Common mental health problems

4.2 Common mental health problems



Michael Sawyer, Brian Graetz


Child and adolescent mental health problems are common in the community. They have a significant impact on the lives of children and parents, and also impose a substantial financial burden on families and communities. In Australia, the National Survey of Mental Health and Wellbeing estimated that 14% of children and adolescents experience significant mental health problems (Table 4.2.1). Adolescents with mental health problems frequently exhibit other health risk behaviours, including smoking, drinking and drug abuse (see Chapter 3.11). They also report much higher rates of suicidal ideation and behaviour than other adolescents in the community. A minority of children and adolescents with mental health problems receive professional help.


Table 4.2.1 Prevalence of mental health problems among children and adolescents aged 4–17 years in Australia













































Child Behaviour Checklist Scale Prevalence (%)*
General areas  
Total problems 14.1
All externalizing problems 12.9
All internalizing problems 12.8
Specific areas  
Somatic complaints 7.3
Delinquent behaviour 7.1
Attention problems 6.1
Aggressive behaviour 5.2
Social problems 4.6
Withdrawn 4.3
Anxious/depression 3.5
Thought problems 3.1

Problem areas are not mutually exclusive, and thus ‘Total problems’ does not equal the sum of externalizing and internalizing problems.


* Percentage of children scoring in the clinical range on the Child Behaviour Checklist Scales in Sawyer MG, Arney FM, Baghurst PA et al 2000 Child and Adolescent Component of the Australian National Survey of Mental Health and Wellbeing. Commonwealth Department of Health and Aged Care, Canberra.


This chapter describes common mental health problems experienced by children (for brevity, the term ‘children’ will be used to refer to children and adolescents). It also describes practical steps that can be taken to help children, parents and families. The chapter is divided into three components. The first describes the features of common mental health problems, the second describes general approaches to the assessment and management of these problems, and the third provides information about some specific problems experienced by children.



Features of mental health problems


Two approaches are used to describe childhood mental health problems. One approach views childhood problems as lying on a continuum from those with very few problems to those with a large number of problems. Children identified as having a very large number of problems are considered to fall in the ‘clinical range’ of the continuum and to be in need of help. Typically, problems are divided into two broad groups called externalizing problems and internalizing problems.


Externalizing problems include over-activity, aggressive and antisocial behaviour. Internalizing problems include anxiety, depression and shyness. Questionnaires completed by children, parents and teachers can be used to assess the level of problems experienced by children. When a continuum approach is used, it is possible to compare the number of problems reported for an individual child with the number typically reported for others of the same age and sex in the community. It is also possible to assess treatment effectiveness by evaluating whether there is a reduction in problems.


The second approach divides childhood mental health problems into a range of different mental disorders. Each mental disorder consists of a different group of symptoms. There are two main diagnostic classification systems that identify these symptom groups. One is the International Classification of Diseases developed by the World Health Organization (ICD-10), and the other is the Diagnostic and Statistical Manual developed by the American Psychiatric Association (DSM-IV; Table 4.2.2). This categorical approach is used widely in mental health services to describe children’s problems. A common feature of both of these approaches is their focus on observable features of children’s problems rather than on their presumed aetiology. This has facilitated a broad investigation of the aetiology of children’s problems during the last three decades. Both the DSM and ICD classification systems are currently being revised, with DSM-V scheduled for release in 2013.


Table 4.2.2 Important DSM-IV disorders among children and adolescents
























DSM-IV category Specific disorders
Disruptive behaviour disorders Attention-deficit/hyperactivity disorder
Conduct disorder
Mood disorders Major depressive disorder
Dysthymic disorder
Bipolar disorder
Anxiety disorders Separation anxiety disorder
Social phobia
Obsessive–compulsive disorder
Post-traumatic stress disorder
Learning disorders Reading disorders
Written expression disorders
Pervasive developmental disorders Autistic spectrum disorders
Elimination disorders Enuresis
Encopresis


Features of internalizing problems


Many children experience anxiety or sadness. However, when these problems are severe, persist over time, and are associated with significant problems with daily functioning, they may indicate the presence of a mental disorder and the need for professional help. Children with high levels of internalizing problems should be assessed for the presence of depressive disorders or anxiety disorders, and for the presence of suicidal ideation.


Children with depressive disorders feel sad, lack interest in activities they previously enjoyed, criticize themselves, and are pessimistic or hopeless about the future. DSM-IV identifies two types of depressive disorder. Major depressive disorder consists of acute episodes of depressed mood, loss of interest and pleasure in activities, reduced appetite, sleep disturbance, low energy, low self-esteem, poor concentration and feelings of hopelessness. Children with dysthymic disorder will experience similar problems, with the distinction being that their symptoms are less severe but more chronic. Children experiencing depression may think that life is not worth living and they may contemplate suicide. It is essential that all children exhibiting depressive symptoms be carefully evaluated for suicidal risk (see Chapter 4.4).


Fear and anxiety are common to the human condition, but some children experience anxiety that is well beyond that which occurs during normal development. These children suffer personal distress and their anxiety interferes with their daily functioning. Children with anxiety disorders exhibit physiological symptoms (e.g. tremors, sweating and palpitations), maladaptive behaviours (e.g. avoidance of feared situations) and maladaptive thinking (e.g. ‘I cannot talk in front of the class because people will think I’m stupid’).


DSM-IV identifies a number of different types of anxiety disorder. One of the most common among children is separation anxiety disorder, which is defined as excessive and developmentally inappropriate anxiety regarding separation from home or from major attachment figures. Separation anxiety disorder is a common cause of persistent school refusal.


Obsessive–compulsive disorder is characterized by obsessions (persistent thoughts, impulses or images that are intrusive and distressing) and compulsions (repetitive behaviours or mental acts employed to reduce anxiety or distress). This disorder causes considerable distress for children and parents. It is important for medical practitioners to be familiar with the typical symptoms of this disorder, because effective interventions are available to provide help. These include both psychotropic medications and behavioural treatments.


Social phobia, which typically begins during the teenage years, comprises fear of social or performance situations in which embarrassment can occur. This condition can adversely affect the development of social skills and can also hinder academic progress at school. Adolescents with this disorder may be reluctant to attend professional services because of their insecurity and fear of social embarrassment.



Features of externalizing problems


Externalizing problems refer to problems such as temper tantrums, aggressive behaviour, stealing and truancy. Boys are more frequently identified as having externalizing problems than girls. Problems in this area, particularly those involving aggressive behaviour, can persist over long periods of time. For example, infants with a difficult temperament may exhibit oppositional and defiant behaviour as preschoolers, and may subsequently develop behavioural disorders during later primary school or high school.


Two common mental disorders in this area are conduct disorder and attention-deficit/hyperactivity disorder (ADHD). The typical behaviour of those with conduct disorder includes bullying, frequent physical fights, deliberate destruction of other people’s property, breaking into houses or cars, staying out late at night despite parental prohibitions, running away from home and frequent truancy from school.


ADHD is defined as a persistent pattern of inattentive behaviour and/or hyperactivity/impulsivity that is more frequent and severe than is typically observed in individuals of the same age. Children with inattentive behaviour problems make careless mistakes with schoolwork, find it hard to persist with tasks and are distracted easily. Those with problems in the area of hyperactivity/impulsivity often fidget and talk excessively, interrupt others, and are described as constantly being ‘on the go’ (see Chapter 4.3).


Young people attending clinical services often have co-morbid conditions. For example, children with behavioural problems may also have problems with anxiety or depression.



image Practical points



Assessment of mental health problems




• Careful assessment is essential before initiating any treatment programme for mental health problems.


• Assessment requires knowledge and understanding of children’s presenting problems, developmental history, family and social environment.


• Information must be obtained from multiple informants (children, parents and teachers).


• Aetiological factors can be divided into predisposing, precipitating, perpetuating or protective factors.

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Aug 4, 2016 | Posted by in PEDIATRICS | Comments Off on Common mental health problems

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