Brief Notes on the Mental Health of Children and Adolescents

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Crystal Sims
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1 Brief Notes on the Mental Health of Children and Adolescents The future of our country depends on the mental health and strength of our young people. However, many children have mental health problems that interfere with normal development and functioning. A 1999 study estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder that caused at least some impairment. When diagnostic criteria were limited to significant functional impairment, the estimate dropped to 11 percent. Moreover, in any given year, it is estimated that fewer than one in five of these youth receives needed treatment. Recent evidence compiled by the World Health Organization indicates that by the year 2020, childhood neuropsychiatric disorders will rise proportionately by over 50 percent, internationally, to become one of the five most common causes of morbidity, mortality, and disability among children. The mental health problems affecting children and adolescents include the following: Depressive Disorders Depressive disorders, which include major depressive disorder, dysthymic disorder, and bipolar disorder, adversely affect mood, energy, interest, sleep, appetite, and overall functioning. In contrast to the normal emotional experiences of sadness, feelings of loss, or passing mood states, symptoms of depressive disorders are extreme and persistent and can interfere significantly with a young person s ability to function at home, at school, and with peers. Researchers estimate that the prevalence of any form of depression among children and adolescents in the U.S. is more than six percent in a six-month period, with almost five percent having major depressive disorder. Major depressive disorder (major depression) is characterized by five or more of the following symptoms: persistent sad or irritable mood, loss of interest in activities once enjoyed, significant change in appetite or body weight, difficulty sleeping or oversleeping, psychomotor agitation or slowing, loss of energy, feelings of worthlessness or inappropriate guilt, difficulty concentrating, and recurrent thoughts of death or suicide. Dysthymic disorder, a typically less severe but more chronic form of depression, is diagnosed when depressed mood persists for at least one year in children and is accompanied by at least two other symptoms of depression (without meeting the criteria for major depression). Youth with dysthymic disorder are at risk for developing major depression. Although bipolar disorder (manic-depressive illness) typically emerges in late adolescence or early adulthood, there is increasing evidence that this illness also can begin in childhood. According to one study, one percent of adolescents ages were found to have met criteria for bipolar disorder or cyclothymia, a similar but less severe illness, in their lifetime. Bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder. Research has revealed that when the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed manic and depressive symptom state that may cooccur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may have features of these disorders as initial symptoms. The manic symptoms of bipolar disorder in children and adolescents may include the following: either extremely irritable or overly silly and elated mood; overly-inflated self-esteem; exaggerated beliefs about personal talents or abilities; increased energy; decreased need for sleep; increased talking; distractibility; increased sexual thoughts, feelings, behaviors, or use of explicit sexual

2 language; increased goal-directed activity or physical agitation; and excessive involvement in risky behaviors or activities. There is evidence that depressive disorders emerging early in life often continue into adulthood, and that early-onset depressive disorders may predict more severe illnesses in adult life. Diagnosis and treatment of depressive disorders in children and adolescents are critical for enabling young people with these illnesses to live up to their full potential. Depressive disorders are associated with an increased risk of suicidal behavior. In 1999, suicide was the 3rd leading cause of death in 15-to 24-year-olds, following unintentional injuries (#1) and homicide (#2), and the 4th leading cause of death among 10- to 14-year-olds. Early identification and treatment of depressive disorders in young people may play an important role in reducing or preventing suicidal behavior. Both medication and specialized forms of psychotherapy are prescribed to treat depressive disorders in children and adolescents. Recent studies indicate that certain selective serotonin reuptake inhibitor (SSRI) medications are safe and efficacious treatments for major depression in young people. In addition, cognitive-behavioral therapy (CBT) has proven effective for treating depression in adolescents. The ongoing Treatment for Adolescents with Depression Study (TADS), funded by NIMH, is comparing the effectiveness of an SSRI medication, CBT, and their combination to determine the best approach for treating major depression in teenagers. Other studies are evaluating the effectiveness of different individual, family, and group psychotherapies for treating depressive disorders in young people. At present, the treatment of bipolar disorder in children and adolescents is based mainly on experience with adults, since as yet there are limited data on the safety and efficacy of treatments for this disorder in young people. The essential treatment in adults involves the use of moodstabilizing medications, typically lithium and/or valproate, which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. However, because medications may have different effects in children than they do in adults, they should be carefully monitored by a physician. For example, there is some evidence indicating that valproate may cause hormonal problems in teenage girls. Antidepressant medication, if needed, generally must be used together with a mood stabilizer, since antidepressants taken alone may induce manic symptoms or rapid cycling in people with bipolar disorder. Current NIMH-funded studies are attempting to fill the gaps in knowledge about treatments for bipolar disorder in children and adolescents. Anxiety Disorders Anxiety disorders, as a group, are the most common mental illnesses that occur in children and adolescents. Researchers estimate that the prevalence of any anxiety disorder among children and adolescents in the U.S. is 13 percent in a six-month period. Generalized Anxiety Disorder: characterized by persistent, exaggerated worry and tension over everyday events. Obsessive-Compulsive Disorder (OCD): characterized by intrusive, unwanted, repetitive thoughts and behaviors performed out of a feeling of urgent need. Panic Disorder: characterized by feelings of extreme fear and dread that strike unexpectedly and repeatedly for no apparent reason, often accompanied by intense physical symptoms, such as chest pain, pounding heart, shortness of breath, dizziness, or abdominal distress. Post-Traumatic Stress Disorder (PTSD): a condition that can occur after exposure to a terrifying event, most often characterized by the repeated re-experience of the ordeal in the form of frightening, intrusive memories; brings on hypervigilance and deadening of normal emotions.

3 Phobias: social phobia extreme fear of embarrassment or being scrutinized by others; specific phobia excessive fear of an object or situation, such as dogs, heights, loud sounds, flying, costumed characters, enclosed spaces, etc. Other disorders: separation anxiety excessive anxiety concerning separation from the home or from those to whom the person is most attached; and selective mutism persistent failure to speak in specific social situations. Various forms of psychotherapy, including cognitive-behavioral therapy and family therapy, as well as certain medications, particularly selective serotonin reuptake inhibitors (SSRIs), are used to treat anxiety disorders in children and adolescents. Research on the safety and efficacy of these treatments is ongoing. ADHD Attention deficit hyperactivity disorder (ADHD) affects an estimated four percent of children and adolescents in the U.S. in a six-month period. Its core symptoms include developmentally inappropriate levels of attention, concentration, activity, distractibility, and impulsivity. Children with ADHD usually have impaired functioning in peer relationships and multiple settings including home and school. Untreated ADHD also has been found to have long-term adverse effects on academic performance, vocational success, and social-emotional development. Psychostimulant medications, including methylphenidate (Ritalin ) and amphetamine (Dexedrine and Adderall ), are by far the most widely researched and commonly prescribed treatments for ADHD. Numerous short-term studies have established the safety and efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD. A major NIMHfunded study of children with ADHD concluded that the two most effective treatment methods for elementary school-aged children with ADHD are a closely monitored medication treatment and a treatment that combines medication with intensive behavioral interventions. Other research has shown that treating ADHD in children may reduce the likelihood of future drug and alcohol abuse. Eating Disorders Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight. In the U.S., eating disorders are most common among adolescent girls and young adult women; only an estimated 5 to 15 percent of people with anorexia nervosa or bulimia nervosa and an estimated 35 percent of those with binge-eating disorder are male. Eating disorders often co-occur with other illnesses such as depression, substance abuse, and anxiety disorders. In addition, eating disorders are associated with a wide range of other health complications, including serious heart conditions and kidney failure, which may lead to death. Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable medical illnesses in which certain maladaptive patterns of eating take on a life of their own. Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, psychotherapy, nutritional counseling, and when appropriate, medication management. The treatment plan depends on the type of illness and the specific needs of the individual. Studies are investigating the causes of eating disorders and effectiveness of treatments. Autism and Other Pervasive Developmental Disorders Autism and other pervasive developmental disorders (PDDs), including Asperger s Disorder,

4 Rett s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), are brain disorders that occur in an estimated 2 to 6 per 1,000 American children. They typically affect the ability to communicate, to form relationships with others, and to respond appropriately to the outside world. The signs of PDDs usually develop by 3 years of age. The symptoms and deficits associated with each PDD may vary among children. For example, while some individuals with autism function at a relatively high level, with speech and intelligence intact, others are developmentally delayed, do not speak, or have serious language difficulty. Research has made it possible to identify earlier those children who show signs of developing a PDD and thus to initiate early intervention. While there is no single best treatment program for all children with PDDs, both psychosocial and pharmacological interventions can help improve their behavioral and cognitive functioning. NIMH is funding studies of behavioral treatment approaches to determine the best time for treatment to start, the optimum treatment intensity and duration, and the most effective methods to reach both high- and low-functioning children. In addition, research and clinical experience have shown that a range of medications originally developed to treat other disorders with similar symptoms can be effective in treating the symptoms and behaviors that cause impairment for children with PDDs. For many individuals, the use of behavioral or educational support is all that is needed. For others, such interventions, by themselves, may be insufficient. The decision to use medication should be based on the symptoms causing the most impairment and on the potential risks and benefits of using and not using medication. Schizophrenia Schizophrenia is a chronic, severe, and disabling brain disorder that affects about one percent of the population during their lifetime. Symptoms include hallucinations, false beliefs, disordered thinking, and social withdrawal. Schizophrenia appears to be extremely rare in children; more typically, the illness emerges in late adolescence or early adulthood. However, research studies are revealing that various cognitive and social impairments may be evident early in children who later develop schizophrenia. These and other findings may lead to the development of preventive interventions for children. Only in this decade have researchers begun to make significant headway in understanding the origins of schizophrenia. In the emerging picture, genetic factors, which confer susceptibility to schizophrenia, appear to combine with other factors early in life to interfere with normal brain development. These developmental disturbances eventually appear as symptoms of schizophrenia many years later, typically during adolescence or young adulthood. Treatments that help manage schizophrenia have improved significantly in recent years. As in adults, antipsychotic medications are especially helpful in reducing hallucinations and delusions in children and adolescents. The newer generation "atypical" antipsychotics, such as olanzapine and clozapine, may also help improve motivation and emotional expressiveness in some patients. Children with schizophrenia and their families can also benefit from supportive counseling, psychotherapies, and social skills training aimed at helping them cope with the illness. Special education and/or other accommodations may be necessary for children with schizophrenia to succeed in the classroom. For More Information Office of Communications, NIMH Information Resources and Inquiries Branch 6001 Executive Blvd., Room 8184, MSC 9663 Bethesda, MD Phone: TTY:

5 FAX: Mental Health FAX 4U: Web site: Updated: October 03, 2002

Advocating for people with mental health needs and developmental disability GLOSSARY

Advocating for people with mental health needs and developmental disability GLOSSARY Accrued deficits: The delays or lack of development in emotional, social, academic, or behavioral skills that a child