Navigating the College Application Process:

Guidelines for Adolescents and their Parents

     I cannot stand how busy I am, the patient, a high school junior, told his

therapist. It is just nonstop, homework, SAT tutor, track practice,

theater, model UN, community service, piano lessons, planning a summer

activity, I feel like I am never done. My grades are all right; I got a

1450 on my PSATs, but still feel as though it is not good enough to get into

the kind of school that I know I want to and that my parents expect me to.

³My entire future depends on this time of my life.

     Therapists are increasingly hearing complaints like this from adolescent

patients from middle and upper middle class families. Many teenagers believe

that unless they achieve at such an extreme level, their college

applications will suffer, they will fall short of their peers, disappoint

parents and teachers, and jeopardize their future.

Applying to College: Past and Present

	Until about 15 years ago, preparation for applying to college was a fairly

simple matter. High school students were expected to get good grades, to be

involved in extra-curricular activities, and do the best they could on their

SATs. Coaches were for sports, not standardized tests. While students were

expected to be well rounded, there were some limits to the number of

activities expected.

   	Today the sheer increased numbers of students attending

college, plus the decrease in available jobs for people without a college

degree, have meant that the college application process carries more

expectations for both students and their parents. Each year preparation

begins sooner. The increased competition for admission to schools, as well

as the cost of education, often produces high levels of anxiety and

pressure. Some teens and their parents insist that they need to get into a

top school in order to make a lot of money, meet the right people, or get

into law/medical/graduate school. They believe that their success in the

future depends largely upon their admission to the "right college". The

right college may not necessarily mean an Ivy League school; but it

usually means the best college they could get into, rated by external

standards. Exaggerated pressures in these families and their surrounding

school culture preclude their teenagers from recognizing that with good

guidance they can find a "right college" for them, in other words, a good

fit. Follow-up admissions data shows that most students can be very happy

with their choices and do well after graduation, irrespective of how their

school is ranked by U.S. News and World Report.

   	While most parents genuinely seek the best for their college-bound

children, some inadvertently create unnecessary pressures for them. Today's

parents work hard to help their children afford a college education (which

can, at many private colleges, exceed $50,000 per year) and spend more money

for tutors and activities that can enrich their child's development. If the

parents cannot afford this and the child will graduate from college with

large loans, everyone may feel that only the best school is worth incurring

such a debt. Some parents impose their financial insecurities on their

children by reinforcing exaggerated beliefs about the relationship between

college admission and future success. Some parents compete with one another,

comparing and trying to outdo each other, using their children's  prowess in college admission

 as a measure of their own success. Some students, believing they will fail, stop trying. 

Parents and students often focus excessively on these issues in order to avoid painful issues

around separation that lie ahead.

   	In schools with high proportions of such families, the school

culture reinforces these pressures. In private high schools with high

tuition, administrators and teachers may want to prove their worth by

sending large numbers of students to top tier schools.

The Dilemma of Perfectionism

	Clinicians often find that middle and upper-middle class families who suffer

the most with the college application process struggle with problems of

perfectionism. Parents or children with high levels of anxiety, depression

or narcissism may be particularly likely to let this process spin out of

control. The children may believe that whatever they do in preparation for

the college application process will never be enough, and that what they do

accomplish is never good enough. Perfectionism exaggerates their fears of

failure: They worry excessively that other students are doing more, doing

better, and will be accepted instead of them when the colleges make their

decisions. When asked what would be "enough" many do not even have an

answer. Some of these children express the belief that there can be no limit

to what they must do in preparation for college applications. Hearing this

helps us better understand the high incidence of symptoms such as sleep

disturbance, upset stomach, irritability, depressed mood, self-destructive

behaviors, and even suicidal thoughts and gestures that occur in these

children. They often attempt to relieve this stress through risky behaviors

such as drugs, alcohol, and sexual acting out. Their families also express

conflicts around perfectionism through repetitive arguments and frustrated

communications and interactions.

Reducing Stress Related to the College Application Process

	With rising costs and increasing competition to get into schools, it is not

likely that the college admission process is going to get easier. Because

adolescence is one of the hardest times in a young person¹s development it

is important that parents and students be aware of things they can do to

help themselves and each other navigate this important transition in family

life.

Parents can help by:

1. Working to decrease their own anxieties and projections

   over their child's performance.

2. Actively listening to their teens and helping them resist school

   pressures.

3. Encouraging a balance of leisure and social activities with

   academic and structured activities.

4. Supporting, modeling, and teaching stress management.

5. Watching for signs of overwhelming stress or burnout.

6. Refraining from comparing their children with those of others.

7. Taking the time to offer praise and reward for accomplishments, but

   also for emotional connection and life balance.

8. Taking the time to do family activities and have conversations outside

   of the college application process.

9. Being aware of teens' eating and sleeping patterns, looking for any

   troubling changes, and seeking appropriate professional help if necessary.

Teens can help themselves by:

1. Learning to be kind to themselves, and not use beating

   themselves up as a motivating force.

2. Focusing on learning, and developing one's own interests,

   rather than working primarily for a good resume.

3. Eating and sleeping on a regular schedule (often a difficult

   thing to do if one is taking 5 AP courses, two sports, and

   several other activities).

4. Avoiding excess caffeine, liquor, drugs, or cigarettes to

   cope with stress. 

5. Exercising. 

6. Finding friends with whom to talk, especially about subjects other

   than grades and colleges.

7. Having the courage to seek professional help if feelings of increased

   stress, anxiety, depression or eating disorder develop. If a friend develops

   these symptoms, seeking the help of an adult rather than trying to handle it

   alone.

8. Telling parents and getting help immediately if there are

   feelings of desire to hurt oneself.

David Wohlsifer, DHS, LCSW is a licensed Clinical Social Worker. He is an

associate at BPR with 12 years of experience in working with children,

adolescents, adults, couples, and families. Dr. Wohlsifer is also a faculty

member at the University of Pennsylvania's Center for Cognitive Therapy.

Winter, 2005

Antidepressant Medications for
Children and Adolescents

The Food and Drug Administration (FDA) recently ordered manufacturers of
antidepressant medications to issue strong warnings about the risk of
increased suicidal thoughts and behavior in children and adolescents who
take these medications. While this order was issued to help save lives, it
has had the effect of scaring many parents and causing some physicians to be
reluctant to use them in treating depressed children. Media coverage has
added to this problem by presenting information in a confusing and
sensational manner. How could it be that the very medications used to treat
the psychiatric illnesses that lead to suicide could possibly in and of
themselves cause suicidal behavior in children and adolescents? This article
attempts to clarify this question and to provide important recommendations
for the use of antidepressant medications in children and teenagers.

Consequences of Untreated Depression in Childhood and Adolescence

Untreated psychiatric illness in a family member can create enormous stress
in the family and lead to additional problems, such as divorce, financial
difficulties, and social isolation. In addition,
children and adolescents who suffer from untreated depression demonstrate
disproportionately high rates of serious mental illness and shortened
mortality in adulthood. Ultimately, untreated depression can lead to the
most tragic consequence of all, suicide.

Consider the following facts:
    

• Suicide ranks third as a cause of death among young Americans ages 15
  to 24 behind accidents and homicides.

• Research indicates that about 90% of those who commit
  suicide have at least one diagnosable psychiatric disorder.
  Depression-related disorders are by far the most common.

•  Currently estimates are that one in ten children and adolescents in
  the United States suffers from psychiatric problems severe enough to cause
  some level of impairment; yet fewer than one in five of these children
  receives treatment.
  

Antidepressant medications are considered to be an important component of
the treatment approach that professionals use in addressing the problem of
depression and preventing suicide. Understanding how these medications work,
their proper role in the treatment of depression, as well as the FDA¹s
current basis for stronger warning, is important for families and health
professionals to better appreciate their value for children and adolescents.

Examining and Interpreting the Data

  What prompted the FDA to make recommendations for stronger warnings about
the use of antidepressant medications in children and adolescents? They
reviewed the studies of 4,400 children who had been treated for depression.
These studies involved the use of nine different antidepressant medications. Out of
these 4,400 children only 78 experienced thoughts of harming themselves.
Among that group there was a 2% higher difference between those children
treated with an antidepressant and those with placebo. In other words, about
4 out of 100 children treated with antidepressant medication had thoughts of
harming themselves, whereas only 2 out of 100 children treated with placebos
had such thoughts. It is important to note that there were no actual
suicides in any of the 4,400 cases.

   The FDA also held hearings during which some families who had lost
children to suicide testified that they believed that the antidepressant
medications had contributed to the suicide of their child. There were also
other families who reported that antidepressant medications had saved their
children¹s lives. Even though these reviews were mixed, the FDA felt in
balance that it was prudent to provide stronger warnings about the use of
antidepressant medications in youth.

   While it seemed to some of the families who lost their children to
suicide that it was the medication that caused their children's suicides,
it seems more likely that what ultimately took their children¹s lives was
the underlying psychiatric disease. Medications can be powerful in combating
the devastating effects of depression, but they cannot reverse these effects
in every case.  

   
   Two other points about suicide risk should be added: First, children and
adolescents may be more sensitive to side effects of medications and may
feel worse, especially when a medication is first started. Close monitoring
by a knowledgeable professional is important here to insure that these
effects are subsiding or, if not, to recommend another medication.

   Second, adults and children with severe depression are often at higher
risk for completed suicide as their depression lifts. This is due to the
sequence of improvement in depressive symptoms. Oftentimes symptoms such as
low energy improve before the sad mood improves. This can lead to the person
having more energy to actually follow through on thoughts of self-harm. This
is why it is so important to have careful monitoring of patients being
treated for severe depression by a qualified professional (s).

   On a positive note, since the mid 1990¹s the suicide rates for youth have
steadily decreased  a trend which strongly correlates with the increased
use of antidepressant medications by psychiatrists and other physicians. It
should also be emphasized that there has been no actual causal link made
between the use of antidepressant medications and an increase in suicide
attempts among adults or children.

Reflections and Recommendations

The most important consequence of the FDA's recent warnings has been to
increase public awareness of adverse events that can occur while children and 
adolescents are in treatment for depression and on antidepressant medication. 
The "take-home" message for parents and professionals should be that while these medications
are generally safe and effective, they should not be used capriciously. The following guidelines
should be considered when a child or adolescent is suspected to be suffering
from a depression-related disorder:

•    Youth who exhibit signs and symptoms of depression and/or other
  psychiatric illness should receive a comprehensive evaluation from a
  psychiatrist or other qualified physician. It is important to obtain an
  accurate diagnosis and consider the full range of treatment options
  available, which may or may not include medication. Any family history of
  depression, bipolar disorder, or completed or attempted suicide should be
  reported.

•   If medications are recommended, they should be started and carefully
  monitored by a qualified physician who will follow the child through
  treatment. These medications are more effective when used in conjunction
  with other therapies such as family and/or individual therapy.  

•  Family members, physicians and therapists need to have good access to
  and communication with each other so that they can effectively collaborate
  in the patient¹s treatment.

• Whenever an antidepressant is started or its dose is changed, the
  physician should meet with the child at least once weekly and more often if
  problems arise. Close attention should be paid to the child¹s moods and
  behaviors, as well as any sudden changes in them. Parents, teachers and
  other important people in the child¹s life should be asked to help in
  observing the child.

• Warning signs and symptoms in a child who is being treated with
  antidepressant medications include: Suicidal thoughts or attempts,
  increasing depression and/or anxiety feelings of agitation or restlessness,
  panic attacks, difficulty sleeping, irritability, angry, aggressive,
  impulsive or violent behavior, hyperactive speech and/or movement, and any
  other unusual changes in behavior. These behaviors should be noted and
  reported to the child¹s parents and therapist.

• While fluoxetine (Prozac) is the only antidepressant that has received
  the FDA¹s formal approval for treating depression in youth, most of the
  other antidepressants used in the treatment of depression in adults have
  also been used safely and effectively with children. Because patients can
  vary widely in their response to medications, it is important that
  physicians are able to utilize the full range of antidepressants available
  in order to combat the devastating effects of depression.
    

Parents should continue to seek treatment for their children suffering from 
depression and other psychiatric disorders. Fortunately, the large majority of
these children can be safely helped by the treatments that are currently available.

Vicki Morrow, MD is a child, adolescent, and adult psychiatrist in private
practice with Bala Psychological Resources. She provides comprehensive
psychiatric care including full psychiatric evaluations, individual
psychotherapy, family therapy and pharmacotherapy. She served as an
independent evaluator for the 2004 NIMH Treatment of Adolescent Depression
Study, and has worked as a psychiatrist in the Philadelphia Juvenile
Detention Center.