Third Edition Tuberous Sclerosis: Tuberous sclerosis is a rare genetic disorder that causes benign tumors to grow in the brain as well as in other vital organs. It has a consistently strong association with ASD. One to four percent of people with ASD also have tuberous sclerosis. The Adolescent Years Adolescence is a time of stress and confusion; and it is no less so for teenagers with autism. Like all children, they need help in dealing with their budding sexuality. While some behaviors improve during the teenage years, some get worse. Increased autistic or aggressive behavior may be one way some teens express their newfound tension and confusion. The teenage years are also a time when children become more socially sensitive. At the age that most teenagers are concerned with acne, popular- ity, grades, and dates, teens with autism may become painfully aware that they are different from their peers. They may notice that they lack friends. And unlike their schoolmates, they aren’t dating or planning for a career. For some, the sadness that comes with such realization motivates them to learn new behaviors and acquire better social skills.

Chapter 47 Bullying What is bullying? A lot of young people have a good idea of what bullying is because they see it every day. Bullying happens when someone hurts or scares another person on purpose and the person being bullied has a hard time defending himself or herself. Usually, bullying happens over and over. What is cyberbullying? In recent years, technology has given children and youth a new means of bullying each other. Cyberbullying, which is sometimes referred to as online social cruelty or electronic bullying, can involve any of the following actions: • Sending mean, vulgar, or threatening messages or images • Posting sensitive, private information about another person • Pretending to be someone else in order to make that person look bad • Intentionally excluding someone from an online group About This Chapter: This chapter includes text excerpting from “Cyberbullying,” 2008, and “Stop Bullying! Now!” 2009, produced by the Health Resources and Services Ad- ministration, 2009. For additional information, visit http://stopbullyingnow.hrsa.gov.

352 Mental Health Information for Teens, Third Edition Children and youth cyberbully ✎ What’s It Mean? each other with these tools: • E-mails Bullying • Instant messaging • Punching, shoving, and other acts that hurt people physically • Text or digital imaging mes- • Spreading bad rumors about sages sent on cell phones people • Web pages • Keeping certain people out of • Blogs a “group” • Chat rooms or discussion • Teasing people in a mean way groups • Getting certain people to “gang • Other information communi- up” on others cation technologies Bullying also can happen online Although little research has been or electronically. Cyberbullying is conducted on cyberbullying, recent when children or teens bully each studies have found this statistical other using the internet, mobile phones, or other cyber technology. information: Source: Health Resources and Ser- • 18% of students in grades 6–8 vices Administration, 2009. said they had been cyberbullied at least once in the last couple of months; and 6% said it had happened to them two or more times. • 11% of students in grades 6–8 said they had cyberbullied another per- son at least once in the last couple of months, and 2% said they had done it two or more times. • 19% of regular internet users between the ages of 10 and 17 reported being involved in online aggression; 15% had been aggressors, and 7% had been targets (3% were both aggressors and targets). • 17% of 6–11 year-olds and 36% of 12–17-year-olds reported that some- one said threatening or embarrassing things about them through e- mail, instant messages, web sites, chat rooms, or text messages. • Cyberbullying has increased in recent years. In nationally representative surveys of 10-17 year-olds, twice as many children and youth indicated

Bullying 353 that they had been victims and perpetrators of online harassment in 2005 compared with 1999/2000. Why do kids bully? There are all kinds of reasons why young people bully others. Do any of these sound familiar to you? • Because I see others doing it • Because it’s what you do if you want to hang out with the right crowd • Because it makes me feel, stronger, smarter, or better than the person I’m bullying • Because it’s one of the best ways to keep others from bullying me Whatever the reason, bullying is something we all need to think about. Whether we’ve done it ourselves, or whether friends or other people we know are doing it, we all need to recognize that bullying has a terrible effect on the lives of young people. It may not be happening to you today, but it could tomorrow. Working together, we can make the lives of young people better. What are the effects of bullying? If you’ve ever heard an adult—or anyone else—say that bullying is “just a fact of life” or “no big deal,” you’re not alone. Too often, people just don’t take bullying seriously—or until the sad and sometimes scary stories are revealed. • It can mess up a kid’s future. Young people who bully are more likely than those who don’t bully to skip school and drop out of school. They are also more likely to smoke, drink alcohol and get into fights. • It scares some people so much that they skip school. As many as 160,000 students may stay home on any given day because they’re afraid of being bullied. • It can lead to huge problems later in life. Children who bully are more likely to get into fights, vandalize property, and drop out of school. And 60% of boys who were bullies in middle school had at least one criminal conviction by the age of 24.

354 Mental Health Information for Teens, Third Edition What can you do if you bully others? Let’s face it, hurting and making others feel bad is NEVER cool. Just admitting that you are doing things to harm others takes some guts. But that’s not enough. Trying to find out what you should do to change the way you’re acting, now that’s a step in the right direction! Think about what you’re doing and how it affects others. If you think calling others names is really harmless, or if you think pushing, hitting, or ✔ Quick Tip Things You Can Do To Stay Out Of A Bully’s Way • Make friends and lots of them—there’s safety in numbers. A bully is less likely to approach you if you’re surrounded by pals. Try to be friendly and respectful to everyone—smile at someone if you make eye contact in the hallways. • If a bully is talking smack about you, keep in mind all the good stuff you know about yourself. Do things that you are good at. Can you spell like a dictionary? Enter a spelling bee. Run like the wind? Join the track team. Sing like an angel? Choir is calling your name. Try something new; you may discover a talent you never knew you had. Take tennis lessons or audition for the school play. Bonus: you’ll meet new people! • Stand up for yourself! Practice what you might say if someone starts picking on you. Saying the words a couple of times will make you feet sure of yourself. One word to the wise: Never start a discussion or argue with a bully—even if you’ve got a zinger that’s begging to be zung. You just want to get them off your back, not make them angry. • Check out the way you act and be aware of your body language. How you carry yourself can bring on a bully. Slouching, looking at the ground or feet, and fidgeting make people think that you are afraid or nervous. Try to walk with your head up, make eye contact, and smile. A bully is less likely to single you out if you are the picture of self-confidence. • Ignore insults or name-calling. It’ll be hard, but stay calm and don’t let them see you sweat. Take a deep breath and try not show that you are upset or angry. Above all, don’t believe for one second what they’re saying.

Bullying 355 stealing from other kids is funny, you’ve forgotten what it feels like to be hurt yourself. Teasing, hitting, keeping others out of a group—all of these things harm someone. All of us have been hurt at one time or another and we all know how it feels—awful. So the next time you are about to bully someone, try these tips: • Put yourself in their shoes. • Think about how it must make them feel. Bullies feed on attention and are just trying to get a reaction from you. It’s easier to give them the brush off if you don’t let them get under your skin. They’ll get bored and move on. • Avoid getting sucked into a scuffle, even if it means losing your stuff— your safety is way more important than your shoes. The only time you should ever fight back is when you have to defend yourself. Even then, keep eyes open for an escape route. Chances are, if someone wants to fight, they know they have a good chance of winning. • Don’t be afraid to tell an adult if you’re being bullied. You are NOT a snitch if you tell an adult you know that someone is hurting you. If you have tried to stop someone from bothering you and it’s not working, get someone you trust involved to help you. And if you see someone else in the same boat, find an adult to help. Get the problem out in the open. Once people know about it, the bully is no longer in control. Not telling anyone—especially because the bully told you not to—is just making him or her feel more powerful. • Have a few one-liners in your pocket to pull out if you need them. Things like, “That’s funny, but enough already, okay?” or “I don’t do this to you. You should really think about that” can help defuse a tense situation and keep you out of harm’s way. While you’re coming up with your witty one-liners, keep in mind you’re trying to take the wind out of the bully’s sails, not add fuel to the fire with a major burn. Embarrassing the bully in front of everyone won’t make your life any easier. Source: From “The Bully Roundup,” BAM! Body and Mind, Centers for Disease Control and Prevention, 2003.

356 Mental Health Information for Teens, Third Edition • And just don’t do it. • Talk to an adult. Making other people feel badly should never make you feel good. If it does, or if you’re not really sure why you bully other kids, you need to talk to an adult about it. Even though you might think an adult won’t understand, or that you’ll get yourself into trouble, they can help. Whether it is your parent, a teacher or another trusted grown-up, you should tell an adult how you’ve been acting so that they help you deal with it. School counselors are also great people to talk to about how you feel and how to change the way you treat others.

Chapter 48 Dating Abuse Dating abuse is a pattern of violent behavior—physical, emotional, or sexual—by one partner in a dating relationship toward the other partner. You might be thinking, “I’ve never experienced anything as serious as being punched!” But hold on a sec. In general, guys and girls don’t usually start hitting their girlfriend or boyfriend out of the blue. It usually starts after a history of verbal and emo- tional abuse, which is far more likely to occur among young teens. If nothing is done about that abuse, it’s likely to become more severe and start includ- ing sexual and physical abuse. Dating Bill Of Rights And Responsibilities You have certain rights and responsibilities in a dating relationship. Here are some examples. Personalize these for yourself, and make a commitment to stick by them. Dating Rights I have these rights: • To be treated with respect always About This Chapter: Information in this chapter is from “Choose Respect,” National Center for Injury Prevention and Control (www.chooserespect.org), 2006.

358 Mental Health Information for Teens, Third Edition • To be in a healthy relationship ✎ What’s It Mean? • To not be abused—physically, sexually, or Dating abuse may include emotionally components like these: • To keep my body, feelings, beliefs, and • Physical property to myself • To have friends and activities apart from • Pinching, shoving, slap- ping, grabbing, etc. my boyfriend or girlfriend • To set limits and values • Intimidation (blocking • To say no doors, throwing objects) • To feel safe in the relationship • To be treated as an equal • Use of weapons • To feel comfortable being myself • To leave a relationship • Sexual Dating Responsibilities • Unwanted touching I have these responsibilities: • Forced sexual activities • To determine my limits and values • Pressure to have sex • To respect my boyfriend’s or girlfriend’s • Threats to find someone limits, values, feelings, and beliefs who will do what he or • To refuse to abuse—physically, sexually, she wants sexually or emotionally • Emotional/verbal • To be considerate • To communicate clearly and honestly • Put-downs, insults, and • To give my boyfriend or girlfriend space rumors to be his or her own person • Threats • To not exert power or control in the rela- • Possessiveness tionship • To compromise when needed • Overdependency • To admit to being wrong when appropriate • To ask for help from friends, family, and • Huge mood swings trusted adults • Humiliation • Accusations • Withdrawal of attention • Isolation from friends or activities

Dating Abuse 359 Dating Abuse Affects Many Teen dating abuse is a huge issue. It is a problem that touches the lives of teens from all walks of life—black and white, rich and poor, big-city and country. These statistics are about real people. They are scary when you consider that anyone can experience dating abuse. People like you, your brother or sister, your friend, or your classmate. Become familiar with these facts so you can talk about the issue with other people and be ready to do something. ✤ It’s A Fact!! • About one in 11 teens reports being a victim of physical dating abuse each year. • About one in four teens reports verbal, physical, emotional, or sexual abuse each year. • About one in five teens reports being a victim of emotional abuse. • About one in five high school girls has been physically or sexually abused by a dating partner. • The overall occurrence of dating violence is higher among black (13.9%) than Hispanic (9.3%) or white (7.0%) students. • About 72% of students in 8th and 9th grade report dating. By the time they are in high school, 54% of students report dating violence among their peers. • One in three teens report knowing a friend or peer who has been hit, punched, kicked, slapped, choked, or otherwise physically hurt by his or her partner. • 80% of teens regard verbal abuse as a serious issue for their age group. • Nearly 80% of girls who have been physically abused in their dating rela- tionships continue to date their abuser. • Nearly one in five teenage girls who have been in a relationship said a boy- friend had threatened violence or self-harm if presented with a break-up. • Almost 70% of young women who have been raped knew their rapist either as a boyfriend, friend, or casual acquaintance. • Teen dating abuse most often takes place in the home of one of the partners.

360 Mental Health Information for Teens, Third Edition Impact Of Dating Abuse Dating abuse can have serious consequences. The effects range from miss- ing a few classes to attempting suicide. Abuse also affects future relation- ships. All consequences make compelling reasons to prevent abuse before it starts, or to speak up against it. Effects On Victims ✔ Quick Tip These things can Recognizing Warning Signs Of Abuse happen shortly after the abuse: Some of the following signs are just part of being a teen. But, when these changes happen suddenly, or • Bruises and aches without an explanation, these signs could signal abuse. Look out for these signs in your friends and class- • Pregnancy mates. • Warning signs of an abusive relationship • Trouble sleeping • Bruises, scratches, or other injuries • Failing grades • Anxiety • Dropping out of school activities • Avoiding friends and social events • Guilt • Indecision • Changes in clothes or make-up • Missed classes • Changes in eating or sleeping habits • Secrecy • Poor grades • Avoiding eye contact • Crying spells or hysteria fits • Distrust in people • Constant thoughts about the dating partner • Alcohol or drug use • Lying to friends or • Anxiety and depression family to hide the • Sudden changes in mood or personality abuse • Fearfulness around the dating partner or when • Withdrawal from his or her name is mentioned friends or family, or avoidance of school or social events • Lower self-esteem • Feelings of loneli- ness • Feelings of isolation

Dating Abuse 361 Dating abuse can also cause ✔ Quick Tip problems in the long run: Recognizing Warning Signs Of An Abusive Person • Depression • Suicide attempts • Wants to get serious in the relation- • Eating disorders ship quickly • Drug and alcohol abuse • Medical problems • Will not take no for an answer • Inability to succeed in school • Is jealous and possessive or at work later in life • Makes all the decisions Effects On Abusers • Dismisses other people’s opinions People who are abusive in dat- and feelings ing relationships can be affected in the long run, too: • Wants to control a person’s friends and activities • Loss of respect from peers • Loneliness • Puts constant pressure on someone • Alienation from friends and • Demands to know where someone family is all the time • Suspension or expulsion from • Uses guilt trips—“If you really school loved me, you would...” • Inability to keep a job • Criminal activity • Feels that he or she deserves un- conditional love and support • Has a history of bad relationships • Blames the person for his or her feelings and actions—“You asked for it” or “You made me mad” • Apologizes for violent behavior and promises not to do it again Why Does Abuse Happen? Treat others with respect. This idea may seem like common sense. After all, why not give respect if you’ll get it in return? The truth is, quite a few teens are abusive in their relationships. And many think it’s justified. After all, society seems to be okay with it—just look at all the TV shows and listen to popular songs these days. Abuse is not fair, and it’s not right. But there are reasons why it happens.

362 Mental Health Information for Teens, Third Edition Abuse Is Related To Certain Risk Factors Risks of having unhealthy relationships increase for teens who may have some of these characteristics: Believe it’s okay to use threats or violence to get their way or to express frustration or anger; use alcohol or drugs; can’t manage anger or frustration; hang out with violent peers; have low self-esteem or are depressed; have learning difficulties and other problems at school; don’t have parental supervision and support; witness abuse at home or in the community; and have a history of aggressive behavior or bullying. Abuse Is A Choice No matter what excuses abusers make to themselves or their dating part- ners for their behaviors, abuse is still their choice. They will continue the abuse unless someone confronts them and helps them stop it. Abuse Is About Power And Control Abusers may feel insecure or uncertain about themselves or their lives. Or they may feel like they don’t have much control over anything. So they use power and control in their relationships to make themselves feel better. Excuses For Abuse Excuses. People who are abusive in a dating relationship use excuses all the time to justify their hurtful behavior. People who hear them may start doubting whether their concerns about the relationship are valid, and they’ll put up with the abuse. Have you heard these excuses before? “It’s not abuse.” “I was having a bad day.” “Jealousy is a normal part of any relationship.” “You got me upset or angry.” “It just happened once. It won’t happen again.” “You deserved it.” “I was drunk or high. Drugs made me do it.” “I had a bad childhood.” “I de- serve your trust, even if I messed up before.” “I deserve unconditional love and support.” “I should be more important than your friends.” “My needs are more important than yours.” “I didn’t mean to hurt you.” Any of these sound familiar? These are signs of an unhealthy relationship. There is no excuse for abuse—excuses should not be tolerated! Abuse is always a choice. While some people will choose respect, others will choose abuse.

Dating Abuse 363 When you hear excuses like these, confront your dating partner about them. Or seek help from your friends or trusted adults, like your parents, about what you should do. Why It Is So Hard To Leave? If you or someone you know is in an unhealthy relationship, it may be very hard to leave. Some of the reasons include the following: • Love: You may sincerely love your dating partner even if you may hate some of his or her behaviors. • Promises: Your partner may sugarcoat his or her words and promise the abuse won’t happen again. • Confusion: You may be confusing genuine love and controlling love, especially if you’ve grown up in an abusive and unsupportive family. • Denial: You may be thinking, “It could be worse.” Trying to downplay abuse is a common reaction, but it still doesn’t make the abuse right. • Guilt: You may feel like the abuse is your fault, given that your boy- friend or girlfriend is likely to blame you for it. • Fear: You may be afraid of what would happen if you told the truth. Or maybe you fear being alone and would rather be in this relation- ship than in none at all. • Belief You Can Change Your Partner: You may cling to the hope that you can change your partner if you try hard enough or put enough time and devotion into it. • False Hopes: You may think the violence will eventually stop. But, abuse is a pattern of behavior that’s been established for a long time. It won’t just stop on its own. • Peer Pressure: The pressure to have a boyfriend or girlfriend can be extreme. You may be afraid of what your friends might think if you were single. • Low Self-Esteem: If you’ve been abused emotionally or verbally, you may feel like you’re not lovable or worthy at all. Even if you’re unhappy

364 Mental Health Information for Teens, Third Edition in the relationship, you may stay because you think you’ll never find someone better who would love someone like you. Do you use any of these reasons to stay in an abusive relationship? It’s up to you to decide whether it’s worth it to stay and whether your dating part- ner is sincerely committed to changing. But if you’re positive that he or she can’t change, leaving the relationship is the best choice to make before you get hurt even more. Leaving The Relationship If you’re in an unhealthy relationship where you’re not getting the respect that you deserve, leaving it is the best thing you can do for yourself. It will take a lot of courage and resolve, but you can do it with support from the people who care about you. You will feel a lot better physically, emotionally, and mentally. You will finally be free of your ex’s abusive and controlling behavior. After The Relationship Just because you’ve left an abusive relationship doesn’t mean the risk of abuse is over. Your ex may start stalking you or calling you constantly. He or she may make threats or plead with you to come back. Here are some tips to help you stay safe and have peace of mind. • Tell your parents what’s going on, especially since your ex may stop by your home and demand to know where you are. • Talk with friends or adults you trust so they can look out for your safety. • Talk to school officials. They can alert school security about your ex and take other measures to make you feel safe at school. • Avoid isolated or dark areas at school and hangout spots. • Don’t walk home alone. • If you go to parties or events where your ex might be, go with good friends.

Chapter 49 Learning Disabilities Learning Disabilities At A Glance Learning disabilities are real. A person can be of average or above-average intelligence, not have any major sensory problems (like blindness or hearing impairment), and yet struggle to keep up with people of the same age in learning and regular functioning. How Can One Tell If A Person Has A Learning Disability? Learning disabilities can affect a person’s ability in the areas of: listening; speaking; reading; writing; mathematics. Other features of a learning disability are: • a distinct gap between the level of achievement that is expected and what is actually being achieved; • difficulties that can become apparent in different ways with different people; • difficulties that manifest themselves differently throughout development; • difficulties with socio-emotional skills and behavior. About This Chapter: Text in this chapter is from “Learning Disabilities at a Glance” and “LD at a Glance: A Quick Look,” © 2009 by National Center for Learning Disabilities, Inc. All rights reserved. Reprinted with permission. For more information, visit LD.org.

366 Mental Health Information for Teens, Third Edition A learning disability is not a disease, so there is no cure, but there are ways to overcome the challenges it poses through identification and accom- modation. Identification ✎ What’s It Mean? If there is reason to What is a learning disability? think a person might A learning disability (LD) is a neurologi- have LD, it is impor- cal disorder that affects the brain’s ability to tant to collect ob- receive, process, store and respond to informa- servations by tion. The term learning disability is used to describe parents, teachers, the seeming unexplained difficulty a person of at least doctors and others average intelligence has in acquiring basic aca- demic skills. These skills are essential for suc- regularly in contact cess at school and work, and for coping with that person. If with life in general. LD is not a single there does seem to be a disorder. It is a term that refers to pattern of trouble that is a group of disorders. more than just an isolated case of difficulty, the next step is to seek help from school or consult a learning specialist for an evaluation. Accommodation And Modification Depending on the type of learning disability and its severity, as well as the person’s age, different kinds of assistance can be provided. Under the Individuals with Disabilities Education Act (IDEA) of 1997 and Americans with Disabilities Act (ADA) of 1990 people of all ages with LD are pro- tected against discrimination and have a right to different forms of assis- tance in the classroom and workplace. What Causes Learning Disabilities? Experts aren’t exactly sure what causes learning disabilities. LD may be due to: • Heredity: Often learning disabilities run in the family, so it’s not un- common to find that people with LD have parents or other relatives with similar difficulties.

Learning Disabilities 367 • Problems During Pregnancy And Birth: LD may be caused by illness or injury during or before birth. It may also be caused by drug and alcohol use during pregnancy, low birth weight, lack of oxygen and premature or prolonged labor. • Incidents After Birth: Head injuries, nutritional deprivation and ex- posure to toxic substances (for example, lead) can contribute to LD. Learning disabilities are NOT caused by economic disadvantage, envi- ronmental factors, or cultural differences. In fact, there is frequently no ap- parent cause for LD. Each type of strategy should be considered when planning instruction and support. A person with dysgraphia will benefit from help from both specialists and those who are closest to the person. Finding the most benefi- cial type of support is a process of trying different ideas and openly exchang- ing thoughts on what works best. Are Learning Disabilities Common? Currently, almost 2.9 million school-aged children in the U.S. are classi- fied as having specific learning disabilities (SLD) and receive some kind of special education support. They are approximately 5% of all school-aged children in public schools. These numbers do not include children in private and religious schools or home-schooled children. Studies show that learning disabilities do not fall evenly across racial and ethnic groups. For instance, in 2001, 1% of white children and 2.6% of non- Hispanic black children were receiving LD-related special education ser- vices (Executive Summary, National Research Council, 2001). The same studies suggest that this has to do with economic status and not ethnic back- ground. LD is not caused by economic disadvantage, but the increased risk of exposure to harmful toxins (lead, tobacco, alcohol, etc.) at early stages of development are prevalent in low-income communities. What Can One Do About Learning Disabilities? Learning disabilities are lifelong, and although they won’t go away, they don’t have to stop a person from achieving goals. Help is available if they are

368 Mental Health Information for Teens, Third Edition identified. Learning disabilities affect every person differently, and the dis- order can range from mild to severe. Sometimes people have more than one learning disability. In addition, approximately one third of people with LD also have attention deficit hyperactivity disorder (AD/HD), which makes it difficult for them to concentrate, stay focused or manage their attention to specific tasks. LD And Adulthood It is never too late to get ✔ Quick Tip help for a learning dis- ability. Finding out [Editor’s Note: Here’s a tip about a learning dis- you can pass along to your parents.] ability can be a great LD And Children: Early identification is vi- relief to adults who tal in helping a child to succeed academically, as could not explain well as socially. If you think your child is displaying the reason for their signs of a learning disability, share them with class- struggles in the room teachers and others who come in contact with past. Testing spe- your child. Observe the way your child develops the lan- guage, motor coordination, and social skills and behaviors cialists are avail- important for success in school. And remember: Early is able for people of better. Even preschoolers can show signs of risk for LD. all ages, and assis- Don’t panic. Not all children who are slow to de- tance is available velop skills have LD. If your child does have a learn- for every stage of ing disability, early intervention with specialized life. Taking the ini- teaching strategies can help to overcome difficul- tiative to seek out ties. As a parent, it is important to learn as much support and services as you can and to help your child under- than can provide help is stand that he or she is not alone: other children struggle too, and adults the first step to overcom- are there to help. ing a learning disability. Many adults (some of whom are unaware of their LD) have developed ways to cope with their difficulties and are able to lead successful, func- tioning lives. LD shouldn’t hinder a person from attaining goals. Regard- less of the situation, understanding the specific challenges and learning strategies to deal with LD directly at every stage can alleviate a lot of frus- tration and make successful living much easier.

Learning Disabilities 369 LD At A Glance: A Quick Look What You Should Know About Learning Disabilities (LD) • LDs are specific neurological disorders that affect the brain’s ability to store, process or communicate information. • “Specific learning disability” (SLD) is the term used in the federal law for any LD. • LDs can affect different aspects of learning and functioning. See the information below for specific types of learning disabilities and related disorders. • LDs can be compensated for and even overcome through alternate ways of learning, accommodations, and modifications. • According to the U.S. Department of Education, LDs affect approxi- mately 5% of all children enrolled in public schools. • LDs can occur with other disorders (AD/HD, information processing disorders). • LDs are NOT the same as mental retardation, autism, deafness, blind- ness, behavioral disorders, or laziness. • LDs are not the result of economic disadvantage, environmental fac- tors, or cultural differences. LD Terminology Learning Disabilities • Dyslexia • Area of difficulty: Processing language • Symptoms include trouble with: Reading, writing, and spelling • Example: Letters and words may be written or pronounced back- wards • Dyscalculia • Area of difficulty: Math skills

370 Mental Health Information for Teens, Third Edition • Symptoms include trouble with: Computation, remembering math facts, concepts of time and money • Example: Difficulty learning to count by 2s, 3s, 4s • Dysgraphia • Area of difficulty: Written expression • Symptoms include trouble with: Handwriting, spelling, compo- sition • Example: Illegible handwriting, difficulty organizing ideas • Dyspraxia • Area of difficulty: Fine motor skills • Symptoms include trouble with: Coordination, manual dexterity • Example: Trouble with scissors, buttons, drawing Information Processing Disorders • Auditory Processing Disorder • Area of difficulty: Interpreting auditory information • Symptoms include trouble with: Language development, reading • Example: Difficulty anticipating how a speaker will end a sentence • Visual Processing Disorder • Area of difficulty: Interpreting visual information • Symptoms include trouble with: Reading, writing, and math • Example: Difficulty distinguishing letters like “h” and “n” Other Related Disorders • Attention Deficit Hyperactivity Disorder (AD/HD) • Area of difficulty: Concentration and focus • Symptoms include trouble with: Over-activity, distractibility and impulsivity • Example: Can’t sit still, loses interest quickly

Chapter 50 Puberty How much will an adolescent grow? The teenage years are also called adolescence. During this time, an ado- lescent will see the greatest amount of growth in height and weight. Adoles- cence is a time for growth spurts and puberty changes. An adolescent may expect to grow several inches in several months followed by a period of very slow growth, then will typically have another growth spurt. Changes with puberty may occur gradually or several signs may become visible at the same time. There is a great amount of variation in the rate of changes that may oc- cur. Some adolescents may experience these signs of maturity sooner or later than others. It is important to remember that these changes happen at dif- ferent times for everyone. Being smaller or bigger than other females or males is normal as each child experiences puberty at his/her own time. On average males begin puberty between 9.5–14 years of age, and females begin puberty between 8–13 years of age. About This Chapter: This chapter begins with information from “Puberty: Adoles- cent Male” and “Puberty: Adolescent Female,” which is reprinted with permission from the Cincinnati Children’s Hospital Medical Center website, http:// www.cincinnati childrens.org. © 2007 Cincinnati Children’s Hospital Medical Cen- ter. All rights reserved. Additional information is cited separately within the chapter.

372 Mental Health Information for Teens, Third Edition Female What changes will occur during puberty? Females experience puberty as a sequence of events, but their pubertal changes usually begin before boys of the same age. Each girl is different and may progress through these changes differently. The following is a list of changes that occur during puberty. • Beginning of puberty: 8 to 13 years • First pubertal change: breast development • Pubic hair development: shortly after breast development • Hair under the arms: 12 years of age • Menstrual periods: 10 to 16.5 years of age ✤ It’s A Fact!! Some adolescents may experience signs of maturity sooner or later than others. It is important to remember that these changes happen at different times for everyone. Source: © 2007 Cincinnati Children’s Hospital Medical Center. There are specific stages of development that females go through when developing secondary sexual characteristics. The following is a brief over- view of the changes that occur: • In girls, the initial puberty change is the development of breast buds, in which a small mound is formed by the elevation of the breast and papilla (nipple). The areola (the circle of different colored skin around the nipple) increases in size at this time. • The breasts then continue to enlarge.

Puberty 373 • Eventually, the nipples and the areolas will elevate again, forming an- other projection on the breasts. • At the adult state, only the nipple remains elevated. • Pubic hair development is similar for both girls and boys. The initial growth of hair produces long, soft hair that is only in a small area around the genitals. This hair then becomes darker and coarser as it continues to spread. • The pubic hair eventually looks like adult hair, but in a smaller area. It may spread to the thighs and sometimes up the stomach. The following are additional changes that may occur for the female as she experiences the changes of puberty: • There may be an increase in hair growth, not only the pubic area, but also under the arms and on the legs. Some women may decide to shave this hair. • Body shape will begin to change. There may be not only an increase in height and weight, but the hips may get wider and the waists get smaller. There may also be an increase in fat in the buttocks, legs, and stomach. These are normal changes that may occur during puberty. • Body size will increase, with the feet, arms, legs, and hands sometimes growing faster than the rest of the body. This may cause an adolescent girl to experience a time of feeling clumsy. • As the hormones of puberty increase, adolescents may experience an increase in oily skin and sweating. This is a normal part of growing. It is important to wash daily, including the face. Acne may develop. • Adolescent girls will also experience menstruation, or menstrual peri- ods. This begins when the body releases an egg from the ovaries. If the egg is fertilized with a sperm from a male, it could potentially grow into a baby inside the uterus. If the egg is not fertilized, the tissues inside the uterus are not needed and are shed through the vagina as fluid. The fluids are bloody and are usually released monthly. After a girl begins to menstruate, she is able to get pregnant.

374 Mental Health Information for Teens, Third Edition Males What changes will occur during puberty? In males, it is difficult to know exactly when puberty is coming. There are changes that occur, but they occur gradually over a period of time rather than as a single event. The following is a list of changes that occur during puberty. • First pubertal change: enlargement of the testicles • Penis enlargement: begins approximately one year after the testicles begin enlarging • Appearance of pubic hair • Hair under the arms, on the face, voice change, and acne • Ability to obtain orgasm, typically experienced as a wet dream The following are additional changes that may occur for the male as he experiences the changes of puberty: • Body size will increase, with the feet, arms, legs, and hands sometimes growing “faster” than the rest of the body. This may cause the adoles- cent boy to experience a time of feeling clumsy. • Some may experience some swelling in the area of their breasts as a result of the hormonal changes that are occurring. This is common among teenage boys and is usually a temporary condition. Consult with your adolescent’s physician if this is a concern. • Voice changes may occur, as the voice gets deeper. Sometimes, the voice may “crack” during this time. This is a temporary condition and will improve over time. • Not only will hair begin to grow in the genital area, but males will also experience hair growth on their face, under their arms, and on their legs. • As the hormones of puberty increase, adolescents may experience an increase in oily skin and sweating. This is a normal part of growing. It is important to wash daily, including the face. Acne may develop.

Puberty 375 • As the penis enlarges, the adolescent male may begin to experience erections. This is when the penis becomes hard and erect because it is filled with blood. This is due to hormonal changes and may occur when the boy fantasizes about sexual things or for no reason at all. This is a normal occurrence. • During puberty, the male’s body also begins producing sperm. Semen, which is composed of sperm and other bodily fluids, may be released during an erection. This is called ejaculation. Sometimes, this may happen while the male is sleeping. This is called a nocturnal emission or “wet dream.” This is a normal part of puberty and will stop as the male gets older. Understanding Normal Adolescent Mental Develop- ment The adolescent years bring many changes, not only physically, but also mentally and socially. During these years, adolescents increase their ability to think abstractly and eventually make plans and set long-term goals. Each child may progress at different rates, and show a different view of the world. In general, the following are some of the abilities that may be evident: • Developing the ability to think abstractly • Concerns with philosophy, politics, and social issues • Thinking long-term • Setting goals • Comparing oneself to one’s peers Relationships With Others In order to achieve independence and control of one’s environment, many changes may need to occur. The following are some of the issues that may be involved with your adolescent during these years: • Independence from parents • Peer influence and acceptance is very important

376 Mental Health Information for Teens, Third Edition • Male-female relationships become very important • He/she may be in love • He/she may have long-term commitment in relationship Questions And Answers About Puberty Excerpted from “Questions Answered,” BAM! Body and Mind, Centers for Dis- ease Control and Prevention, 2003. What is puberty? Puberty is a time in your life when your body makes changes that cause you to develop into an adult. These changes affect both how you look like growing taller and developing more muscle. They also affect how you feel— one minute you want to be treated like an adult, at other times you want to be treated like a kid. What causes these changes? Hormones in your body increase, and these make the changes of puberty happen. For girls, these hormones are estrogen and progesterone. For boys it’s testosterone. Much of what happens to your body is controlled by your hormones and the “genetic map” that your body is following. Of course, no one can control these two things. What is that smell? During puberty, both boys and girls sweat glands are more active. Kids will also sweat more during puberty. A lot of kids notice that they have a new smell under their arms and elsewhere on their bodies when they hit puberty, and it’s not a pretty one. That smell is body odor (you may have heard people call it B.O. for short), and everyone gets it. The hormones become more active, affect the glands in your skin, and the glands make chemicals that smell bad. So what can you do to feel less stinky? Well, keeping clean can stop you from smelling. You might want to take a shower every day, either in the morning before school or at night before bed. Showering after you’ve been

Puberty 377 ✔ Quick Tip Learning To Love What You See In The Mirror We all want to look our best, but a healthy body is not always linked to appearance. In fact, healthy bodies come in all shapes and sizes. Chang- ing your body image means changing the way you think about your body. At the same time, healthy lifestyle choices are also key to improving body image. • Healthy eating can promote healthy skin and hair, along with strong bones. • Regular exercise has been shown to boost self-esteem, self-image, and energy levels. • Plenty of rest is key to stress management. Source: Excerpted from “Loving Your Body Inside and Out,” National Women’s Health Infor- mation Center, March 19, 2008. playing sports or exercising is a really good idea. Another way to cut down on body odor is to use deodorant. If you use a deodorant with antiperspirant, it will cut down on sweat as well. Does everyone get pimples during puberty? About 85–90% of all kids—boys and girls—have acne during puberty. The hormonal changes that are happening inside your body cause the oil glands to become more active. It doesn’t mean that you are dirty, it just means that what is happening on the inside has put your oil glands into high gear and can causes acne or pimples. You may notice pimples on your face, your upper back, or your upper chest. Pimples usually start around the beginning of puberty and can hang around for a few years as your body changes.

378 Mental Health Information for Teens, Third Edition No one understands me. I am not in control. Why do I feel this way? Just as suddenly as your body starts changing, your mind is also making changes. The same hormones that cause changes in your appearance can also affect your emotions, making you feel like no one understands what you’re experiencing. You may feel like your emotions are all over the place. One minute you’re happy and bouncing off the walls, the next minute you’re los- ing your temper, or bawling your eyes out. What’s going on? Confusion and mixed-up feelings are normal. The dif- ferent hormones in your body can send your emotions on a roller-coaster ride. Puberty makes almost everyone feel that way. Make no mistake—your body has taken control and you are along for the ride. These changes in emotions are normal and once you’ve gone through puberty, the emotional roller coaster should slow down. Just keep your cool. It’ll gradually become easier as you get used to the new you. In the meantime, you can control other things that affect how you look, how you feel, and how healthy you are. Taking charge of your health can help you to feel good, and in control during the changes of puberty.

Chapter 51 Running Away “I’m afraid that my friend may run away. How can I stop it?” It is estimated that on any given night, there are between five hundred and one thousand homeless youth on the streets of Seattle, Los Angeles, Las Vegas, and other major cities. Many of them are runaways—teens under the age of 18 who leave their home or place of legal residence without the per- mission of parents or a legal guardian. They come from every social class, race, and religion. And they are usually hungry, scared, desperate, and very vulnerable to crime. If you think your friend is about to run away, ask her or him these ques- tions: • What else can you do to improve your home situation before you leave? • What would make you stay at home? • How will you survive? • What will you do for money? • Is running away safe? • Who can you count on for help? About This Chapter: This chapter includes text from “Running Away,” Office on Women’s Health (www.girlshealth.gov), June 11, 2008.

380 Mental Health Information for Teens, Third Edition • Are you being realistic? ✤ It’s A Fact!! • Have you given this enough According to the National Runaway thought? Hotline, there are many problems of be- ing a runaway, including the following: • What are your other options? • Nine out of ten teens return • If you end up in trouble, who home or are returned to their will you call? home by the police within a month. If your friend runs away, • When you return home, what she or he may not be one of the will happen? nine that returns home. • Why run away? • A lot can happen in one month. Many runaways, who remain in The most common reason that the streets for two or more teens run away is family problems weeks, will become involved in over such issues as: curfew, behav- theft, drugs, or pornography. ior, dress code,grades,and the choice One out of every three teens on of friends. Teens also may choose to the street will be lured into pros- run away because of problems they titution within 48 hours of leav- are afraid to face, such as bullying at ing home. school, pregnancy, sexual orienta- tion, or alcohol and drug problems. • Your problems at home are re- placed by more serious and dan- There are a number of teens gerous problems on the street. that may choose life on the street It’s not worth it. because of emotional, physical, and sexual abuse in their home. The • Being a teen is not easy. There nature of ANY kind of abuse—the are a whole lot of ups and downs, shame your friend may have, and changes, and new experiences. the possible involvement of par- ents, stepparents, or other family • Sometimes it may feel that your members—may make it extremely parents don’t make things easier difficult for your friend to tell.This with their demands. “My parents is not a time for your friend to run- don’t listen to me!” This is the away. most common complaint teens and even younger children have Encourage your friend to tell a about their parents. Parents, on teacher, counselor, babysitter, the other hand, have the same complaint: “She won’t listen to me.”

Running Away 381 neighbor, clergy person, or your parents. Offer to go along with your friend to give her or him support. Let your friend know that being abused is not her or his fault. Be clear to your friend—nothing about what they say, the way they look, or how they behave gives ANYONE the right to use or hurt them. Here are some signs that your friend may run away: • She or he has sudden and dramatic mood swings that affect eating and socializing patterns. • Her or his school grades, attendance, and behavior suddenly drop. • She or he suddenly starts carrying large amounts of money and even asks you to keep some of it. • She or he gives away clothing and other valuable items. • She or he starts talking to you about running away. “Do you think any- one would miss me if I leave home?” (Take these statements seriously.) If you are afraid that your friend may run away, consider these sugges- tions: • Let her or him know that running away will not solve anything. It will make things worse. • Ask your friend to get permission to stay with you and your family for a couple of days. • Encourage your friend to talk to her or his parents, grandparents, or teacher. • If your friend says she or he is being abused, tell your parents immedi- ately. Your friend’s life may depend on it. Your parents can call the police, local child protective services, or 1-800-4-A-CHILD (Childhelp USA). Here are some family communication tips: • Set aside time to talk to your parents every day. • Don’t expect your parents to read your mind.

382 Mental Health Information for Teens, Third Edition • Be specific about your expectations and requests. • Have patience—good communication takes time and effort. • Brainstorm ideas with your parents before making a final decision. • Ask for input from all family members. • Write things down. Make a list of changes you want to see. • Be willing to compromise with your parents. • Use community resources when you need help. Ask a teacher or school counselor for leads. If this doesn’t work, and you find yourself in a crisis with your parents, contact the National Runaway Hotline (1-800-RUNAWAY). They can help you work through your problems and even set-up conference calls with you and your parents. The hotline is staffed 24 hours a day. It is also confidential and free. Remember, running away doesn’t solve anything. It can make things worse.

Chapter 52 Suicide ✤ It’s A Fact!! Why do some teens If you are thinking about suicide, call think about suicide? 800-273-TALK (800-273-8255). Thinking about suicide NOW! often goes along with stressful Source: Office on Women’s events and feeling sad. Some Health, 2008. teens feel so overwhelmed and sad that they think they will never feel better. Some things that can cause these feelings include the following: • Death of a loved one • Seeing a lot of anger and violence at home • Having parents get divorced • Having a hard time in school, struggling with grades or having prob- lems with other teens • Depression or alcohol or drug problems • Anger or heart-break over a relationship break-up • Feeling like you don’t belong, either within the family or with friends • Feeling left out or alone About This Chapter: Text in this chapter is from “Suicide,” Office on Women’s Health (http://www.girlshealth.gov), March 12, 2008.

384 Mental Health Information for Teens, Third Edition ✔ Quick Tip Help is available anytime, anywhere. The National Suicide Prevention Lifeline is a free and confidential service for those who are seeking help when they feel like there is nowhere to turn. 800-273-TALK (8255) can be dialed toll free from anywhere in the United States 24 hours a day, 7 days a week. Trained crisis center staff are available to listen to your needs and offer these services: • Crisis counseling • Suicide intervention • Mental health referral information You are not alone. We are here to listen and to help you find your way back to a happier, healthier life. Source: Excerpted from “Lonely? Trapped? Hopeless? Alone? When it seems like there is no hope, there is help,” Substance Abuse and Mental Health Ser- vices Administration, January 2006. Sometimes, teens may feel very sad for no one clear reason. Every teen feels anxiety and confusion at some point, but it helps to get through tough times by turning to people you trust and love. If you don’t think you have people like this in your life, talk to a school counselor, teacher, doctor, or another adult who can help you talk about your feelings. There are ways to help teens deal with these intense feelings and work on feeling better in the future. How common is the problem of teen suicide? Suicide is one of the leading causes of death for teens. Girls try to com- mit suicide more often than boys. The important thing for you to know is that it doesn’t have to happen. It is also important to know that suicide is not a heroic act, even though sometimes media images can make it seem so. Often, a person who is thinking about attempting suicide isn’t able to see that suicide is never the answer to problems. Remember, there is always help—as well as support and love—out there for you or a friend.

Suicide 385 How can you help a friend? If you have a friend or friends who have talked about suicide, take it seriously. The first thing you should do is to tell an adult you trust—right away. You may wonder if your friend(s) will be mad at you, but telling an adult is the right thing to do. This can be someone in your family, a coach, a school nurse, counselor, or a teacher. You can call 911 or the toll-free number of a suicide crisis line. You can’t help your friend(s) alone. They will need a good support system, including friends, family, teachers, and professional help. Suggest that they should talk with a trusted adult. Offer to listen and encourage them to talk about their feelings. Don’t ignore their worries or tell them they will get better on their own. Listening shows that you take your friend(s) and their problems seriously and that you are there to help. If some- one is in danger of hurting himself or herself, do not leave the person alone. You may need to call 911. What about you? If you feel suicidal, talk to an adult right away. Call 911 or 800-SUICIDE, or check in your phone book for the number of a suicide crisis center. The centers offer experts who can help callers talk through their problems and develop a plan of action. These hotlines can also tell you where to go for more help in person. Things may seem bad at times, but those times don’t last forever. Your pain right now probably feels like it is too overwhelming to cope with— suicide may feel like the only form of relief. But remember that people do make it through suicidal thoughts. Ask for help—you can feel better. Don’t use alcohol or drugs, because they can’t take your problems away. If you can’t find someone to talk with, write down your thoughts. Try to remember and write down the things you are grateful for. List the people who are your friends and family and care for you. Write about your hopes for the future. Read what you have written when you need to remind yourself that your life is IMPORTANT! There is no reason that you or a friend has to continue hurting. There are ways to find help and hope.

386 Mental Health Information for Teens, Third Edition What if someone you ✔ Quick Tip know attempts or dies Suicide Warning Signs by suicide? Seek help as soon as possible by contacting a If someone you know mental health professional or by calling the Na- attempts or dies by sui- tional Suicide Prevention Lifeline at 800-273- cide, it’s important to re- TALK if you or someone you know exhibits any member that it isn’t your of the following suicide warning signs: fault. You may feel many different emotions: anger, • Threatening to hurt or kill oneself or talk- grief, guilt, or you may ing about wanting to hurt or kill oneself even feel numb. All of your feelings are okay; • Looking for ways to kill oneself by seek- there is not a right or ing access to firearms, available pills, or wrong way to feel. If you other means are having trouble dealing with your feelings, talk to • Talking or writing about death, dying, or a trusted adult or use the suicide when these actions are out of the contact information be- ordinary for the person low. It is important that you feel strong ties with • Feeling hopeless people at this time. • Feeling rage or uncontrolled anger or If you are thinking about sui- seeking revenge cide these places can help you. • Acting reckless or engaging in risky ac- • National Hopeline tivities—seemingly without thinking Network: 800-SUI- CIDE (784-2433) • Feeling trapped—like there’s no way out • National Suicide • Increasing alcohol or drug use Prevention Lifeline: 800-273-TALK (8255) • Withdrawing from friends, family, and society • Suicide Awareness- Voices of Education: • Feeling anxious or agitated, being unable 612-946-7998 to sleep, or sleeping all the time • Experiencing dramatic mood changes • Seeing no reason for living or having no sense of purpose in life Source: Excerpted from “Lonely? Trapped? Hopeless? Alone? When it seems like there is no hope, there is help,” Substance Abuse and Men- tal Health Services Administration, January 2006.