Adolescence is an amazing phase of life. True, there are some who think the phase is overstated, including psychologist Robert Epstein, the founding director of the Cambridge (Massachusetts) Center for Behavioral Studies and the author of The Case Against Adolescence: Rediscovering the Adult in Every Teen. He believes that, as a nation, we are infantilizing our youth by relegating them to the frivolous world of teen culture. Epstein also argues that the teenage brain may well be as much the product of the turmoil around it as the cause, and to some extent the authors of Treating and Preventing agree: “The brain is an eminently plastic organ that develops both in accord with genetic rules and in response to its environment.”

But those same authors also provide a lot of evidence that adolescence is a unique period of “dramatic change in brain structure and function.”

Synaptic change. Synapses are the small junctions across which a nerve impulse passes from one nerve cell to another (or to a muscle cell or gland cell). Oddly enough, there is a “major reduction in the number of synapses” during adolescence, which appears to reflect “active restructuring of connections and the sculpting of more mature patterns, with a corresponding pruning of connections with very little activity.” That reduction helps the adolescent brain become “more efficient and less energy consuming,” which in turn “may permit more selective reactions to stimuli …”

Myelination. The process of myelination during adolescence is also thought to contribute to the development of the brain’s “executive functions,” including faster information processing. (Myelination is the formation of a myelin sheath around a nerve fiber; myelin both insulates the nerves and permits the rapid transmission of nerve impulses.)

Matter. The brain is made up mostly of white matter (whitish nerve tissue containing mostly myelinated fibers) and gray matter (brownish-gray nerve tissue composed of nerve-cell bodies and fibers). Adolescence is marked by an increase in white-matter density and a corresponding decrease in gray matter, especially in the frontal and prefrontal areas; the overall result is a net decrease in volume of the prefrontal cortex. The dorsal lateral prefrontal cortex, which controls impulses, doesn’t reach adult size until the early 20s, by which time there is “improvement in prefrontal executive functions, including response inhibition and organizational and planning skills.” Though more research needs to be done in this area, some studies indicate that adolescents with depression have relatively small frontal lobes, with less white matter in them. The frontal lobes “regulate the capacity to think something through and see the potential adverse outcome—and to say to yourself, No, not just to act impulsively or instinctually,” notes Evans. “Add to that an actual illness on top of it, whether it’s depression or an anxiety disorder, or substance abuse and alcohol, and you have a pretty uneven mix in terms of brain behavior and potential for adverse outcome.”

Some of the transformations in the adolescent brain have to do with the “hormonal reawakening of puberty,” which leads to sexual maturation and is “characterized by a cascade of hormones,” explains psychologist Linda Spear in another AMHI book, Adolescent Psychopathology and the Developing Brain. There is also a chicken-or-egg component, she notes: While rising hormone levels may be “precipitated” by the brain, they “also in turn may serve to trigger some adolescent-associated brain transformations.”

Though most mental illnesses first appear during adolescence or early adulthood, recent research suggests that those years offer an opportunity for preventing them and even changing the pathways of the brain. That could have far-reaching consequences.

“Mental health has not, historically, been preventive,” says Evans. “We treat conditions once they’re set up, but it’s like a cardiologist who might be studying an established ischemic heart disease—the real bang for the buck, so to speak, is to prevent ischemic heart disease. If one could prevent depression, that could be a real target.”

“There are opportunities to intervene early,” says Daniel Romer. “If the brain is still forming, then we still have the opportunity to use that plasticity to our advantage.”

If we don’t, that same plasticity can be a curse.

“It is dangerous because kids learn very well,” says Charles O’Brien. “Drugs can activate the brain’s reward system,” which is more fully developed at that age than the inhibitory or executive-function systems. “Many kids start smoking when they’re 12 to 14 or 16, and they develop addiction more rapidly than adults. That very plasticity, which can be good when learning a language or music, can be very bad when learning a bad habit.”

 

Patrick was 11 when he first began showing the manic symptoms of bipolar disorder during his family’s six-month stay in Hawaii. Two years later, the Jamiesons moved to Austin, where his mother chaired the Department of Speech Communication at the University of Texas. There his condition morphed into a “mixed state” in which both manic and depressive symptoms—fast thoughts, lack of focus, and low energy—reared their heads. After some months of “little sleep and still less focus,” Patrick “crashed out of the mixed state and into a five-month depression,” sleeping up to 18 hours a day and missing more school than he attended. But despite getting “poked and probed, scanned and scrutinized … as if every bodily fluid of mine that could be extracted was tested for diseases both rare and common,” no one could figure out what was wrong.

“We were in a town [Austin] that is highly educated,” recalls Kathleen. “It’s a university town. But the doctors there were one degree removed from a medical-research hospital. I’m sure doctors try to stay in touch with their own literature. But we went from doctor to doctor—who never, in the time that we confronted any of them, said, ‘This could be bipolar disorder.’ Which led me to think that maybe there are a lot of people out there who don’t have the benefit that we had of being tied to a major research hospital, whose children are not getting the treatment that they should have, as quickly as possible, simply because the doctors don’t know.”

When the Jamiesons moved to Philadelphia and Kathleen became dean of the Annenberg School, Patrick’s mania kicked back in. The move also put the Jamiesons into the orbit of a “local medical teaching hospital”—feel free to connect the dots—and with it “experts who not only recognized but also studied adolescent bipolar disorder.” They quickly diagnosed it as such.

Patrick was not, at the time, pleased with the diagnosis. “I wanted an illness caused by a bacterium that could be treated with an antibiotic or one produced by a splinter that could be removed by surgery,” he writes. A psychiatric illness “wasn’t real,” he felt; “it was ‘all in your head’—the ultimate form of self-indulgent hypochondria.” (One of the “insidious things about stereotypes is that you think they are facts,” he points out, and the stigma of mental illness is something he helped address in Treating and Preventing as well as in Mind Race.)

Nor was he keen on taking lithium for the rest of his life—or having to forgo such customary adolescent mood-enhancers as beer. But as he soon found out, doing so was a lot better than the alternative.

For Kathleen, the diagnosis meant that now she knew what she was dealing with and could start to address it. Or so she thought.

“The first impulse of an academic when you’re confronted with a problem is to try to find research,” she says. “So when we finally got into the Penn system and Patrick was diagnosed, we did a literature review. We pulled everything we could find.”

At that time, apart from one “excellent” book—Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, by Frederick Goodwin and Kay Redfield Jamison (no relation)—there was nothing. “That was an Oxford University Press book, and I am an Oxford author, so I could very easily go to Oxford and ask, ‘Is there anything else in the pipeline?’” says Jamieson. “There was virtually nothing for Patrick to read. What we found was that one excellent book, but it wasn’t written for lay people and it certainly wasn’t written for a teenager.

“Nevertheless, Patrick read it, and kind of clutched at it all the way through this process, because it provided something that looked like systematized knowledge.”

It was at that point that she realized that the intellectual resources available to her son and her family were not adequate. If she wanted something done, she would have to start it herself.