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The 180 Podcast Feb 4, 2022

The 180 Podcast: Pamela Cantor, M.D.: State of Emergency in Adolescent Mental Health

Pamela Cantor, M.D.: State of Emergency in Adolescent Mental Health

It’s a national emergency: child and adolescent mental health. 

The CDC reports that “in May 2020, emergency department visits for suspected suicide attempts began to increase among adolescents aged 12–17, especially girls.” And from February to March 2021, visits for suspected suicide attempts were up 51% for adolescent girls and nearly 4% for boys compared with the same period in 2019. 

And now, U.S. Surgeon General Dr. Vivek Murthy has released a strongly worded advisory entitled Protecting Youth Mental Health. Here’s one excerpt: “The pandemic era’s unfathomable number of deaths, pervasive sense of fear, economic instability, and forced physical distancing from loved ones, friends, and communities have exacerbated the unprecedented stresses young people already faced.”

So what is it about adolescents and the adolescent brain that has made them particularly vulnerable to pandemic stress. And what can we as teachers, parents, and caregivers do to support them? 

Dr. Pamela Cantor has helped many young people surmount times of crisis. She practiced child and adolescent psychiatry for nearly two decades, specializing in trauma. She is also the Founder and Senior Science Advisor of Turnaround for Children, and is an author, and thought leader on the science of learning and development and human potential. 


Complete Transcript

Chris Riback: Pam, thanks for joining me. I look forward to talking with you.

Dr. Pamela Cantor: It’s great to be with you, Chris.

Chris Riback: Pam, today we read nearly every day, it seems, about a crisis facing our young people, especially their well-being and their mental health. In addition to the data I mentioned in the intro, more than 140,000 children in the US have lost a caregiver during the pandemic, with youth of color disproportionately impacted. as someone who is a physician and a mental health professional, set the context for us. Is there a crisis and who’s most affected by it?

Dr. Pamela Cantor: There is a crisis today, particularly for young people between the ages of 10 and 25. Overall, the message in the data to me is that there is a certain group most deeply affected. But then if we look across genders and races and say, “Who is most likely to access help?” We have an additional problem, because kids that are non-White, Black, Latino, Asian American, Native American, and kids from low income households, are much less likely to have access to good care. Today, we have lots of kids needing supports. Some are intense, some not, but the problem is that we have very poor ways of differentiating who needs what, and we have issues of access based on distrust of the mental health system, of stigma and labeling, and we have fewer and fewer resources that are high quality. So what makes this a crisis is the compounding of all of these things. Yes, adolescents are the most vulnerable among our kids and our mental health system is the most fragile, under-resourced and under-developed of our support systems.

Chris Riback: There is so much to consider there. Let’s go deeper on a few of the points that you’ve raised. First, why adolescence? Most parents think of teens as challenging on a good day, is this just more of that, Pam? Or is there something more going on here?

Dr. Pamela Cantor: Chris, this is such an important question, because adolescence is actually one of the most misunderstood periods in a young person’s life. So let me tell you five myths about adolescence.

One, it’s a crazy period full of impulsive risk taking, because hormones are raging. Wrong, hormones play an important role in the period, but those hormones are actually part of a much more significant biologic process going on in the brain where the brain during adolescence is actually getting remodeled. Where capacities for thinking, reflecting, discovering, self-awareness, they become established and these capacities are essential to that young person becoming a healthy, capable adult. 

Number two, adolescents want independence and they don’t think of adults as particularly useful. Also wrong, adolescents crave connection. They crave engagement with people, especially people outside their families, but also inside their families and especially their siblings. What they really want is interdependence.

Number three, adolescents don’t respect boundaries, they’re always testing limits. Also wrong. The work of adolescence is exploration. It’s about curiosity and novelty. Curiosity grows exponentially in adolescence and for many kids, this is where creativity is born. Character is shaped by the experiences that adolescents have and what they learn from them. 

Four, adolescents are emotionally intense. Well, I think we’d agree with that point.

Chris Riback: Yes.

Dr. Pamela Cantor: But it also has an upside. The downside we know, adolescents are moody and emotions rule, but the upside is the discovery of interests, passions, energy, creativity, and above all, a sense of purpose. 

And adolescents live in the present, another myth, because adolescents actually live in the future in what is new, what is novel, what’s coming next. Always thinking about the next thing that’s going to happen, graduation, college, job, who they will be, where they will go, who they will go with. Adolescents have a huge future focus, which is one of the reasons for the profound effect of the pandemic on this age group, being able to see one’s future and watching all of these hopes get disrupted.

Chris Riback: That is fascinating context and insight. And now that you have destroyed virtually everything I thought I knew about adolescence, can you tell me what’s true about them?

Dr. Pamela Cantor: What is true about adolescents is that life is on fire for them. The changes that occur in the adolescent brain, in their ways of thinking, and being, and reasoning, and relating, and focusing, and making decisions can’t happen at any other time in a child’s life. So these are crucial capacities that depend on this period and they very much become the shapers of who this young person is going to become. Chris, can you imagine trying to have a conversation with your eight year old that is the same as the conversation you’d have with your 16 year old?

Chris Riback: Absolutely not.

Dr. Pamela Cantor: All of this change, all of it is driven by two primary things. The biologic changes in the brain at this time of life, and then, because of the brain’s malleability, which means that the brain can change from experience. The experiences that adolescents will have, will have a huge influence on how their brains develop. So if experiences are unusually confining as opposed to expansive, if they are blaming and shaming as opposed to affirming, they will have very, very different influences on the development and health of the emerging adolescent brain. Now, maybe you can see where I’m heading here, but these are some of the reasons why the impact of the pandemic has been so, so difficult for this age group.

Chris Riback: Yes, I mean, the pandemic has created stress for all of us for sure, and for some populations more than others, as you’ve identified, such as Black, Indigenous and Asian people. But I think you’re also saying that the stress that adolescents are experiencing is particularly intense and unique to that age group and that this has a lot to do with the mental health issues that are surging, that we see in the data that I’ve mentioned.

Dr. Pamela Cantor: So there’s something I want to say at the outset that is intuitively obvious, but I need to be explicit about it when we talk about health as compared to illness, wellness and illness exist on a continuum. It is shades of gray, it’s not black and white. The human mind and body are living structures. Every single cell and structure that we are made of can get frayed, it can get worn out, because of cumulative stress. And that will move us on the continuum from health and wellness toward illness. So think about a physical activity like sports, and what happens to knees and hips and shoulders from running, basketball or football. The cumulative stress on any body part is something we call allostatic load. Allostatic load which refers to the impact of stress on any living system.

For a while, the body will adapt to the stress and adaptation is a good thing. If we take care of our bodies with sleep, with nutrition, with stretching, coaching, meditation, we can even increase the adaptive capabilities that we have, we can increase our performance, because we have taken care of ourselves. We try to do more, run farther, play better, but if we don’t protect our human structures, they will wear out and then we can suffer an injury and we’ll have to recover. The brain is also a target of stress, it has incredible adaptive and resilient capabilities. As anyone who’s recovered from a loss or an accident or an illness will attest, but it too is a target of stress and all the hormonal activities that goes with stress, hormones like cortisol and others will affect the brain. And when that cumulative stress hits the brain and we don’t do things to offset that stress, we start to move from health toward illness and symptoms appear.

Chris, if I asked you, have you ever been anxious? Have you ever had a low mood? Have you ever had trouble concentrating or had a sleepless night? What would you say?

Chris Riback: I would say I’m not going to lie, Pam, I’m starting to get worried that you have spy cams in my house. So yes, I take your point and I’m listening, doctor.

Dr. Pamela Cantor: Okay. Well, that’s because most of us have had these kinds of experiences some of the time. But like I said about physical structures, that can just wear out when the brain is hit with unremitting, unbuffered stress, eventually, there are chemical imbalances in the brain of neurotransmitters that start to alter the way the brain functions. In other words, we start to move from wellness toward illness, to things like a more persistent low mood, one that doesn’t lift, or anxiety that doesn’t go away, or a feeling of hopelessness and despair or worse helplessness.

Chris Riback: I hear what you are describing, that there is a biological story behind the crisis. Tell me more about that, about the science of stress and how that science ties to emotional wellness, and even, if you would, learning?

Dr. Pamela Cantor: You know, we all have lived through just an extraordinary and unique period in this time of COVID where there is a paradox: to stay physically safe, we have had to be physically distant from some of the most important relationships in our lives. All of that side by side… Remember what you said, 140,000 kids having lost a primary or secondary caregiver. Uncertainty, losses, and grief have taken a huge toll on our families and our kids, and no group has been more affected than our teens. This is because relationships are biologically mediated by a very powerful hormone called oxytocin. This is the hormone that produces feelings of love, trust, attachment and safety. And that’s not all. Oxytocin hits the same structures in the brain as cortisol, our primary stress hormone, but oxytocin is the more powerful hormone at the level of the cell.

It can literally protect us from the damaging effects of stress and cortisol, and this is the reason why the effects of trauma are reversible. Not the events, of course, but the effects, the feelings and the emotions associated with trauma are reversible. So this what I meant about protecting our bodies and our brains from the effects of stress. And by far, the most powerful way to do that is through relationships, connection and trust. Relationships that are strong and positive cause the release of oxytocin and this not only helps us manage stress, it offsets the damaging effects of cortisol and it can even produce resilience to future stress.

Chris Riback: It’s fascinating to think of relationships as an antidote. Given that, can you say a little more about the kinds of relationships you’re talking about?

Dr. Pamela Cantor: I’m so glad that you used that word, Chris, because I often say that trust is the antidote to stress and trust is mediated by relationships. So when we speak about relationships, we’re not just talking about being nice to a child, we’re speaking about deep connections that are built through presence and through trust. And adolescents are so vulnerable today because they crave social connection, we know this. Social connection is the defining feature of adolescence and all of this has been profoundly disrupted for them by the pandemic. And with all this disruption, and given what we said before about emotional intensity in adolescents. 

Adolescents act on their emotions, and that could mean reaching for help, which is great, and we see this in the data, but it can also mean reaching for drugs or worse, self-harm, and we are seeing that in the data, too. But on the positive side, just think about all the stories that we have heard this year from extraordinary young people who have come forward to talk about their mental health challenges. Naomi Osaka, Simone Biles, Justin Bieber, and most recently, Lindsey Vonn, coming forward courageously to help others and say, “You are not alone.” If you’ll let me, I want to read you something from Naomi Osaka. She wrote this for Time Magazine last summer, shortly after removing herself from The French Open, citing her struggles with depression and anxiety. Remember the press she got for that?

Chris Riback: I do remember. We all remember. 

Dr. Pamela Cantor: She says, “Believe it or not, I’m naturally introverted, and I do not court the spotlight. I always try to push myself to speak up for what I believe to be right, but that often comes at a cost of great anxiety. I feel uncomfortable being the spokesperson or face of athlete mental health, as it’s still so new to me and I don’t have all the answers. I do hope that people can relate and understand that it’s okay not to be okay and it’s okay to talk about it. There are people who can help and there is usually light at the end of the tunnel.”

And just recently, Lindsay Vonn, in her new memoir, “There’s no reason to suffer in silence. There are so many of us out there that are experiencing the same thing. You’re definitely not alone.”

Chris Riback: Both of them are really chipping away at the stigma of mental illness.

Dr. Pamela Cantor: But in spite of the fact that adolescents often do feel alone, they are not sitting still. A 2020 national survey of 14 to 22 year-olds found that 90% of teens and young adults experiencing symptoms of depression are researching mental health issues online and most are accessing other people’s health stories, including, but not only the celebrities through blogs and podcasts and videos.

Chris, when I practiced as a therapist and a young person would come in telling me the latest disaster that had happened in their lives, something they thought was just terrible about themselves, I thought, “Wow, is this ever an opportunity?” One, because they trusted me enough to tell me about it and second, because they wanted help. They wanted changed something and gave me this big open door to help them. And there is nothing, I want to tell you, nothing as powerful or awesome as an adolescent that wants to make a change in their lives. I watched young people do the most extraordinary things, overcome things, perform in ways that they never thought possible. It’s an incredible thing to watch.

Chris Riback: And it’s an incredible thing to hear, and it segues back for me, to one of the things that you just read from Osaka, “It’s okay not to be okay.” That permissioning has to be so consequential. And given what you just said at the very end there, the power that can come from the opportunity when an adolescent does demonstrate that trust, it just connects. What a powerful statement, “It’s okay not to be okay.”

Dr. Pamela Cantor: Mm-hmm (affirmative).

Chris Riback: That makes me then think, Pam, so how does a teacher or a parent know where a young person is on this spectrum? How do they get to recognize it? Then hopefully we will get to what all of us can do about it.

Dr. Pamela Cantor: I want to try to say something helpful here, which is why I rely sometimes on sports analogies, because somehow if we were speaking about a strained knee or a pain in the shoulder, we’d take that as a signal that something might be wrong. And maybe we’d rest, maybe we’d go to the doctor, maybe we’d get some physical therapy, no shame or weakness in that. It’s not the same for mental health. The first signs of any challenge to emotional wellness are quite similar. There are things that we’re just not going to be able to do the way we do them when we’re feeling well. Maybe we can’t focus, maybe we can’t sleep, maybe we can’t have the same energy level or we feel demotivated.

It’s the change that needs to be noticed by the person, but if the person can’t see it or doesn’t want to see it, it has to be noticed by somebody else. And if these things persist day after day and they don’t change, even if something good happens and the symptom doesn’t change, it’s a clear signal that something is wrong and attention must be paid. But here’s the problem, and it is a big one. We spoke about shame, we spoke about stigma in mental health, because for some reason, when it comes to mental health, this is seen as weakness, it’s seen as damage, and in many, many cultures, there is enormous pressure to hide it, especially in families.

And even worse, there are people who just don’t trust mental health treatment, that if you are somebody who is having mental health treatment, you’re going to be labeled, you’re going to be made to feel defective. And this is especially true for families and kids of color. Parents in many cultures will not access resources, even if they’re there, for fear that the information is going to be used in a way that makes kids feel bad about themselves or that they get labeled. Nonetheless, today teens are taking matters into their own hands, they’re seeking help in surging numbers and this is great. They know something isn’t right, they know connection can help them. So the challenge for us is to make it a whole lot of easier than it is right now for kids to get help.

Chris Riback: So Pam, you’re also describing the opportunity and to some level responsibility for adults to have awareness and recognize what is going on. So what can we do to respond to this? How can we help people see emotional well-being as something to protect or a muscle to build?

Dr. Pamela Cantor: So, that means we’ve got to normalize things. Right now we have a crisis, because of a collision between the needs of our most vulnerable young people, our adolescents, and our most fragile systems, our learning and our mental health systems. This means that schools and the communities that they’re nested in need to be wired for relationships and support, whether learning is remote or in person, with the recognition that relationships and learning can happen anywhere in any setting. Schools are important, they’re absolutely important settings for relationships, but so are after-school settings. And any place that can normalize the experience of getting help will increase the access to help. The message coming from the science is clear, we need a new design in all of the settings in which children grow and learn mapped to the way the brain grows and develops.

Chris Riback: Well, you know what I want to ask you now, of course, is what does that new design look like? How do you do this?

Dr. Pamela Cantor: Well, you know a lot of work has been done on this, particularly over the last year and a half. And in fact, there is a playbook called the Essential Guiding Principles for Whole-Child Design and it was created by Turnaround for Children and the Learning Policy Institute, Linda Darling-Hammond’s organization. You can access it at, Whole-Child Design Principles. In this playbook, we describe five key components of any of the settings in which children grow and learn: positive developmental relationships, a culture of safety and belonging, rich, meaningful learning experiences so students discover what they’re capable of, the intentional development of the skills, mindsets, and habits that all successful learners have, and of course, integrated student supports free of shame, free of blame/stigma, easy to access, aimed at connection and prevention as well as intervention. Today, we know that a healthy context for learning requires attention to all of these things, health, mental health, academics, culture, 21st century skills.

Chris Riback: Pam, I love, anyone would love what you are outlining here. They provide some sense of optimism because of tactics and things that people could do. But blue-sky here with me for a moment, if school settings were to provide all of these elements, what then?

Dr. Pamela Cantor: Well, I think one thing I’d want you to know, Chris, is that school settings today, there are places where this is going on. And in that playbook that I mentioned to you, that’s what we elevate. We elevate places that are actually doing this. So this is not a theory, this is something that has been done, it’s going on, and because of that, what we’re really saying is, how do we have this go on in many, many, many more places? But it can be done. 

But let’s imagine what would happen to the emotional well-being of every young person if every environment had a relationship that gave them a view of their future, a belief in themselves, good coaching and mentoring, encouragement, think about the agency that we would harness and the curiosity and learning we’d ignite. Our young people would not just surmount the challenges of this year, we would push the arc of stress that we talked about away from illness, toward wellness, and at the same time, create a big down payment on the kinds of settings that will nurture emotional well-being for all children.

Chris Riback: So if you were designing, say a prescription for what communities, schools, parents, should prioritize, and maybe there are examples to point to from any of the places that you mentioned, that are implementing your playbook, what should be prioritized when those groups, communities, schools, parents, are seeking to address the well-being of young people?

Dr. Pamela Cantor: I wanted to prepare this for you, so here’s what I prioritize. First, we need a big public awareness campaign to correct misinformation about mental health, reduce stigma and shame, and get the right information about emotional wellness and mental health to kids and families. Meaning what I talked about before, about building emotional muscle. Second, we need good materials and training for adults and young people on how to know if there is something really wrong and there are good places to go for help, different kinds of places. Not everybody wants to go to a clinic or a hospital, some folks don’t want to access services in schools.

Chris Riback: Mm-hmm (affirmative).

Dr. Pamela Cantor: There is the internet, there are many, many different kinds of settings, and we have to give people choices about where they would be most comfortable accessing help. Third, we need systems of support that are organized. Remember I talked about differentiating need, set up in tiers, to make it easy for adults to differentiate who needs what. And this is not just in schools, this is in all settings that young people are in.

Chris Riback: What does that look like?

Dr. Pamela Cantor: Well, if all adults were trained to know how to support kids and they received actual training… Now, I’m talking about teachers, of course, but not just teachers, I’m talking about cafeteria workers, coaches, everybody knows about how to recognize the signs of trouble in young people and how to support their well-being. And building relationships with kids, there is nothing more important than connection. But what if all adults knew how to do that? So that kind of training for everyone. Fourth, we need to plan specialized training for crises. If you think about how in an ER, if somebody comes in with physical trauma, there’s kind of a trauma team and a trauma room.

Chris Riback: Yes.

Dr. Pamela Cantor: Not for mental health. In mental health, those kinds of teams and that kind of specialized training doesn’t exist. There are no places for kids to be while a crisis gets stabilized. And finally, fifth, mental health intervention hasn’t changed much in several decades. Do we know what the active ingredient is in a mental health intervention? Is it the relationship? Is it a medication? Is it a way of communicating? But if we knew that, we would understand that like all interventions, one size doesn’t fit all, so we could deconstruct it and again, get much, much more targeted help to kids. So bottom line is we need much more R and D on the interventional side of mental health.

Chris Riback: So within a sense of urgency, what you’ve just described about investing in more R and D, is there funding to do that? Is there incentive to do that? Is there energy to do that? Where does that come from?

Dr. Pamela Cantor: There is a much greater sense of urgency now and you can see it in something like the advisory that was just published by the Surgeon General, Dr. Vivek Murthy’s office. This is an advisory that compiles an enormous amount of information that will be useful to teachers, parents and kids. And at the very same time, the Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association have actually come together to declare a national emergency in child and adolescent mental health. This is the opportunity we have now and the inflection point we are in. 

Chris Riback: And to close, Pam, because in listening to that, I can’t help but think, you have spent a career at this, you have seen what happens first-hand with the children and adolescents that you have worked with, with the schools that you have engaged with, with the panels and thought leaders and surgeons general that you have engaged with, and you have described in incredible detail, our current situation, where we all are right now. How do you balance the hopefulness that I know you have as a person and that I’m hearing in what you’re describing right now, how do you balance that hopefulness with the reality of the challenge that you also have just described?

Dr. Pamela Cantor: Well, you know me very well, so you know that nothing is going to change the hopeful side of me.

Chris Riback: Indeed.

Dr. Pamela Cantor: But I think there actually are some very important reasons to have that hope. I mean, if we look back, we know that we have made progress against obstacles. I certainly know it from my career in medicine. We have found cures to diseases, we have changed public health crises and turned them into opportunities. Even when you look at something like climate and electric cars and all of the changes that are happening in that space, you’re looking at how new knowledge becomes new practice, which then becomes a movement toward a change at scale. So what gives me hope is that you need a disruption often to get that big boost, to get that more significant change. And I do think when we look back at this time of disruption because of the pandemic, there are some very, very big things that will have changed. One of the biggest is in our learning systems and the other is going to turn out to be in our health and wellness systems.

Chris Riback: Well, I’m not surprised that you see the opportunity in what we are all facing. Pam, thank you. Thank you for the conversation and thank you for everything that you are doing and Turnaround is doing for our children.

Dr. Pamela Cantor: Thank you, Chris, for this opportunity to talk.

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