Mental Illness in Children

ADHD, anxiety, and depression are the most common mental illnesses in children.

• Mental disorders in children are quite common, occurring in about 25% of this age group in any given year.
• The most common childhood mental disorders are anxiety disorders, depression, and attention deficit hyperactivity disorder (ADHD).
• Although less common, developmental disorders and psychotic disorders in children can have a lifelong impact on the child and his or her family.
• As in any age group, there tends to be no single cause for mental illness in children.
• In addition to the specific symptoms of each mental disorder, children with a psychiatric illness can exhibit signs that are specific to their age and developmental status.
• Establishing the diagnosis of a mental illness in children usually involves the combination of comprehensive medical, developmental, and mental health assessments.
• There are varieties of treatments available for managing mental illness in children, including several effective medications, educational or occupational interventions, as well as specific forms of psychotherapy.
• Children with mental health problems can have lower educational achievement, greater involvement with the criminal justice system, and fewer stable placements in the child welfare system than their peers.
• Attempts at prevention of childhood mental illness tend to address both specific and nonspecific risk factors, strengthen protective factors, and use an approach that is appropriate for the child's developmental level.
• Research on mental illness in children focuses on a number of issues, including increasing the understanding of how often these illnesses occur, the risk factors, the most effective treatments, and how to improve the access that children have to those treatments.

Mental disorders in children are quite common and sometimes severe. About 25% of children and teens experience some type of mental disorder in any given year, one-third at some time in their lives. The most common type of mental disorder is anxiety disorders, like generalized anxiety disorder (formerly called overanxious disorder of childhood) or separation anxiety disorder.

Other common types of mental illnesses in childhood include

• behavior disorders like attention deficit hyperactivity disorder (ADHD); 
• mood disorders like depression; and
• substance-use disorders like alcohol use disorders.

Statistics indicate how relatively common these disorders occur. ADHD affects 8%-10% of school-aged children. Depression occurs at a rate of about 2% during childhood and from 4%-7% during adolescence, affecting up to about 20% of adolescents by the time they reach adulthood. In teens more frequently than in younger children, addictions, eating disorders, bipolar disorder, and less often early onset schizophrenia may manifest.

Although not as commonly occurring, developmental disabilities like autism spectrum disorders can have a significant lifelong impact on the life of the child and his or her family. Autism spectrum disorder is a developmental disorder characterized by impaired development in communication, social interaction, and behavior. Statistics about autism spectrum disorders include that it afflicts one out of every 59 children, a 15% increase from 2016-2018.

Children with mental illness may experience the classic symptoms of their particular disorder but may exhibit other symptoms as well, including:

• Poor school performance
• Persistent boredom
• Frequent complaints of physical symptoms, such as headaches and stomachaches
• Sleep and/or appetite problems like sleeping too much or too little, nightmares, or sleepwalking
• Behaviors returning to those of a younger age (regressing), like bedwetting, throwing tantrums, or becoming clingy
• Noncompliant or aggressive behaviors
• More risk-taking behaviors and/or showing less concern for their own safety

Examples of risk-taking behaviors include running into the street, climbing too high, engaging in physical altercations, or playing with unsafe items.

As is the case with most mental health disorders at any age, such disorders in children do not have one single definitive cause. Rather, people with these illnesses tend to have a number of biological, psychological, and environmental risk factors that contribute to their development. Biologically, mental illnesses tend to be associated with abnormal levels of neurotransmitters, like serotonin or dopamine in the brain, a decrease in the size of some areas of the brain, as well as increased activity in other areas of the brain.

Physicians are more likely to diagnose girls with mood disorders like depression and anxiety compared to boys, while disorders like attention deficit hyperactivity disorder and autism spectrum disorders are more often assigned to boys. Gender differences in mental illness are the result of, among other things, a combination of biological differences based on gender, as well as the differences in how girls are encouraged to interpret their environment and respond to it compared to boys.

There is thought to be at least a partially genetic contribution to the fact that children and adolescents with a mentally ill parent are up to 4 times more likely to develop such an illness themselves. Teens who develop a mental disorder are also more prone to having other biological challenges, like low birth weight, trouble sleeping, and having a mother younger than 18 years old at the time of their birth.

Psychological risk factors for mental illness in children include low self-esteem, poor body image, a tendency to be highly self-critical, and feeling helpless when dealing with negative events. Teen mental disorders are somewhat associated with the stress of body changes, including the fluctuating hormones of puberty, as well as teen ambivalence toward increased independence, and changes in their relationships with parents, peers, and others. Teenagers who suffer from conduct disorder, attention deficit hyperactivity disorder (ADHD), clinical anxiety, or who have cognitive and learning problems, as well as trouble relating to others, are at higher risk of also developing a mental disorder.

Childhood mental illness may be a reaction to environmental stresses, including trauma like being the victim of verbal, physical, or sexual abuse, the death of a loved one, school problems, or being the victim of bullying or peer pressure. Gay teens are at higher risk for developing mental disorders like depression, thought to be because of bullying by peers and potential rejection by family members. Children in military families are at risk of experiencing depression as well.

The aforementioned environmental risk factors tend to predispose individuals to childhood mental illness. Other risk factors tend to predispose people to develop a mental disorder at any age. Such nonspecific risk factors include a history of poverty, exposure to violence, having an antisocial peer group, or being socially isolated, abuse victimization, parental conflict, and family dissolution. Children who have low physical activity, poor academic performance, or lose a relationship are at higher risk for mental illness as well.

Many health care professionals may help make the diagnosis of a mental illness in children. One of these professionals will likely conduct an extensive medical interview and physical examination or refer the child for those assessments as part of establishing the diagnosis.

Childhood mental illnesses may be associated with a number of other medical conditions or can be a side effect of various medications. For this reason, health care professionals perform routine laboratory tests during the initial evaluation to rule out other causes of symptoms. Occasionally, it may be necessary to get an X-ray, scan, or other imaging studies.

As part of this examination, a health care provider may ask the child and his or her parents a series of questions from a standardized questionnaire or self-test to help further assess symptoms. The use of screening tools is particularly important for detecting early signs of mental illness in infants and toddlers, due to their being largely preverbal in their communication.

There are varieties of treatments available for managing mental illnesses in children, including educational or occupational interventions, specific forms of psychotherapy, and several effective medications. In terms of medications, medications from specific drug classes treat childhood mental illness.

For individuals who may be wondering how to manage the symptoms of a childhood mental illness using treatment without prescribed medications, psychotherapies are often used. While interventions like limiting exposure to food additives, preservatives, and processed sugars have been found to be helpful for some people with an illness like ADHD, the research evidence is still considered to be too limited for many physicians to recommend nutritional interventions. Also, placing such restrictions on the eating habits of a child or teenager can prove to be difficult and contentious at best, and nearly impossible at worst.

Psychotherapy

Psychotherapy ("talk therapy") is a form of mental health counseling that involves working with a trained therapist to figure out ways to solve problems and cope with childhood emotional disorders. Two major approaches treat childhood mental illness, interpersonal psychotherapy and cognitive behavioral therapy. In general, these therapies take several weeks to months to complete. Each has a goal of alleviating symptoms. More intense psychotherapy may be needed for longer periods when treating very severe mental illness.

Psychotherapies used to treat children with mental illness include

• Cognitive behavioral therapy (CBT): This form of therapy seeks to help those with many different kinds of psychiatric disorders identify and decrease the irrational thoughts and behaviors that reinforce maladaptive behaviors.
• Behavioral techniques that health care providers often use to decrease symptoms in children with behavioral disorders like ADHD, oppositional defiant disorder, or conduct disorder or to help children with anxiety disorders like separation anxiety disorder or obsessive-compulsive disorder involve the parents, teacher, and other adult caretakers understanding the circumstances surrounding both positive and negative behaviors and how each kind of behavior is encouraged and discouraged. 

Often, a combination of medication and nonmedication interventions produces good results in helping the child with a mental illness. Depending on the illness, improvement may be noticed in a fairly short period of time, from two to three weeks to several months. Thus, appropriate treatment for mental illness can relieve symptoms or at least substantially reduce their severity and frequency, bringing significant relief to many children.

There are also things that families of children with mental illness can do to help make treatment more effective. Tips to manage symptoms of most childhood mental health problems include getting adequate sleep, having a healthy diet and adequate exercise, as well as having the support and encouragement of parents and teachers.

Interpersonal therapy (IPT)

This helps to alleviate symptoms of mood disorders like anxiety and depression and helps the sufferer develop more effective skills for coping with relationships. IPT employs two strategies to achieve these goals:

• Educating the child and family about the nature of their illness. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment.
• Defining problems (such as abnormal grief, interpersonal conflicts, or having significant anxiety when meeting new people). After the problems are defined, the therapist is able to help set realistic goals for solving these problems and work with the child and his or her family using various treatment techniques to reach these goals.

Cognitive behavioral therapy (CBT)

This has been found to be effective as part of treatment for childhood mental illness. This approach helps to alleviate depression, anxiety, and some behavioral problems and reduce the likelihood that symptoms will come back by helping the child change his or her way of thinking about or otherwise reacting to certain issues. In CBT, the therapist uses three techniques to accomplish these goals:

• Didactic component: This phase helps to set up positive expectations for therapy and promote the child's cooperation with the treatment process.
• Cognitive component: This helps to identify the thoughts and assumptions that influence the child's behaviors, particularly those that may predispose the sufferer to have the emotional or behavioral symptoms that they have.
• Behavioral component: This employs behavior-modification techniques to teach the child more effective strategies for dealing with problems.

Most practitioners will continue treatment of a mental illness for at least 6 months. Treatment for children with a mental illness can have a significantly positive effect on the child's functioning with peers, family, and at school. Without treatment, symptoms tend to last much longer and may never get better. In fact, they may get worse. With treatment, chances of recovery are much improved.

Medications

The major type of antidepressant and anti-anxiety medication prescribed for children is selective serotonin reuptake inhibitors (SSRIs). SSRI medications affect levels of serotonin in the brain. For many prescribing doctors, these medications are the first choice because of the high level of effectiveness and general safety of this group of medicines.

The medications available for attention deficit hyperactivity disorder (ADHD) can have slightly different effects from individual to individual, and currently, no way exists to tell which will work best. Medications indicated for ADHD work by improving the imbalance of neurochemicals that are thought to contribute to ADHD. Some commonly prescribed medications include stimulants and nonstimulants.

Treatment of bipolar disorder with medications tends to address two aspects: relieving already existing symptoms of mania or depression and preventing symptoms from returning. There are medications that are thought to be particularly effective in treating manic and mixed symptoms and have been approved by the Food and Drug Administration (FDA) for use in children 10 years of age and older. 

Children and youth with mental health problems are at risk for having lower educational achievement, greater involvement with the criminal justice system, and fewer stable and longer-term placements in the child welfare system than their peers. Children and youth with mental health problems are more likely to experience problems at school, be absent, or be suspended or expelled than children with other disabilities. Youths in high school with mental health problems are more likely to fail or drop out of school. When treated, children and youth with mental health problems fare better at home, in schools, and in their communities.

Children with more anxiety disorders are at higher risk for anxiety, depression, and substance-abuse disorders in adulthood. They tend to achieve less academically and are more likely to engage in early parenthood and suicidal behaviors.

Depression can be quite chronic, in that 85% of people who have one episode of the illness will have another one within 15 years of the first episode. A bit over 50% of teens who are part of research studies on the treatment of depression improve significantly. Over 8% of adolescents suffer from depression that lasts a year or more. Depression is the leading cause of disability in the United States in people over 5 years of age. This illness is a leading cause of health impairment (morbidity) and death (mortality). Certainly, the worst potential outcome of depression, suicide is the third leading cause of death in teens.

About half of children diagnosed as having attention deficit hyperactivity disorder (ADHD) are thought to continue to have significant symptoms of the disorder into adulthood. Of those individuals, about half tend to exhibit less overt hyperactivity than they did as children. People with this disorder are at higher risk for lower educational achievement as children, job and relationship loss, as well as experiencing more automobile accidents and drug use as teens and adults, particularly if left untreated.

While the prognosis for bipolar disorder indicates that individuals with this disorder can expect to experience episodes of some sort of mood problem up to 60% of the time, comprehensive treatment can manage those episodes. There are a number of potential complications of bipolar disorder, particularly if left untreated. Other mental health problems, including substance abuse and addiction, may compound this illness. The risk of committing suicide is 60 times higher for people with bipolar disorder compared to the general population. Bipolar disorder is the fifth leading cause of disability and the ninth leading cause of years lost to death or disability worldwide.

Attempts at prevention of childhood mental illness tend to address both specific and nonspecific risk factors, strengthen protective factors, and use an approach that is appropriate for the child's age and developmental level. Such programs often use cognitive behavioral and/or interpersonal approaches, as well as family-based prevention strategies because research shows that these interventions tend to be the most helpful.

The inverse of most risk factors, protective factors for childhood mental illness include:

• Preventing exposure to community violence
• Having the involvement of supportive adults
• Strong, consistent family and peer relationships
• Healthy coping skills
• Emotional regulation

Children and adolescents of a mentally ill parent tend to be more resilient when the child is more able to focus on age-appropriate tasks in their lives and on their relationships, as well as being able to understand their parents' illness. For mentally ill parents, their children seem to be more protected from developing a psychiatric illness when the parent is able to demonstrate a commitment to parenting and to healthy relationships.

American Academy of Child and Adolescent Psychiatry
http://www.aacap.org

American Association of Suicidology
http://www.suicidology.org
1-202-237-2280

American Foundation for Suicide Prevention
http://www.afsp.org

American Psychiatric Association
http://www.psych.org

American Psychological Association
http://helping.apa.org

Autism Society of America
7910 Woodmont Ave. Suite 650
Bethesda, MD 20814
Phone: 301-657-0881 or 800-3AUTISM
Fax: 301-657-0869
http://www.autism-society.org/

Children and Adults with Attention Deficit Hyperactivity Disorder
http://www.chadd.org/

Depression and Related Affective Disorders Association
2330 West Joppa Road, Suite 100
Lutherville, MD 21093
Phone: 410-583-2919
Fax: 410-614-3241
[email protected]

FEAT Families for Early Autism Treatment

Lifetime Advocacy Network

National Alliance for the Mentally Ill
2101 Wilson Boulevard Suite 302
Arlington, VA 22201
HelpLine: 800-950-NAMI [6264]
http://www.nami.org/

National Autism Association
20 Alice Agnew Drive
Attleboro Falls, MA 02763
Phone: 877-622-2884
Fax: 774-643-6331
http://nationalautismassociation.org/

National Federation of Families for Children's Mental Health
9605 Medical Center Drive
Rockville, MD 20850
Phone: 240-403-1901
Fax: 240-403-1909

National Society for Children and Adults with Autism
1234 Massachusetts Avenue N.W., Suite 1017
Washington, DC 20005
Phone: 202-783-0125