Childhood Psychiatric Disorders

Overview of childhood psychiatric disorders including children and depression, ADHD, anxiety, conduct disorder, and autism.

Contents

• children and depression
• children and attention deficit disorder
• children and anxiety
• children and simple phobias
• children and separation anxiety
• children and conduct disorder
• children and pervasive developmental disorder

That sentiment, expressed by the late 19th-century naturalist and plant expert Luther Burbank, still bears some truth today. Concern about children's health has certainly increased since Burbank's day. But that concern has not translated into knowledge about children's mental health. Of 12 million American children suffering from mental illness, fewer than one in five receive treatment of any kind. That means that eight out of 10 children suffering from mental illness do not receive the care they need. By comparison, 74 percent or nearly three out of four children suffering from physical handicaps receive treatment.

For much of history, childhood was considered a happy, idyllic period of life. Children were not thought to suffer mental or emotional problems because they were spared the stresses adults must face. Research conducted since the 1960s, however, shows that children do suffer from depression and bipolar disorder and anxiety disorders, illnesses once thought to be reserved for adults. From 3 to 6 million children suffer from clinical depression and are at high risk for suicide, the third leading cause of death among young people. Every hour, 57 children and teenagers try to kill themselves; every day 18 succeed.

Between 200,000 and 300,000 children suffer from autism, a pervasive developmental disorder that appears in the first three years of life. Millions suffer from learning disorders--attention deficit disorder, attachment disorders, conduct disorders, and substance abuse.

Parents whose children suffer from these illnesses often ask themselves, "What did I do wrong?" Self-blaming is not appropriate since the causes are complex and never due to any single factor. Research indicates that many mental illnesses have a biological component which makes a child susceptible to the disorder. Feelings of guilt about a child's mental illness are often as inappropriate as feelings of guilt about other childhood illnesses or about inherited health problems.

The key is to recognize the problem and seek appropriate treatment. As with other types of illnesses, mental disorders have specific diagnostic criteria and treatments, and a complete evaluation by a child psychiatrist can determine whether a child needs help. Here's an overview of the illnesses, their symptoms, theories of causes and available treatments.

Children and Depression

Like adults, children can experience the normal mood many of us refer to as "depression." This happens when we're frustrated, disappointed or sad about a loss in our lives. Part of the normal ups and downs of life, this feeling fades relatively quickly. Studies of children aged six to 12, however, have shown that as many as one in 10 suffers from the illness of depression. These children cannot escape their feelings of sadness for long periods of time.

Like depression in adults, depression has the following symptoms in a child:

• sadness
• hopelessness
• feelings of worthlessness
• excessive guilt
• change in appetite
• loss of interest in activities
• recurring thoughts of death or suicide
• loss of energy
• helplessness
• fatigue
• low self-esteem
• inability to concentrate
• change in sleep patterns

Unlike adults, children may not have the vocabulary to accurately describe how they feel. Up to a certain age, they simply do not understand such complex concepts as "self-esteem" or "guilt" or "concentration." If they don't understand the concepts, they can't express these feelings in ways an adult would quickly recognize. As a result, children may show their problems in behavior. Some key behaviors--in addition to changes in eating or sleeping patterns--that may signal depression are:

• a sudden drop in school performance
• inability to sit still, fidgeting, pacing, wringing hands
• pulling or rubbing the hair, skin, clothing or other objects;

in contrast:

• slowed body movements, monotonous speech or muteness
• outbursts of shouting or complaining or unexplained irritability
• crying
• expression of fear or anxiety
• aggression, refusal to cooperate, antisocial behavior
• use of alcohol or other drugs
• complaints of aching
• arms, legs or stomach, when no cause can be found

 

Causes of Depression in Children

Researchers are making new discoveries about the causes of depression every day as they study the roles of biochemistry, heredity and environment in the development of the illness.

Studies show that people suffering from depression have imbalances of important biochemical's in their brains. These biochemical's, called neurotransmitters, allow the brain's cells to communicate with one another. Two neurotransmitters that tend to be out of balance in depressive people are serotonin and norepinephrine. An imbalance in serotonin may cause the sleep problems, irritability and anxiety characteristic of depression, while an imbalance of norepinephrine, which regulates alertness and arousal, may contribute to the fatigue and depressed mood of the illness.

Researchers have also found that depressed people have imbalances in cortisol, another natural biochemical the body produces in response to extreme cold, anger or fear. Scientists don't know if these biochemical imbalances cause depression or if depression causes the imbalances. They do know, however, that cortisol levels will increase in anyone who must live with long-term stress.

Family history is important. Studies indicate that depression is three times more common in children whose biological parents suffer from depression, even if the children have been adopted into a family whose members do not have the illness. Other research indicates that if one identical twin develops depression, the other twin has a 70 percent chance of also suffering from it. These studies suggest that some people inherit a susceptibility to the illness.

Family environment is also important. A drug-dependent or alcoholic parent cannot always provide the consistency a child needs. The loss of a loved one through divorce or death is stressful, as is enduring the long-term illness of a parent, a sibling or the child himself. A child living with a parent who is psychologically, physically or sexually abusive must cope with incredible stress. All of these can contribute to depression.

That's not to say that children coping with these situations are the only ones susceptible to depression. Many youngsters from stable and loving environments also develop the illness. For this reason, scientists suspect that genetics, biology and environment work together to contribute to depression.

Treatment of Childhood Depression

Therapy is essential for children struggling with depression so that they can be free to develop necessary academic and social skills. Young people respond well to treatment because they adapt readily and their symptoms are not yet entrenched.

Psychotherapy is a very effective treatment for children. During therapy, the child learns to express his feelings and to develop ways of coping with his illness and environmental stresses.

Researchers have also looked at the effectiveness of medications and have found that some children respond to antidepressant medications. However, the use of medications must be closely monitored by a physician with expertise in this area, usually a child psychiatrist. The American Academy of Child and Adolescent Psychiatry emphasizes that psychiatric medication should not be the only form of treatment but, rather, part of a comprehensive program that usually includes psychotherapy.

Children with Attention-Deficit/Hyperactivity Disorder (ADHD)

You may hear attention-deficit/hyperactivity disorder called by various names: hyperactivity, minimal brain dysfunction, minimal brain damage, and hyperkinetic syndrome. All of these terms describe a condition that affects a child's ability to concentrate, to learn and to maintain a normal level of activity. Attention-deficit/hyperactivity disorder affects from three to 10 percent of all children in America. Thought to be 10 times more common in boys than in girls, this disorder often develops before the age of seven but is most often diagnosed when the child is between ages eight and 10.

The child with ADHD:

• has difficulty finishing any activity that requires concentration at home, school or play; shifts from one activity to another.
• doesn't seem to listen to anything said to him or her.
• acts before thinking, is excessively active and runs or climbs nearly all the time; often is very restless even during sleep.
• requires close and constant supervision, frequently calls out in class, and has serious difficulty waiting his of her turn in games or groups.

In addition, children may have specific learning disabilities that can lead to emotional problems as a result of falling behind in school or receiving constant reprimands from adults or ridicule from other children.

No single cause for ADHD is known. As with depression, scientists suspect that a combination of heredity, environment and biological problems contribute to the development of the disorder. For example, studies show that parents of some children suffering from ADHD also were diagnosed as having the illness. Investigators have suggested many other theories, but their validity has not been established.

A child should undergo a complete medical evaluation to ensure an accurate diagnosis and proper treatment. Youngsters may develop inappropriate behaviors because they can't hear or see well enough to know what is going on around them. Or another physical or emotional illness may be contributing to the behavioral problem.

Treatment can include the use of medications, special educational programs that help the child keep up academically, and psychotherapy.

Between 70 and 80 percent of children with ADHD respond to medications when they are properly used. Medication allows the child a chance to improve his attention span, perform tasks better, and control his impulsive behavior. As a result, children get along better with their teachers, classmates and parents, which improves their self-esteem. Also, the effects of the medication help them gain the benefits of educational programs geared toward their needs.

Like virtually all medications, those used for ADHD have side effects. These include insomnia, loss of appetite and, in some cases, irritability, stomach aches or headaches. Such side effects can be controlled by adjusting the dosage or timing of the medication.

Psychotherapy is commonly used in combination with medications, as are school and family consultation. By working with the therapist, a child can learn to cope with his or her disorder and the reaction of others to it, and develop techniques to better control his or her behavior.

Anxiety and Children

Children have fears that adults often don't understand. At certain ages, children seem to have more fears than at others. Nearly all children develop fears of the dark, monsters, witches, or other fantasy images. Over time, these normal fears fade. But when they persist or when they begin to interfere with a child's normal daily routine, he or she may need the attention of a mental health professional.

Simple Phobias

As in adults, simple phobias in children are overwhelming fears of specific objects such as an animal, or situations such as being in the dark, for which there is no logical explanation. These are very common among young children. One study reported that as many as 43 percent of children aged six to 12 in the general population have seven or more fears, but these are not phobias.

Often, these fears go away without treatment. In fact, few children who suffer from fears or even mild phobias get treatment. However, a child deserves professional attention if he or she is so afraid of dogs, for example, that he or she is terror-stricken when going outside regardless of whether a dog is nearby.

Treatment for childhood phobias is generally similar to that for adult phobias. Combined treatment programs are helpful, including one or more of such treatments as desensitization, medication, individual and group psychotherapy, and school and family consultation. Over time, the phobia either disappears or substantially decreases so that it no longer restricts daily activities.

Separation Anxiety Disorder

As its name implies, separation anxiety disorder is diagnosed when children develop intense anxiety, even to the point of panic, as a result of being separated from a parent or other loved one. It often appears suddenly in a child who has shown no previous signs of a problem.

This anxiety is so intense that it interferes with children's normal activities. They refuse to leave the house alone, visit or sleep at a friend's house, go to camp or go on errands. At home, they may cling to their parents or "shadow" them by following closely on their heels. Often, they complain of stomachaches, headaches, nausea, and vomiting. They may have heart palpitations and feel dizzy and faint. Many children with this disorder have trouble falling asleep and may try to sleep in their parents' bed. If barred, they may sleep on the floor outside the parents' bedroom. When they are separated from a parent, they become preoccupied with morbid fears that harm will come to them, or that they will never be reunited.

Separation anxiety may give rise to what is known as school phobia. Children refuse to attend school because they fear separation from a parent, not because they fear the academic environment. Sometimes they have mixed fears--fear of leaving the parents as well as fear of the school environment.

Children should receive a thorough evaluation before treatment is started. For some, medications can significantly reduce anxiety and allow them to return to the classroom. These medications may also reduce the physical symptoms many of these children feel, such as nausea, stomachaches, dizziness or other vague pains.

Generally, psychiatrists use medications as an addition to psychotherapy. Both psychodynamic play therapy and behavioral therapy have been found helpful in reducing anxiety disorders. In psychodynamic play therapy, the therapist helps the child work out the anxiety by expressing it through play. In behavior therapy, the child learns to overcome fear through gradual exposure to separation from the parents.

Conduct Disorder

Studies indicate that conduct disorders are the largest single group of psychiatric illnesses in adolescents. Often beginning before the teen years, conduct disorders afflict approximately nine percent of boys and two percent of girls under the age of 18.

Because the symptoms are closely tied to socially unacceptable, violent or criminal behavior, many people confuse the illnesses in this diagnostic category with either juvenile delinquency or the turmoil of the teen years.

However, recent research suggests that young people suffering from conduct disorders often have underlying problems that have been missed or ignored--epilepsy or a history of head and facial injuries, for example. According to one study, these children are most often diagnosed as schizophrenic when discharged from the hospital.

Children who have demonstrated at least three of the following behaviors over six months should be evaluated for possible conduct disorder:

• Steals--without confrontation as in forgery, and/or by using physical force as in muggings, armed robbery, purse-snatching or extortion.
• Consistently lies other than to avoid physical or sexual abuse.
• Deliberately sets fires.
• Is often truant from school or, for older patients, is absent from work.
• Has broken into someone's home, office or car.
• Deliberately destroys the property of others.
• Has been physically cruel to animals and/or to humans.
• Has forced someone into sexual activity with him or her.
• Has used a weapon in more than one fight.
• Often starts fights.

Researchers have not yet discovered what causes conduct disorders, but they continue to investigate several psychological, sociological and biological theories. Psychological and psychoanalytical theories suggest that aggressive, antisocial behavior is a defense against anxiety, an attempt to recapture the mother-infant relationship, the result of maternal deprivation, or a failure to internalize controls.

Sociological theories suggest that conduct disorders result from a child's attempt to cope with a hostile environment, to get material goods that come with living in an affluent society, or to gain social status among friends. Other sociologists say inconsistent parenting contributes to the development of the disorders.

Finally, biological theories point to a number of studies that indicate youngsters could inherit a vulnerability to the disorders. Children of criminal or antisocial parents tend to develop the same problems. Moreover, because so many more boys than girls develop the disorder, some think male hormones may play a role. Still other biological researchers think a problem in the central nervous system could contribute to the erratic and antisocial behavior.

None of these theories can fully explain why conduct disorders develop. Most likely, an inherited predisposition and environmental and parenting influences all play a part in the illness.

Because conduct disorders do not go away without intervention, appropriate treatment is essential. Aimed at helping young people realize and understand the effect their behavior has on others, these treatments include behavior therapy and psychotherapy, in either individual or group sessions. Some youngsters suffer from depression or attention-deficit disorder as well as conduct disorder. For these children, use of medications as well as psychotherapy has helped lessen the symptoms of conduct disorder.

Pervasive Developmental Disorder

Thought to be the most severe of psychiatric disorders afflicting children, pervasive developmental disorders strike 10 to 15 in every 10,000 children. The disorders affect intellectual skills; responses to sights, sounds, smells and other senses; and the ability to understand language or to talk. Youngsters may assume strange postures or perform unusual movements. They may have bizarre patterns of eating, drinking or sleeping.

Within this diagnosis is autism, which afflicts as many as four out of every 10,000 children. The most debilitating of the pervasive developmental disorders, autism is generally apparent by the time the child is 30 months old. It is three times more common in boys than in girls.

As infants, autistic children don't cuddle and may even stiffen and resist affection. Many don't look at their caregivers and may react to all adults with the same indifference. On the other hand, some autistic children cling tenaciously to a specific individual. In either case, children with autism fail to develop normal relationships with anyone, not even their parents. They may not seek comfort even if they are hurt or ill, or they may seek comfort in a strange way, such as saying "cheese, cheese, cheese," when they are hurt. As they grow, these children also fail to develop friendships and generally, they prefer to play alone. Even those who do want to make friends have trouble understanding normal social interaction. For example, they may read a phone book to an uninterested child.

Autistic children cannot communicate well because they never learn to talk, they don't understand what is said to them or they speak a language all their own. For example, they may say "you" when they mean "I," such as "You want cookie," when they mean "I want a cookie." They may not be able to name common objects. Or they may use words in a bizarre way, such as saying, "Go on green riding," when they mean "I want to go on the swing." Sometimes they may repeatedly say phrases or words they have heard in conversation or on television. Or they make irrelevant remarks, such as suddenly talking about train schedules when the topic was football. Their voices may be in a high-pitch monotone.

Autistic children also go through repetitive body movements such as twisting or flicking their hands, flapping their arms or banging their heads. Some children become preoccupied with parts of objects, or they may become extremely attached to an unusual object such as a piece of string or a rubber band.

They become distressed when any part of their environment is changed. They may throw extreme tantrums when their place at the dinner table changes or magazines are not placed on the table in a precise order. Likewise, these children insist on following rigid routines in precise detail.

Scientists have not identified any one cause for these disorders. Research has shown, however, that parents' personalities or methods of rearing their children have little if any effect on the development of pervasive developmental disorders.

On the other hand, scientists have learned that certain medical situations are associated with pervasive developmental disorders. Autism has been reported in cases where the mother suffered from rubella while she was pregnant. Other cases have been associated with inflammation of the brain during infancy or lack of oxygen at birth. Still others are associated with disorders that have genetic links. Among those disorders are phenylketonuria, an inherited problem with a metabolism that can cause mental retardation, epilepsy and other disorders.

For comprehensive information on parenting children with psychiatric disorders, visit the HealthyPlace.com Parenting Community.

(c) Copyright 1988 American Psychiatric Association
Revised June 1992.

Produced by the APA Joint Commission on Public Affairs and the Division of Public Affairs. This text of this document originated as a pamphlet developed for educational purposes and does not necessarily reflect opinion or policy of the American Psychiatric Association.

Additional Resources

Giffin, Mary, M.D. and Carol Felsenthal. A Cry for Help. Garden City, New York: Doubleday and Co., Inc., 1983.

Looney, John G., M.D., editor. Chronic Mental Illness in Children and Adolescents. Washington, DC: American Psychiatric Press, Inc., 1988.

Love, Harold D. Behavior Disorders in Children: A Book for Parents. Springfield, Illinois: Thomas, 1987.

Wender, Paul H. The Hyperactive Child, Adolescent, and Adult: Attention Deficit Disorder Through the Lifespan. New York: Oxford University Press, 1987.

Wing, Lorna. Autistic Children: A Guide for Parents and Professionals. New York: Brunner/Mazel, 1985.

Other Resources

American Academy for Cerebral Palsy and Developmental Medicine
(804) 355-0147

American Academy of Child and Adolescent Psychiatry
(202) 966-7300

American Academy of Pediatrics
(312) 228-5005

American Association of Psychiatric Services for Children
(716) 436-4442

American Pediatrics Society
(718) 270-1692

American Society for Adolescent Psychiatry
(215) 566-1054

Association for the Care of Children's Health
(202) 244-1801

Child Welfare League of America, Inc.
(202) 638-2952

National Alliance for the Mentally Ill
(703) 524-7600

National Center for Clinical Infant Programs
(202) 347-0308

National Institute of Mental Health
(301) 443-2403

National Mental Health Association
(703) 684-7722

National Society for Children and Adults with Autism
(202) 783-0125