Editor's Note: The following article is part one of a three-part series on Asian Americans and mental health. By Katherine Kam, New America Media It was late on a school night—3 a.m.—and Tracy’s 17-year-old son, Jason, was still playing video games in their one-bedroom apartment in Flushing, New York. The noise infuriated her and kept Jason’s younger brother awake. The family had uprooted from Hong Kong to move here a few years ago, and Jason had become angry and withdrawn. When he wasn’t arguing with his mother or brother, he would retreat into endless hours of video games. That night, Jason blocked all of her attempts to shut down his game, Tracy says. “We were fighting over the TV. I’d turn it off and he’d turn it on again. I got so angry that I threw the TV antenna out of the window.” Tracy had arrived with such big hopes for her boys—a shot at one of New York City’s top public high schools, a chance for college. But making a new life in Queens was tougher than she had imagined. “Life is very hard here; to get used to the new environment, the finances, the economic problems,” she says. While her husband remained in Hong Kong, she got up in the mornings to work at an office job and then came home to take care of her children like a single mom. Her younger son had adjusted smoothly, but not Jason. He refused to go to school. He had few friends. His angry outbursts rattled the household. “I though he was being rebellious,” she says. But eventually, Tracy learned the truth: Jason was deeply depressed. Depression in Asian American teens is a problem that few people glimpse, let alone imagine. But it’s a reality--a painful one that’s often obscured by stigma, misinformation, and shame. Jason’s social worker, Chi-Kit Ho, sees depressed teens who are referred to his mental health clinic inside the Charles B. Hwang Community Health Center, located just off Flushing’s bustling main artery of shops, banks and Asian restaurants. Inside his office, Ho, whose affability helps him to connect with teens, says that it can be hard to spot the ones who are depressed. Yes, some, like Jason, isolate themselves. Some also cut themselves, drink or abuse drugs to cope. But many are adept at hiding their depression, he says. “From the outside, they may look popular and fabulous, but deep down, they may feel so bad about themselves.” Ho’s young patients don’t use the word “depression,” he says. “But they will say that they feel bad all the time and don’t see the point in doing anything. Or some of them feel that they are a disappointment to their parents, so they don’t actually feel depressed, but guilty.” Make no mistake: most Asian American teens are emotionally healthy and thriving. But government statistics suggest that a substantial number struggle emotionally. Among Asian American high school students, 29 percent have reported feeling “sad or hopeless” for at least two weeks in a row during the past year, enough to interfere with their daily lives, according to a recent national youth survey conducted by the Centers for Disease Control and Prevention (CDC). That figure is slightly higher than that of teens from all racial groups, 28 percent. With suicidal thoughts, the gap widens. When the CDC asked Asian American students if they had seriously considered suicide during the past year, 19 percent answered yes, compared to 16 percent of all high school students. About four percent of Asian American teens reported a suicide attempt within the past year that required medical attention, compared to two percent of all students. Of course, not all teens who report sadness and hopelessness may actually be clinically depressed. But in 2003, social worker Teddy Chen, Ho’s colleague at the Charles B. Hwang health center in Manhattan’s Chinatown, conducted a survey in which 1,032 healthy Chinese American children, ages 12 to 18, had undergone a professional mental health screening. In a finding that Chen calls “alarming,” the screening discovered that 12 percent showed signs of depression. And yet, these children’s parents often declined help. As Chen noted in his assessment, “The high refusal rate reflects the significant barrier to providing mental health care to Asian American children.” Trying to understand mental illness Across the nation, Asian Americans encompass a wide range of ethnic groups, from fourth-generation Japanese to first-generation Cambodians—all with differing life circumstances and notions of mental health. But as a group, Asian Americans aren’t likely to use mental health services. One national survey found that Asian American children 18 and younger were less likely than whites, African Americans and Latinos to receive mental health care. In Flushing, which now has a large Chinatown, many immigrants have come in recent years from mainland China, Hong Kong, and Taiwan. Few understand depression and mental illness, Ho says. His clinic provides health care, including mental health services, to mainly low-income families. When he counsels depressed teens, their stories often share common themes. Their mothers and fathers are coping with culture shock and financial stress. These parents often work long, exhausting hours at restaurants and factories, persevering to give their children an education and better prospects. But the grueling schedules often exact a cost. “The parents work until 10 or 11 in restaurants, and they and their kids live separate lives,” Ho says. “Their teenagers don’t really see them. If they see them, the first question is, ‘Did you finish your homework?’ The teenager feels that ‘they just want me to study all the time.’” Given their own cultural upbringing—what one cultural psychiatrist called “the stoic approach”-- many parents don’t even have the vocabulary to talk with their children about their emotional lives, Ho says. “The Chinese say that if you feel pain, it forces you to grow. You suppress your feelings and get things done. Don’t think about being sad or unhappy. That’s not helpful.” For some parents, tremendous upheavals, such as the Cultural Revolution, have shaped their outlook on life. “The mainland Chinese, they’ve actually had very tough lives,” Ho says. “They feel that if they’re providing their kids with a home and a computer, they should be happy. There’s no reason to be unhappy.” When teens become depressed, their parents often draw a different conclusion. “We see angry kids, we see unhappy kids. Right now, we see a lot of kids really addicted to computer games,” Chen says. “Unfortunately, a lot of the symptoms will be interpreted by parents as a bad kid’s behavior.” Jason was a quiet and introverted child in Hong Kong, Tracy says. He was always an average student, but had no real problems at school. When he came to Flushing, his first year as a seventh-grader seemed uneventful, but by eighth grade, he was skipping school frequently. When Tracy left for work early in the morning, she had no idea that Jason was planning to hide at home. His mood darkened, too. “When he was in eighth grade and started getting angry, I didn’t pay attention. I should have,” Tracy says. Shortly after tenth grade began, Jason stopped going to school altogether. He refused to leave the apartment. He slept a lot. “He wouldn’t wake up, even if I tried to get him up,” Tracy says. “He showed no interest in anything. He just slept and played a lot of video games.” These were all signs of depression, but Tracy did not know. She tried to coax him out with the promise of a restaurant meal, but they’d always return home shortly after leaving. Jason would complain that his stomach hurt. He was anxious and fearful that people might see him, Tracy says. Then during one particularly angry confrontation that year, she called the police, which led to a psychiatric evaluation and diagnosis of depression. “I knew he had a problem, but I didn’t know how to take care of him,” Tracy says with regret. Her son’s sadness weighs on her, too, she says, “like a heavy stone in my heart all the time.” At Tracy’s request, her husband moved to Queens from Hong Kong. “I couldn’t handle such intense stress alone,” she says. Now under a psychiatrist’s care, Jason takes an antidepressant. He meets with Ho for counseling and has opened up about his struggles. “He trusts Kit Ho. If he’s unhappy, he’ll tell him,” his mother says. Tracy learned that her son dreaded going to school because his English was poor. He couldn’t keep up in class, and he felt alone and despairing. Stubborn stereotypes can breed stress in Asian American students, Ho says. “If you go into a school and you’re Asian, teachers already assume you’re smart.” If students don’t perform well, many agonize—not just for themselves, but also for failing their families. In the Manhattan clinic, Chen sees teens who are afraid of disappointing parents who brought them here for a better education. “The parents gave up their good life in Asia. In coming here, they sacrifice for the children, and the children know that. So the pressure is actually pretty serious on the teenagers,” he says. Since parents commonly use academics to measure a child’s well-being, they’ll tend to deny any psychological problems as long as teens keep going to class, Ho says. Usually, it takes a crisis—for example, a depressed teen’s truancy—to force the issue. “Parents get a call saying that the kid has missed school for a month, and they need to come in or the school will call Child Protective Services,” he says. An intense stigma Besides lack of knowledge about depression, mental health professionals face a second formidable obstacle: stigma. Asian American teens become depressed for various reasons. Family conflicts and academic failure loom large, but some have a family history of depression, which might make them genetically vulnerable. Often, though, when a mental health professional delivers a diagnosis of depression, many parents will reject it. They fear that any mental problems will reflect badly on their son or daughter, as well as tarnish their entire lineage. “Parents feel strongly stigmatized. People will label their child as being crazy or different, or put some sort of shadow onto it,” says Dr. Zheya Jenny Yu, a child and adolescent psychiatrist at the University of Pennsylvania Health System. “And families might feel that it’s challenging to their heritage by reflecting family dysfunction or weakness or by reflecting poor parenting skills.” In many parents’ minds, depression threatens a child’s future. If outsiders see the mental illness as hereditary, the child might face poor marriage prospects. Parents worry, too, about their child’s success. “It’s not like they are bad parents,” says Chen. “It’s just that they are so concerned about the stigma. How are their kids going to get into a good school? How are they going to have a good career?” Given the traditional Asian focus on education, a child’s school achievement is seen as evidence of good parenting, as well as the harbinger of a bright future. “Acknowledging that ‘my child has problems’ will probably shatter the dreams of the parents,” says Yu, who works with Asian families in Philadelphia. In China, where one child is the norm, mothers and fathers aspire to raise a “dragon child,” powerful like the legendary dragon of Chinese mythology. “We talk about expecting or anticipating that ‘my son will become a dragon.’ It’s just a saying,” Yu says. “If you think there’s a problem in your son, that dragon may never come true.” Teens can sense the stigma. “A teenager can pick up that kind of information and also start denying,” Chen says. “They’ll say, ‘no, I’m fine now. I have no problem anymore.’” Yu can’t always convince parents that depression is a disease that needs treatment, similar to asthma or hypertension, so she’ll mention the consequences of leaving depression untreated, including school failure. “That is what parents usually worry about the most,” she says. Integrating mental health and physical health makes a difference, too, Chen says. The Charles B. Hwang clinics in Manhattan and Flushing formally connect the two spheres, housing mental health in the same buildings as their internal medicine, pediatrics and other medical departments. “We’re not an isolated system,” Chen says. Instead, pediatricians screen every teen for depression during annual physicals. Sometimes, they’ll uncover symptoms during other visits. “The kids present a lot of physical, somatic types of conditions,” Chen says. While parents typically avoid mental health professionals, “they will tend to go to a pediatrician and say, ‘My son is not doing well. He’s stopped eating. He’s starting to lose weight.’ ” “The beautiful thing is that the pediatricians know the parents, and somehow, Chinese parents will actually listen to the doctor,” Ho says. If a doctor makes a mental health referral, parents are more likely to follow up. Families aid recovery Jason was fortunate that Tracy supports his treatment, but not all parents do, Ho says. “Sometimes, I have to tell a teen, ‘You just have to take care of yourself. Your parents may never accept the fact that you are depressed.’” But family is central to Asian cultures. “If parents are involved, we have a much better chance,” Ho says. That’s an approach that Rocco Cheng, a psychologist at the Pacific Clinics in Los Angeles, embraces. For the past ten years, his behavioral health care agency has offered three-month parenting courses through its Asian Pacific Family Center. Cheng knows that many immigrant parents feel blamed, especially at their teen’s school. “We try very hard to respect where they’re coming from, their decisions, and not to place blame on them. Many times, parents may feel that whenever they have problems with their kid at school, the teachers always say that parents are wrong.” The course empathizes with parents’ struggles, but also shows them how life looks from their teens’ point of view, he says. “We let them know what it’s like to be growing up and going to school here, how disorienting that is, how crazy-making that can be, that you try to learn one system at school, and you go home and it’s a totally different system.” In class, parents also learn how to build better relationships with their children, for example, by spending more fun time together and communicating with less friction. “A lot of Asian parents, they are not used to expressing themselves verbally or physically in a way that’s more conducive to positive communication. A lot of times, they’re more used to an authoritarian style and kids do not like it,” Cheng says. “We talk to them about different styles of communication and have them practice. What can we do to enhance the relationship?” Without support, parents of depressed teens may feel hopeless and overwhelmed, Ho says. He invites former teen patients who have recovered to come back and talk with depressed teens and their parents. Not only do these older teens help make depression real, but they also offer parents tangible hope that their children will get better. Ho has already told Jason, “Someday, you’ll be a survivor and I’ll ask you to come in and help a younger one.” Once a virtual shut-in, Jason has begun to recover. He’s back in school and hopes to still be able to go to college, Tracy says. Even though he still has trouble making friendships, he has developed an online social group by publishing his fictional stories on the Internet. Ho continues to help him explore his emotions and find ways to cope, and Jason has gained a new source of self-esteem as others applaud his writing. Tracy sees the stigma that so many parents feel about depression, but now knows that it causes unnecessary suffering. “They’re afraid they’ll lose face. They try to avoid it,” she says. “But you need to face the problem. Otherwise, the problem will grow very big. You cannot control it.” Katherine Kam specializes in reporting on health and medicine. This series on Asian American youth and mental health, supported by a Rosalynn Carter Mental Health Journalism Fellowship, was produced for New America Media and its national ethnic media network partners.