Diseases

Attempts at prevention of childhood mental illness tends 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 having the involvement of supportive adults, strong family and peer relationships, healthy coping skills, and 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.

Many health-care professionals may help make the diagnosis of a mental illness in children, including licensed mental-health therapists, pediatricians or other primary-care providers, emergency physicians, psychiatrists, psychologists, psychiatric nurses, and social workers. 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, routine laboratory tests are often performed during the initial evaluation to rule out other causes of symptoms. Occasionally, an X-ray, scan, or other imaging study may be needed. As part of this examination, the child and his or her parents may be asked 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.

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. Girls are more likely to be diagnosed 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 thought to be 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 four times more likely to develop such an illness themselves. Teens who develop a mental disorder are also more prone to having had 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 with 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 the bullying by peers and potential rejection by family members. Children in military families have been found to be at risk for experiencing depression as well. The aforementioned environmental risk factors tend to specifically predispose individuals to childhood mental illness. Other risk factors tend to predispose people to developing 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.

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;
• 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.

Mental disorders in children are quite common and sometimes severe. About one-fourth 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 kind of mental disorders are anxiety disorders, like 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, 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 that is characterized by impaired development in communication, social interaction, and behavior. Statistics about autism include that it afflicts one out of every 88 children, a 78% increase in the past 10 years.

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 are children with other disabilities. Youth 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 who are 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, those episodes can be well managed by comprehensive treatment. There are a number of potential complications of bipolar disorder, particularly if left untreated. This illness may be compounded by other mental-health problems, including substance abuse and addiction. 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.

There are a variety of treatments available for managing mental illnesses in children, including several effective medications, educational or occupational interventions, as well as specific forms of psychotherapy. In terms of medications, medications from specific drug classes are used to treat childhood mental illness. Examples include the stimulant class for treating ADHD, serotonergic medications for treating depression and anxiety, and neuroleptic medications for management of severe mood swings, anxiety, aggression, or in the treatment of childhood schizophrenia. 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 at best, 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. It can be a powerful intervention, even producing positive biochemical changes in the brain. Two major approaches are commonly used to treat childhood mental illness, interpersonal psychotherapy and cognitive behavioral therapy. In general, these therapies take weeks to months to complete. Each has a goal of alleviating symptoms. More intense psychotherapy may be needed for longer time periods when treating very severe mental illness. The behavioral, educational/vocational, and psychotherapy components of treatment for childhood mental illnesses are usually at least as important as the medication treatment. Dealing with the specific challenges that mentally ill children present takes patience, understanding, and a balance of structure and flexibility. One kind of psychotherapy used to treat children with mental illness is 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. This therapy can be administered either individually or in group therapy. CBT that seeks to help the sufferer of many childhood mental illnesses may decrease the tendency of the depressed or anxious child to pay excessive attention to potential threats, while helping the child with ADHD appropriately refocus their attention. Behavioral techniques that are often used 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. Specifically, learning when and where specific behaviors occur can go a long way toward understanding how to encourage the behavior to happen again if it's positive or extinguishing it if the behavior is negative. Being aware of how the reactions of others contribute to a behavior's continuing or not continuing tend to help the child with a behavior disorder shape their behaviors more positively. Also, developing a fair, meaningful, and effective repertoire of ways to encourage positive behaviors and provide consequences for negative behaviors is a key component of any behavior-management plan and therefore in parenting children with behavioral disorders. Often, a combination of medication and nonmedication interventions produces good results in helping the child with a mental illness. Depending on the illness, the length of time it existed before treatment starts, as well as the course of treatment deemed most appropriate, 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 a mental illness can do to help make treatment more effective. Tips to better manage symptoms of most childhood mental-health problems include getting adequate sleep, having a healthy diet, and having the support and encouragement of parents and teachers. If symptoms indicate that your child is suffering from mental illness, the health-care professional will likely strongly recommend treatment. Treatment may include addressing any medical conditions that cause or worsen the psychiatric symptoms. For example, an individual who is depressed and found to have low levels of thyroid hormone might receive hormone replacement with levothyroxine (Synthroid, Levoxyl). It may be found that a hyperactive, anxious, or psychotic child is having a reaction to a medication. Other components of treatment may be supportive therapy, such as changes in lifestyle and behavior, psychotherapy, and may include medication for moderate to severe mental illness. If symptoms are severe enough to warrant treatment with medication, symptoms tend to improve faster and for longer when medication treatment is combined with psychotherapy. 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:

• The first is 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.
• The second is 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 having 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 six 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 the 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. Examples of medications in this class that are approved for use in children are listed here. The generic name is first, with the brand name in parentheses.

• Fluoxetine (Prozac)
• Sertraline (Zoloft)

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 are thought to work by improving the imbalance of neurochemicals that are thought to contribute to ADHD. Some commonly prescribed medications include the following:

• Stimulants
• Methylphenidate (Ritalin, Concerta, Metadate, Daytrana patch)
• Dexmethylphenidate (Focalin)
• Dextroamphetamine or pre-Dextroamphetamine (Adderall, Dexedrine, Dextrostat, Vyvanse)
• Nonstimulants
• Atomoxetine (Strattera)
• Guanfacine (Tenex or Intuniv)
• Clonidine (Catapress or Kapvay)

Treatment of bipolar disorder with medications tends to address two aspects: relieving already existing symptoms of mania or depression and preventing symptoms from returning. 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 (in children 10 years of age and older) include

• Risperidone (Risperdal)
• Aripiprazole (Abilify)
• Quetiapine (Seroquel)

For treatment of irritability in individuals with autism spectrum disorder, Risperdal has been FDA approved in children 5 years of age and older, while Abilify has been approved in children 6 years of age and older.

Due to the historical lack of understanding of this topic, research on mental illness in children is occurring on a number of fronts. In an effort to better understand how often childhood mental illnesses occur, a great deal of research is focused on achieving that goal. Understanding more about the protective factors against mental illness is being explored. Ways to improve the access that children have to treatment is another topic of considerable research interest.

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 http://www.drada.org [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