76 Mental Illness in Children and Adolescents

Mental illness is not uncommon among children and adolescents. Approximately 12 million children under the age of 18 have mental disorders. The National Mental Health Association has compiled some statistics about mental illness in children and adolescents:

• Mental health problems affect one in every five young people at any given time.
• An estimated two-thirds of all young people with mental health problems are not receiving the help they need.
• Less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services.
• As many as 1 in every 33 children may be depressed. Depression in adolescents may be as high as 1 in 8.
• Suicide is the third leading cause of death for 15- to 24-years-olds and the sixth leading cause of death for 5- to 15-year-olds.
• Schizophrenia is rare in children under age 12, but it occurs in about 3 of every 1,000 adolescents.
• Between 118,700 and 186,600 youths in the juvenile justice system have at least one mental illness.
• Of the 100,000 teenagers in juvenile detention, an estimated 60 percent have behavioral, cognitive, or emotional problems.

Child Mental Health

It’s easy to know when your child has a fever. A child’s mental health problem may be harder to identify, but you can learn to recognize the symptoms. Pay attention to excessive anger, fear, sadness, or anxiety. Sudden changes in your child’s behavior can tip you off to a problem. So can behaviors like exercising too much, or hurting or destroying things.

Some common mental health problems in children are

• Depression
• Anxiety
• Behavior disorders
• Attention deficit hyperactivity disorder

Mental health problems can disrupt daily life at home, at school or in the community. Without help, mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence or even suicide. However, help is available. Talk to your health care provider if you have concerns about your child’s behavior.

The Consequences of Not Treating Mental Illness

Most people don’t think twice before going to a doctor if they have an illness such as bronchitis, asthma, diabetes, or heart disease. However, many people who have a mental illness don’t get the treatment that would alleviate their suffering. Studies estimate that two-thirds of all young people with mental health problems are not receiving the help they need and that less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services. Mental illness in adults often goes untreated, too.

What are the consequences of letting mental illness go untreated?

The consequences of mental illness in children and adolescents can be substantial. Many mental health professionals speak of accrued deficits that occur when mental illness in children is not treated. To begin with, mental illness can impair a student’s ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school. They are more likely to drop out of school and are less likely to be fully functional members of society when they reach adulthood. We also now know that depressive disorders in young people confer a higher risk for illness and interpersonal and psychosocial difficulties that persist after the depressive episode is over. Furthermore, many adults who suffer from mental disorders have problems that originated in childhood. Depression in youth may predict more severe illness in adult life. Attention deficit hyperactivity disorder, once thought to affect children and adolescents only, may persist into adulthood and may be associated with social, legal, and occupational problems. Mental illness impairs a student’s ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school.

Depression

In children, depression lasts an average of seven to nine months with symptoms similar to those in adults. Symptoms in children may include

• sadness,
• loss of interest in activities they used to enjoy,
• self-criticism,
• feelings that they are unloved,
• hopelessness about the future,
• thoughts of suicide,
• irritability,
• indecisiveness,
• trouble concentrating, and
• lack of energy.

Children and adolescents with depression are more likely than adults to have anxiety symptoms and general aches and pains, stomachaches, and headaches. The majority of children and adolescents who have a major depressive disorder also have another mental illness such as an anxiety disorder, disruptive or antisocial behavior, or a substance-abuse disorder. Children and adolescents who suffer from depression are more likely to commit suicide than are other youths. As in adults, episodes of depression are likely to recur.

Depression in Children and Adolescents

About 11 percent of adolescents have a depressive disorder by age 18 according to the National Comorbidity Survey-Adolescent Supplement (NCS-A). Girls are more likely than boys to experience depression. The risk for depression increases as a child gets older.

Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child who shows changes in behavior is just going through a temporary “phase” or is suffering from depression.

In the past, people believed that children could not get depression. Teens with depression were often dismissed as being moody or difficult. It wasn’t known that having depression can increase a person’s risk for heart disease, diabetes, and other diseases. Today’s most commonly used type of antidepressant medications did not exist. Selective serotonin reuptake inhibitors (SSRIs) resulted from the work of the late Nobel Laureate and NIH researcher Julius Axelrod, who defined the action of brain chemicals (neurotransmitters) in mood disorders.

We now know that youth who have depression may show signs that are slightly different from the typical adult symptoms of depression. Children who are depressed may complain of feeling sick, refuse to go to school, cling to a parent or caregiver, or worry excessively that a parent may die. Older children and teens may sulk, get into trouble at school, be negative or grouchy, or feel misunderstood.

Depressed teens with coexisting disorders such as substance abuse problems are less likely to respond to treatment for depression. Studies focusing on conditions that frequently co-occur and how they affect one another may lead to more targeted screening tools and interventions.

With medication, psychotherapy, or combined treatment, most youth with depression can be effectively treated. Youth are more likely to respond to treatment if they receive it early in the course of their illness.

Although antidepressants are generally safe, the U.S. Food and Drug Administration has placed a “black box” warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in youth taking antidepressants. Youth and young adults should be closely monitored especially during initial weeks of treatment.

Years of basic research are now showing promise for the first new generation of antidepressant medications in 2 decades, with a goal of relieving depression in hours, rather than weeks. Such a potential breakthrough could reduce the rate of suicide, which is consistently one of the leading causes of death for young people. In 2007—the most recent year for which we have statistics—it was the third leading cause of death for youth ages 15 to 24.

Is it safe for young adults to take antidepressants?

It may be safe for young people to be treated with antidepressants. However, drug companies who make antidepressants are required to post a “black box” warning label on the medication. A “black box” warning is the most serious type of warning on prescription drugs.

It may be possible that antidepressants make children, adolescents, and young adults more likely to think about suicide or commit suicide. In 2007, the FDA said that makers of all antidepressant medications should extend the warning to include young adults up through age 24.

People of all ages taking antidepressants should be watched closely, especially during the first weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. Families and caregivers should pay close attention to the patient, and report any changes in behavior to the patient’s doctor.

Suicide in Childhood and Adolescence

Children and adolescents who are suicidal report feelings of depression, anger, anxiety, hopelessness, and worthlessness. They feel helpless to change frustrating circumstances or to find a solution for their problems. In addition to depression, family conflicts and suicidal death of a relative, friend, or acquaintance are risk factors for suicide among children and adolescents. In the case of another person’s suicide, children or teens may need intervention to prevent feelings of guilt, trauma, or social isolation. Programs offered by school professionals that address these concerns can be extremely helpful for identifying grieving youths who may need help.

Anxiety

Anxiety can be a normal reaction to stress. It can help us deal with a tense situation, study harder for an exam, keep focused on an important speech. In general, it can help us cope. But when anxiety becomes an excessive, irrational dread of everyday situations, it has become a disabling condition. Examples of anxiety disorders are obsessive compulsive disorder, post-traumatic stress disorder, social phobia, specific phobia, and generalized anxiety disorder. Symptoms of many of these disorders begin in childhood or adolescence.

In the past, the brain areas and circuitries underlying symptoms of anxiety disorders were unknown, and no targeted psychotherapies for anxiety disorders existed. Fortunately, today s large, national survey of adolescent mental health reported that about 8 percent of teens ages 13-18 have an anxiety disorder, with symptoms commonly emerging around age 6. However, of these teens, only 18 percent received mental health care.

ADHD

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood. In any six-month period, ADHD affects an estimated 4.1 percent of youths ages 9 to 17. Boys are two to three times more likely than girls to develop ADHD. Although ADHD is usually associated with children, the disorder can persist into adulthood. One researcher estimated that as many as two-thirds of the children he evaluated with ADHD continued to have the disorder in their twenties, and that many of those who no longer fit the clinical description of ADHD nonetheless had significant problems at work or in other social settings.

The symptoms of ADHD

The three predominant symptoms of ADHD are impaired ability to regulate activity level (hyperactivity), to attend to tasks (inattention), and to inhibit behavior (impulsivity).Individuals who have ADHD may display predominantly hyperactive/impulsive behavior, predominately inattentive behavior, or a combination of both. Children and adolescents with ADHD

• are often unpopular among their peers,
• have trouble in school,
• have higher injury rates than their peers,
• have difficulty paying attention to details,
• are easily distracted,
• find it difficult and unpleasant to finish their schoolwork,
• put off things that require continued mental effort,
• make careless mistakes,
• are disorganized,
• appear not to listen when spoken to, and
• fail to follow through on tasks.

The DSM-IV specifies several conditions in addition to the symptoms listed above before making a diagnosis of ADHD. For a diagnosis of ADHD, the behaviors must

• appear before age seven,
• continue for at least six months,
• be more frequent or severe than in other children of the same age, and
• cause dysfunction in at least two areas of life, such as school, home, work, or social settings.

The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, as of yet, there is no independent valid test for ADHD.

Among children, ADHD frequently occurs along with other learning, behavior, or mood problems such as learning disabilities, oppositional defiant disorder, anxiety disorders, and depression.

The causes of ADHD

The exact causes of ADHD are unknown; however, research has demonstrated that factors that many people associate with the development of ADHD do not cause the disorder. For example, ADHD is not caused by minor head injuries, damage to the brain from complications during birth, food allergies, excess sugar intake, too much television, poor schools, or poor parenting. No single cause of ADHD has been discovered. Rather, a number of significant risk factors affecting neurodevelopment and behavior expression have been implicated. Events such as maternal alcohol and tobacco use that affect the development of the fetal brain can increase the risk for ADHD. Injuries to the brain from environmental toxins such as lack of iron have also been implicated.

Treating ADHD

A variety of medications and behavioral interventions are used to treat ADHD. The most widely used medications are methylphenidate (Ritalin), D-amphetamine, and other amphetamines. These drugs are stimulants that affect the level of the neurotransmitter dopamine at the synapse. Nine out of 10 children improve while taking one of these drugs.

In addition to the well-established treatments described above, some parents and therapists have tried a variety of nutritional interventions to treat ADHD. A few studies have found that some children benefit from such treatments. Nevertheless, no well-established nutritional interventions have consistently been shown to be effective for treating ADHD.

Autism

Autism spectrum disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior. Autistic disorder, sometimes called autism or classical ASD, is the most severe form of ASD, while other conditions along the spectrum include a milder form known as Asperger syndrome, and childhood disintegrative disorder and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Although ASD varies significantly in character and severity, it occurs in all ethnic and socioeconomic groups and affects every age group. Experts estimate that six children out of every 1,000 will have an ASD. Males are four times more likely to have an ASD than females.

What are some common signs of autism?

The hallmark feature of ASD is impaired social interaction. As early as infancy, a baby with ASD may be unresponsive to people or focus intently on one item to the exclusion of others for long periods of time. A child with ASD may appear to develop normally and then withdraw and become indifferent to social engagement.
Children with an ASD may fail to respond to their names and often avoid eye contact with other people. They have difficulty interpreting what others are thinking or feeling because they can’t understand social cues, such as tone of voice or facial expressions, and don’t watch other people’s faces for clues about appropriate behavior. They lack empathy.

Many children with an ASD engage in repetitive movements such as rocking and twirling, or in self-abusive behavior such as biting or head-banging. They also tend to start speaking later than other children and may refer to themselves by name instead of “I” or “me.” Children with an ASD don’t know how to play interactively with other children. Some speak in a sing-song voice about a narrow range of favorite topics, with little regard for the interests of the person to whom they are speaking.

Children with characteristics of an ASD may have co-occurring conditions, including Fragile X syndrome (which causes mental retardation), tuberous sclerosis, epileptic seizures, Tourette syndrome, learning disabilities, and attention deficit disorder. About 20 to 30 percent of children with an ASD develop epilepsy by the time they reach adulthood.