By Janice Lovelace, Ph.D.
“My daughter is staying in her room and sleeping a lot. She hasn’t made many friends since we moved here six months ago to live with my mother. It is hard to get her up in the morning to go to school. Sometimes she says she doesn’t feel well. When I took her to the pediatrician he suggested she might be depressed and we should go to counseling. I’ve been depressed before, but thought that 9 years old is too young for depression. Don’t all children go through rough periods like this?”
This girl presented a constellation of symptoms we see in depressed children: isolation, sadness, withdrawal from activities, family history and a precipitating event. Her mother, like many parents I have seen as a child psychologist, wasn’t sure which behaviors are in the normal range for children and which might be indicators of emotional difficulties. Because of the wide range of developmental skills, it can be difficult for parents to recognize and professionals to diagnose emotional struggles in children.
One reason is that many young children are not able to verbalize how they are feeling. It is important that parents, teachers and other adults in a child’s life pay attention to the child’s behaviors and any changes. If parents notice changes in behavior, it might help to decide if the current behavior is normal for that child. They should also look for patterns of behavior, rather than isolated incidents after a loss or sad event.
Some behaviors are developmental – they may be normal at one age, but not another. An example is that a tantrum by a 2-year-old who doesn’t want to do something might not be unusual, but a tantrum by a 10-year-old might be. Some behaviors may be expected after a traumatic experience, like abuse or a serious accident. In addition, young children might regress to an earlier behavior when a new sibling is born, but that regression is generally not seen in older school-age children. Children who are under stress, at home or at school, or who experience loss are at greater risk for having problems adjusting and may need professional help.
Figures on how many children suffer from mental health disorders vary widely, with 10 percent being an accepted average. On the higher end of the scale, the U.S. Surgeon General’s 2001 Report on Mental Health states that almost 21 percent of children and adolescents ages 9 to 17 had a mental or addictive disorder. The President’s New Freedom Commission estimated in 2002 that every classroom in the nation has one or two children with severe emotional problems.
The University of Washington “Kids Count” study found that mental health problems are the most common reason for child hospitalizations in the state, even surpassing injuries. In 1990 one in 900 children in Washington was hospitalized for mental health reasons; in 1999 the figure was one in 750. This need for the intensive treatment of hospitalization suggests that mental illness is more severe in children now than in the past.
Child Psychiatrist Dr. Shirley Stallings, medical director at Compass Health in Snohomish County, has noticed a dramatic shift in the past two decades.
“There are more children brought in who are aggressive and destructive, and whose symptoms have started at an earlier age,” Stallings says.
Some experts believe that family and school stress, recreational drug use (even by preteens) and genetics may be the reason that more children are being seen and appear to have more severe symptoms.
A collection of genes that are expressed more aggressively in each generation may impact families with mental illness. The National Institute of Mental Health (NIMH) is studying “gene penetrance” in families with a mental health history. This means that later generations may suffer more than earlier ones because of a genetic mechanism making the defective gene sequence grow longer each time it is inherited.
Despite the increase, the Surgeon General’s report estimates that two-thirds of children with mental health problems do not receive treatment, often because of poor insurance coverage. This will improve as the Washington state legislature has passed a mental health parity law, to be phased in between 2006 and 2010, covering mental illness in the same way physical illness is covered.
The most common reasons children are brought to counseling are mood disorders (such as depression or bipolar disorder), impulse control disorders (like hyperactivity or oppositional behavior), and anxiety disorders (often seen as separation and attachment issues, panic attacks and obsessive-compulsive disorder).
Let’s look in more detail at these disorders, their causes and common treatments.
The NIMH estimates that there are 1.5 million children younger than the age of 18 with depression; other organizations double that amount. The American Academy of Child and Adolescent Psychiatry estimates that at any given time, 5 percent of children and adolescents are suffering from depression. However, the symptoms exhibited may differ in children, reflecting their age and developmental stage.
Young children might not know how to use words to tell their parents about depression. They may show fears or separation anxiety and express somatic (physical) complaints, such as tummy aches or headaches. The preschool child might be less active and spontaneous. Maybe he doesn’t want to leave home to go to school or daycare. He might be tearful and irritable at times when other children are not. On rare occasions, the child may try to hurt himself – he may run out in front of cars, jump off a balcony, cut himself with a knife or scissors or wrap a cord around his neck.
School-age children may say negative things about themselves or engage in self-destructive behaviors. Parents might notice that the older child prefers to spend time alone rather than play with other children. When asked, she cannot identify interests or things that are fun for her. Her school performance may be affected as she seems less focused or has trouble concentrating. A child, especially a boy, may not act sad but instead get in trouble at school because of aggressive behavior. Teachers and parents may not realize that the child is acting out their depression.
If there is a family history of mood disorders, the child is at a higher risk of developing depression. This might be due to genetic vulnerability. It might also be environmental. If parents or other important adults have not modeled successful ways of coping with stressful situations, then the child might learn to give up on the situation and act in a negative manner.
Other causes of depression in children can be loss of a family member or close friend (by death or moving away), rejection by an important person (like a parent or teacher), a serious hospitalization (especially for a chronic disease), and the loss of attention due to a prolonged absence of a parent or primary caretaker. For school-age children, difficulty in learning can lead to lower self-esteem and depression.
Treatment can include individual counseling, family counseling and possibly anti-depression medication. Stallings reminds parents that medication can have many benefits for children, especially when combined with counseling.
“Parents may be hesitant to get help from mental health providers, so go to their family primary provider first,” she says. “We will work with those providers to help find the right treatment, including medication.”
People with depression appear to have too little of the neurotransmitter serotonin. The most common anti-depressant medications, SSRIs (selective serotonin reuptake inhibitors, like Prozac) increase the levels of serotonin by blocking the reuptake of serotonin by neurons. However, there have been studies indicating that use of anti-depressants in children may be harmful.
Bipolar disorder, a cycling between lows of depression and highs of mania, is estimated to affect about 1 million preteen and younger children in the United States. It is characterized by excessive temper outbursts, irritability, mood changes and difficulty concentrating and keeping still. Young children may be prone to aggressive outbursts and try to hurt family members and peers. The depressive phases show the same symptoms as clinical depression; the manic phases can be characterized by overly silly and elated moods, increased energy and decreased need for sleep and overly inflated self-esteem.
In the past, this disorder was thought to only affect adults. But therapists are seeing ups and downs in children, beyond what is expected for their developmental age. In addition, some adult clients are reporting that their bipolar episodes began in late childhood but were not diagnosed until adulthood.
One of the biggest risk factors for bipolar disorder in preteens and teens is the use of recreational drugs, especially cocaine and amphetamines. Bipolar disorder also seems to run in families. According to the NIMH, children with one parent who is bipolar have a 10 to 30 percent chance of developing the condition; if both parents are bipolar the risk rises to 75 percent. Environment can play a part as well. Family and school stress can make the disorder worse. If the home is steady and stable, the odds are reduced that the disorder will be as devastating.
Treatment is generally a combination of medications for mood stabilization as well as individual and family counseling. Medications like Lithium and Depakote are standard for this disorder.
Attention Deficit Disorder with Hyperactivity (ADHD)
One of the most frequently diagnosed disorders in children is Attention Deficit Disorder with Hyperactivity (ADHD). It occurs in about 5 to 10 percent of children, and appears to run in families.
Many mental health professionals think it may be overdiagnosed. Dr. Matthew Speltz, chief of Outpatient Psychiatry at Children’s Hospital and Regional Medical Center in Seattle, suggests that in the past decade there may be less tolerance for the range of normal behavior in children and more pathologizing of that behavior. Teachers may refer any child who is active for possible ADHD diagnosis, or parents may want their child to be more focused and attentive. Teachers and parents may think that a child who is fidgety is hyperactive when it may be something else – like depression or anxiety.
A true ADHD child is restless, impulsive, easily distracted and inattentive nearly all the time. He is forgetful, frequently loses things, has trouble finishing class work or homework, has difficulty following multiple commands, has difficulty sitting quietly and always seems to be “on the go.” The symptoms are seen across multiple settings (i.e., not just at home or just at school) and are exhibited before age 8.
Medication can help improve attention, focus and organizational skills in ADHD children. Medications are most likely to include those in the stimulant category (like Ritalin).
Therapy can help children and their families control the symptoms. Behavioral therapy can help a child control and modulate his own behavior. Cognitive therapy can help reduce negative thoughts and improve problem-solving skills. Parents can learn to tell the child one thing at a time, so that the child is not so easily distracted by multiple requests. Family therapy and social skills training can also help.
Oppositional Defiant Disorder
Oppositional Defiant behavior reflects a difficulty in controlling behavior. The NIMH says it occurs in 5 to 15 percent of children, but the cause is unknown. Children may disobey and argue with adults, be uncooperative and act in a hostile manner. All children may be oppositional from time to time, but this is an ongoing pattern that is so frequent and consistent that it affects all aspects of a child’s life.
Children may be suspended or expelled from school because of the behavior. They may be easily annoyed and get into fights, and blame others for their misbehavior. Occasionally they are physically assaultive toward adults. Many therapists work with families in counseling to reduce the family stress.
Anxiety disorders include separation anxiety, post-traumatic stress disorder, generalized anxiety disorder and obsessive-compulsive disorder. The client may experience a physiological panic attack because of the anxiety. The NIMH reports that more than 3 million Americans will experience panic disorders during their lifetime. These may begin in childhood or adolescence and sometimes run in families.
Generalized Anxiety Disorder
Children with this disorder may feel anxious most of the time. They experience anxiety panic attacks – unexpected periods of intense fear, along with physical symptoms like fast heartbeat and shortness of breath. They may have fears about “bad things” happening, so they start to avoid situations where they become more anxious and might have a panic attack. They may be reluctant to go to school or be separated from caretakers. In more severe situations, the child may not want to leave home at all. If not treated, the anxiety can interfere with social relationships, schoolwork and normal development.
Stallings notes that anxiety might be missed in children more than adults because the child may react by having tantrums or refusing to go somewhere. The child also may not have the verbal skills to tell about their anxiety, so the parents believe the behavior is oppositional rather than caused by a fear. Behaviors that might suggest generalized anxiety include increased worrying, refusal to go to school, increased fidgeting, nightmares and unexpected temper outbursts.
Obsessive-Compulsive Disorder (OCD)
The National Mental Health Association estimates that about 1 million children and teens in America deal with OCD every day. Obsessive-compulsive behavior, caused by an imbalance in the neurotransmitter serotonin, appears to run in families.
Some symptoms are worries about having things “right” and in order, continual checking and rechecking, concern about germs or disease, re-reading material in case something important was missed and rituals like frequent hand washing, counting and constantly repeating words or phrases. The rituals are performed to provide relief from the obsessive thoughts.
Many anxiety disorders respond well to treatment. This can include both counseling, especially cognitive behavioral therapy, and medication. Specific anti-anxiety medications may help with the panic attacks. The SSRI medications used for depression also appear to be helpful. Counseling helps the child and family learn how to reduce stress and anxiety, and manage panic attacks when they occur.
When to Seek Help
What can parents do? Parents are usually the first to recognize differences in their child’s behavior. You might ask the child’s teacher or other adults in the child’s life if they are noticing differences as well. It will help when you approach your health care provider if you can talk about both home and school behavior. Is there a cluster of behaviors that you and the teacher notice?
Although it may be difficult to seek professional help, a first step can be to talk to your primary care provider about your concerns. Tell your primary care provider what you are observing and ask if a referral to a specialist in children’s mental health is appropriate. After a complete evaluation, be open to considering a combination of medication and therapy (both individual and family) for treatment. Finally, remember that there are a number of other families struggling with some of the same issues. A family support group might be helpful to you as a parent.
Once you start counseling, stay involved with the process. Speltz suggests that parents be active consumers – asking about the diagnosis and the suggested treatment.
“By the end of the first session parents should have a clear idea of proposed interventions and how success will be measured,” Speltz says.
A treatment plan should state what methods of intervention the therapist will use, what the goals are, and what the time frame will be. If you disagree with the therapist, don’t be reluctant to ask questions and express your concerns, Speltz advises.
The U.S. Surgeon General encourages us all to think of children’s mental health as a community issue, because it impacts us all – even when it is not our child.
Who Treats Mental Disorders?
It may be confusing when you enter the mental health system to know who does what. Who can prescribe medication? What’s the difference between a social worker and counselor? Here is a primer to help you navigate the differences.
Psychiatrist – This person is an M.D. with specialized training in psychiatry. As a physician, he can prescribe medication. Many psychiatrists in private practice also work with clients in therapy, although in an agency they generally only prescribe medications.
RN – These are nurses with extra training, allowing them to prescribe medication under the supervision of a physician. In an agency, they may only prescribe and follow clients medically. They may also work in a private practice setting.
Psychologist – This person generally has a PH.D. in psychology and is trained to do psychological testing as well as individual or family therapy with clients. She may work in private practice or an agency.
Psychiatric Social Worker – This person has a Master’s degree in Social Work (M.S.W.) He is trained to do individual or family therapy with clients. He may work in private practice, agency or hospital setting. In the hospital, the social worker generally focuses on connecting clients to community resources.
Counselor – This is a person with a Master’s degree in Counseling. Sometimes the term is used generically for all people who do therapy with clients. You can find counselors at agencies and in private practice. School counselors have specialized training to work in schools.
The following organizations offer information on and support for various mental health issues:
• American Academy of Child and Adolescent Psychiatry – 202-966-7300; www.aacap.org.
• American Foundation for Suicide Prevention – 888-333-AFSP (2377); www.afsp.org.
• Anxiety Disorder Association of America – 240-485-1001; www.adaa.org.
• Carter Center Mental Health Program – 404-420-5100; www.cartercenter.org/healthprograms/program6.htm.
• Depression and Bipolar Support Alliance – 800-826-3632; www.DBSAlliance.org.
• National Institute for Mental Health – 866-615-6464; www.nimh.nih.gov.
• National Mental Health Information Center – 800-789-2647; www.mentalhealth.samhsa.gov.
• Obsessive Compulsive Foundation – 203-401-2070; www.ocfoundation.org.
• The Anxiety Cure for Kids: A Guide for Parents, by Elizabeth DuPont Spencer, Robert L. DuPont and Caroline M. DuPont, Wiley & Sons, 2003.
• Acquainted With the Night: A Parent’s Quest to Understand Depression and Bipolar Disorder in His Children, by Paul Raeburn, Broadway Books, 2004.
• Freeing Your Child from Anxiety: Powerful, Practical Solutions to Overcome Your Child’s Fears, Worries and Phobias, by Tamar E. Chansky, Broadway Books, 2004.
• National Institute for Mental Health – http://store.mentalhealth.org/publications/ordering.aspx – Offers fact sheets on specific mental health problems.
• Raising Depression-Free Children: A Parent’s Guide to Prevention and Early Intervention, by Kathleen Panula Hockey, Hazelden Publishing & Educational Services, 2003.
• Survival Strategies for Parenting Children with Bipolar Disorder: Innovative Parenting and Counseling Techniques for Helping Children with Bipolar Disorder and the Conditions That May Occur With It, by George T. Lynn, Jessica Kingsley Publishers, 2000.
Dr. Janice Lovelace is a child psychologist in the Seattle area with more than 20 years’ experience.