Children and Mental Health
Instructors: Dr. Dawn-Elise Snipes, Ph.D
Course Objectives
• To recognize normal developmental stages in children and signs of problems in development.
• To list risk factors that negatively affect children’s mental health.
• To describe and identify symptoms of childhood mental health disorders.
• To name community-based prevention/treatment resources and identify major services offered by these organizations.
• To gain knowledge of treating children’s mental health problems.
Beginning Notes…
• Children are not “little adults.” They have their own unique development and needs.
• The definition of mental disorders in children might be best expressed something different than normal developmental expectations for the child.
• Estimates for the prevalence of mental disorders in children range from 5% (“severe”) to 21% (“minimum”).
• Research indicates that half of all lifetime cases of mental illness begin by age 14.
• Additional training ensure increased availability for early intervention in preschools, schools, juvenile justice and medical offices.
Normal Development
• Theories of Development
• Erikson’s Psychosocial Stages
• Trust vs. mistrust
• Autonomy vs. shame
• Initiative vs. guilt
• Industry vs. inferiority
• Piaget’s Cognitive Development
• Bandura’s Social Learning Theory
• Kohlberg’s Moral Development
• Obedience
• Instrumental purpose
• Conformity
• Individual rights
Developmental Psychopathology
• Understanding Multiple Sources
• Specific characteristics of the child (including biological, psychological, and genetic factors)
• His or her environment (including parent, sibling, and family relations, peer and neighborhood factors, school and community factors, and the larger social-cultural context) (Brofenbrenner’s Ecological Systems Theory)
• Understanding Adaptability
• “self-righting” and “self-organizing” tendencies; namely, that a child within a given context naturally adapts (as much as possible) to a particular ecological niche, or when necessary, modifies that niche to get needs met
• i.e. psychopathology may be the result of survival adaptations to a pathological environment.
Developmental Psychopathology
• Understanding Timing
• Is the behavior appropriate at this age?
• Understanding Context
• The same behavior in one setting or culture might be acceptable and even “normative,” whereas it may be seen as pathological in another.
• For this child at this time
• Understanding degree
• Of impairment in comparison to others in the same age group
Risk Factors for Psychopathology
• Biological
• Genetics
• Substance exposure
• Low birth weight
• Prematurity
• Psychosocial
• Domestic violence
• Abuse
• Substance misuse
• Household mental illness
• Bullying
• Parental Depression
• Stressful Life Events
• Parent separation
• Parent incarceration
• Parent abandonment
• Childhood Maltreatment
• Peer and Sibling Influences
Adverse Childhood Experiences
• Almost two-thirds of surveyed adults report at least one ACE, and more than 20% reported three or more ACEs.
• The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress.
• There is a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course.
• As the number of ACEs increases so does the risk for the following:
• Heart attack and heart disease
• Mental distress, depression
• Smoking
• Disability
• Unemployment
• Lowered educational attainment
• Stroke
• Diabetes
Assessment and Treatment
• Assessment is more difficult because children can’t verbalize some things, much has to be observed. Also, information on assessment is often gained from adults, whether or not it is appropriate for child diagnosis.
• Treatment focuses on psychotherapy, play therapy, and psychopharmacology.
Overview of Childhood Mental Disorders
• Categories:
• Anxiety Disorders
• Attention/Disruptive Disorders
• Eating Disorders
• Mood Disorders
ADHD
• Two major components: hyperactivity-impulsivity and inattention.
• Usually symptoms present before the age of 7.
• Causes
• Genetics
• Brain injury
• Exposure to environmental toxins (e.g., lead) during pregnancy or at a young age
• Alcohol and tobacco use during pregnancy
• Premature delivery
• Low birth weight
• Treatment
• Medication
• Parent training and Parent-child Interaction Therapy
• Behavior therapy
PTSD
• Examples of PTSD symptoms include
• Reliving the event over and over in thought or in play
• Nightmares and sleep problems
• Becoming very upset when something causes memories of the event
• Lack of positive emotions
• Intense ongoing fear or sadness
• Irritability and angry outbursts
• Constantly looking for possible threats, being easily startled
• Acting helpless, hopeless or withdrawn
• Denying that the event happened or feeling numb
• Avoiding places or people associated with the event
ADHD or PTSD
• Symptom overlap
• Difficulty concentrating and learning
• Easily distracted
• Doesn’t seem to listen
• Disorganization
• Hyperactive
• Restless
• Difficulty sleeping
Depression and Suicide
• Most frequently diagnosed mood disorders in teens are Major Depressive Disorder, Bipolar Disorder and Persistent Depressive Disorder.
• Approximately 2/3 of children with Major Depressive Disorder also have another mental health disorder.
• In the 15-19 age group, boys are four times more likely to commit suicide than girls.
• Girls are twice as likely to attempt.
Depression
• Factors than can trigger youth depression include:
• Bullying and other peer issues
• Academic pressure or problems
• Chronic disease
• Alcohol or drug use
• Family discord
• Sleep deprivation
• Confusion about sexual orientation
• Other mental health disorders
• Learning disabilities and ADHD
• Low self-esteem
• History of violence (witness to or victim of)
Depressive Symptoms
• Examples of behaviors often seen when children are depressed include
• Feeling sad, hopeless, or irritable a lot of the time
• Not wanting to do or enjoy doing fun things
• Changes in eating patterns – eating a lot more or a lot less than usual
• Changes in sleep patterns – sleeping a lot more or a lot less than normal
• Changes in energy – being tired and sluggish or tense and restless a lot of the time
• Having a hard time paying attention
• Feeling worthless, useless, or guilty
• Self-injury and self-destructive behavior
Depression Among Young People
• Relapse rate is high.
• Runs in families.
• Is higher in families in which a parent had postpartum depression.
• Higher among girls.
• CBT has been deemed effective for preadolescent children.
• For adolescents, behavioral-solving and self-control therapies were studied.
Suicide Risk Factors & Suicidal Behavior
• Hopelessness, low self-esteem, the “attribution bias” and negative views about their own competency are major risk factors for suicidality.
• Over 90% of teens who commit suicide have a history of mental illness.
• A low level of communication between parents and teens, or a stressful event, can also be linked to suicide.
• Exposure to suicide in the media.
• Bullying
Treatment for Suicidal Ideation
• CBT focused on problem-solving.
• DBT focused on
• Vulnerability prevention
• Distress Tolerance
• Problem Solving
• Interpersonal Effectiveness Skills
• Intervention after the suicidal death of a peer or loved one.
• Community outreach.
• Crisis hotlines.
• Method restriction.
Anxiety in Children
• Being very afraid when away from parents (separation anxiety)
• Having extreme fear about a specific thing or situation, such as dogs, insects, or going to the doctor (phobias)
• Being very afraid of school and other places where there are people (social anxiety)
• Being very worried about the future and about bad things happening (general anxiety)
• Having repeated episodes of sudden, unexpected, intense fear that come with symptoms like heart pounding, having trouble breathing, or feeling dizzy, shaky, or sweaty (panic disorder)
Treatment Options
Cognitive-Behavioral Therapy, Contingency Management
Autism
• Risk factors include:
• Having a sibling with ASD
• Having older parents
• Having certain genetic conditions—people with conditions such as Down syndrome, fragile X syndrome, and Rett syndrome are more likely than others to have ASD
• Very low birth weight
• People with ASD have:
• Difficulty with communication and interaction with other people
• Restricted interests and repetitive behaviors
• Symptoms that hurt the person’s ability to function properly in school, work, and other areas of life
• Repeating certain behaviors or having unusual behaviors. For example, repeating words or phrases, a behavior called echolalia
• Having a lasting intense interest in certain topics, such as numbers, details, or facts
• Having overly focused interests, such as with moving objects or parts of objects
• Getting upset by slight changes in a routine
• Being more or less sensitive than other people to sensory input, such as light, noise, clothing, or temperature
Autism
• Strengths, including:
• Being able to learn things in detail and remember information for long periods of time
• Being strong visual and auditory learners
• Excelling in math, science, music, or art
• Treatment focuses on special education, behavioral modification, and limited psychopharmacological medications.
Disruptive Disorders
• Oppositional Defiant Disorder.
• ODD usually starts before 8 years of age, but no later than by about 12 years of age.
• Children with ODD are more likely to act oppositional or defiant around people they know well and more frequently than their peers.
• Examples of ODD behaviors include
• Often being angry or losing one’s temper
• Often arguing with adults or refusing to comply with adults’ rules or requests
• Often resentful or spiteful
• Deliberately annoying others or becoming annoyed with others
• Often blaming other people for one’s own mistakes or misbehavior
Disruptive Disorders
• Conduct Disorder.
• Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.
• Examples of CD behaviors include:
• Breaking serious rules, such as running away, staying out at night when told not to, or skipping school
• Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals
• Lying, stealing, or damaging other people’s property on purpose
Disruptive Disorders
• Treatment that seems to have an effect has included
• behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behavior.
• For school-age children and teens, a combination of training and therapy that includes the child, the family, and the school.
• Other Interventions
• Videotape modeling
• Parent training
• Parent group therapy.
Substance Abuse & Eating Disorders
• Substance abuse has a high correlation with mental disorders, highest in the 15-24 age group.
• Likely reason is self-medication.
• Eating disorders
• Mainly affect females and consist of anorexia nervosa, bulimia nervosa, or binge-eating disorder.
• Age of onset is approximately 17 years old.
Treatment Options
• Outpatient
• Day Treatment/Partial Hospitalization
• Residential Treatment
• Inpatient Treatment
• Community-Based: Case Management, Home-Based Services
• Therapeutic Foster Care
• Therapeutic Group Homes
Crisis Intervention
• Three Basic Components
• Evaluation and Assessment
• Crisis Intervention and Stabilization
• Followup Planning
• Examples
• Crisis group homes, telephone hotlines, runaway shelters, mobile crisis teams and walk-in crisis centers.
Service Delivery
• Service delivery is any of the interventions described previously.
• Resources were developed when it was realized that families were not receiving adequate care.
• Emphasis is on being culturally competent, community-based, family-inclusive.
• A major problem is complexity of the system.
• Underutilized: 1 in 5 children with serious emotional disturbance get the help they need.
Financing of Services
• Private Sector
• Private insurance often covers outpatient counseling, medication, short-term hospitalizations.
• Often insurance provides no coverage for complex mental health problems.
• Public Sector
• Coverage is wider.
• Managed-care style thinking is taking place as well.
Effectiveness Studies
• Fort Bragg Study
• Tried to provide a wide range of services without any limitations.
• Access was increased, children stayed in treatment longer, higher satisfaction with services.
• Methodology has been questioned.
• Stark County Study
• Served in the public sector within a multi-agency system.
• More case management and home care provided than comparison group.
• No difference in clinical/functional status 12 mos. after intake.
Summary
• Deviations from developmental standards within cultural and familial context is the best standard by which to define childhood mental illness.
• Children deserve their own category when it comes defining mental health problems.
• Family history, genetics, stressful events, child abuse and more can be risk factors for child psychopathology.
• Prevention is key.
• Research is still underway to validate the effectiveness of mental health treatment forms in children.
• Often the best approach is a multi-systemic approach.