19 Coping and Stress Tolerance Mental Health and Illness
The term “mental health disorder” describes conditions that affect behavioral, emotional, and neurological development, psychiatric illnesses, and circumstances that result in stress and altered coping (Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health, 2009). There are many reasons for mental health problems in children, including exposure to environmental toxins, such as lead and mercury; genetic inheritance; caregiver neglect or abuse; and exposure to violence. Anxiety and depression stem from genetic predispositions, neurohormonal influences, and the stresses and strains of modern family life. An increasing body of evidence indicates that epigenetics, or the role of nongenetic influences in gene expression, may be a significant contributor to mental illness. Known epigenetic influences include trauma, parenting style, nutrition, hormones, stress, social support, drugs, and family interactions (Stufferin-Roberts et al, 2008). Common childhood stressors include parental divorce or separation, domestic violence, child abuse or neglect, natural disasters, familial mental illness, exposure to media reports of traumatic events, school problems, interpersonal conflict, and military deployment of a loved one (American Academy of Pediatrics [AAP], 2009).
The 2009 America’s Children’s Report of Leading Health Indicators for Children 4 to 17 years old (Forum on Child and Family Statistics, 2009) showed that 5% of responding parents identified their children as having definite or severe emotional or behavioral problems. Significant problems were identified for 6.4% of males and 3.9% of females and were more likely to occur for children living in families with incomes at 100% of the federal poverty level (7%) than those with incomes at or above 200% of the federal poverty level (3.9%). Children without parents (11.5%) or those living with their mother only (7.1%) were more likely to have significant problems compared with children living in two-parent families (4.2%). National estimates indicate that between 13% and 20% of American children require mental health services, and that most children with diagnosed psychiatric disorders have severe impairment. Yet only half of the children and adolescents who meet diagnostic criteria for a mental health disorder have visited a health care provider for treatment of their condition in the past year and less than 20% receive the treatment they need (Forum on Child and Family Statistics, 2009; Hagan et al, 2008; Merikangas et al, 2010; Report on Healthy Development, 2009).
As of 2009 there were only 7400 child psychiatrists and an estimated 15 million children and adolescents who required their services (American Academy of Child and Adolescent Psychiatry [AACAP], 2009b). The availability of child psychiatrists is especially limited in rural counties and in areas of high poverty (AACAP; Thomas and Holzer, 2006). In addition, health insurance coverage for mental health services has declined, and cost control results in more restrictions on access to mental health care. Consequently, primary care providers must take active roles in the identification, and early intervention of children and adolescents with mental health disorders (Foy et al, 2010; National Association of Pediatric Nurse Practitioners [NAPNAP], 2007). However, primary care providers often do not appropriately recognize, treat, or refer children with significant psychopathology. Additionally, studies show that when primary care providers do use psychopharmacotherapeutic approaches, they often do not leave patients on these medications long enough to get the desired therapeutic benefit (Kelleher and Stevens, 2009). Barriers to the creation of a mental health medical home include insufficient provider education, time constraints, limited reimbursement for services provided, provider lack of familiarity with screening methods, and social stigmas that affect the child, family, and providers (Foy et al, 2010; Jellinek et al, 2009).
Mental Health Influences
Neurobiological Context
Early mental health influences include the child’s genetic composition and the intrauterine environment’s effects on the developing fetus. Maternal nutrition, especially B12 and folic acid intake, and stress hormone levels are among the most documented influences on the structure and function of the evolving central nervous system (Beydoun and Saftlas, 2008). Severe prenatal nutritional deficiency is associated with the development of schizophrenia, schizoaffective disorders and congenital central nervous system abnormalities (Tottenham et al, 2010). Genetic disorders with behavioral components, like Prader-Willi, are more common in children born through in vitro technologies, raising the concern that suboptimal embryonic nutrition can alter brain development and differentiation (Stufferin-Roberts et al, 2008).
Risk and protective factors for psychopathological conditions emerge from the interaction of genes and environmental experiences. The protective effect of nurturing parenting is evident in animal research that demonstrates that rats who receive lots of maternal attention have a weaker hypothalamic-pituitary-adrenal (HPA) stress response (Szyf et al, 2005). Children exposed to physical abuse, sexual abuse, verbal abuse, or neglect are more likely to have altered white matter development than their nonabused peers (Choi et al, 2009). The number and combinations of risk and protective factors for any individual are likely to determine behavior patterns, comorbidities, severity, and course of psychopathological conditions during childhood, adolescence, and adulthood.
Functional magnetic resonance imaging (fMRI) and positron-emission tomography (PET) scans allow the identification and description of patterns in brain structure and function in normal children and adolescents. These imaging techniques also document altered patterns of structure and function in children and adolescents diagnosed with psychopathological conditions. From infancy through early adulthood, changes in the limbic system, specifically the amygdala and hippocampus, influence emotional development and the emergence of affective disorders, substance abuse, and high-risk behaviors (Stufferin-Roberts et al, 2008). However, none of these brain differences appear to be necessary or sufficient for psychopathological conditions to occur. Rather, environmental strengths and vulnerabilities, and cumulative life experiences influence the number and severity of symptoms and the adaptive competencies the child displays at any age (Burt, 2009).
Research demonstrates the profound effects of stress and environmental deprivation on the young child’s brain development (Carmody and Bendersky, 2006). Activation of the HPA axis triggers release of cortisol, feeding the fight-or-flight response. Elevated serum cortisol levels act as a toxin on neurons in the central nervous system, inhibiting the growth of dendrites and neurons and causing the death of neurons. Research also demonstrates the profound effects of the use-it-or-lose-it phenomenon on the number of neurons and dendritic growth and interconnections. In the final phase of brain growth, known as differentiation, the brain prunes away unused neurons and dendritic connections. Brain imaging of children exposed to the chronic stress of emotionally and materially deprived environments shows reduced brain volumes compared with the brain size of age- and sex-matched children from nondeprived environments (Tottenham et al, 2010). In short, all forms of material and interactive experiences actively shape children’s brain architecture.
Chronic triggering of the HPA stress response hones the speed and intensity of a neurological response. Chronic stress leads to swift, strong expressions of distress to even minor stressful stimuli. For example, preterm infants respond with a strong cry to even minor chilling or discomfort. Infant and child crying has profoundly negative effects on normal adults, triggering the adult’s own stress response. Thus excessive and prolonged crying is a significant risk factor for child abuse and the development of problems in the parent-child relationship. Normal developmental changes add an important layer of influence and complexity to the interaction between the genetically driven biology of the child and his or her interaction with the environment.
Mental Health in Primary Care
Child and adolescent mental health has profound effects on child development, family functioning, and society as a whole. Primary care providers, as medical home providers, are ideal mental health advocates because of their:
• Established therapeutic relationships with children and families
• Capacity to engage in mental health promotion and anticipatory guidance
• Familiarity with normal child development and healthy parenting
• Experience coordinating care with other health care specialists
• Familiarity with chronic care principles and practice improvement (Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health, 2009; NAPNAP, 2007).
According to the Report on Healthy Development: A Summit on Young Children’s Mental Health (2009), the following strategies can be used to ensure optimal mental health. First, parents need to know that when they provide for their child’s social and emotional needs, their child is more likely to have healthier behavior, improved school performance, and better interpersonal relationships. Second, responsive and stable caregiving positively influences brain development. Next, parents should be educated about normal child development, with special emphasis on developmental stress points and transitions. Parents need to know that predictable home, childcare, and school routines are essential to a child’s mental health. Anticipatory guidance related to healthy prenatal care, diet, and exposures should be a part of routine wellness care. Lastly, parents need support of healthy parenting skills, and they need to know that early mental, verbal, and emotional abuse is particularly toxic to the developing child. The following discussion details strategies that can be used to foster childhood mental wellness.
Prevention
Primary Prevention
Primary prevention of mental health problems occurs through positive, nurturing parent-child relationships. Children need to experience a secure attachment relationship and a sense of self-worth and being worthy of love. This serves as a foundation for developing social, emotional, and cognitive competence (Lieberman and Van Horn, 2009). Additional protective factors that promote resilience and mental wellness include:
• Responsive, thoughtful caregivers
• Parental recognition of individual achievements, efforts, and improvements
• High-quality preschool, elementary, and secondary schools
• Sense of control over one’s life
• Sense of one’s purpose, and clear self-identity
• Opportunities to interact with positive peers and adults
• Freedom from racism, sexism, discrimination, and poverty (Foy et al, 2010)
Pediatric providers must consistently screen for parent depression at health visits beginning with the prenatal visit because parental depression threatens healthy parenting (Hagan et al, 2008). A large body of research supports the significant negative effects of maternal depression, including prenatal depression, on the behavior and development of infants and young children (Pfefferle and Spitznagel, 2009). The U.S. Preventive Services Task Force (USPSTF) (2006) states that the two-question depression screen (i.e., persistent feelings of sadness or the blues and lack of pleasure in things previously enjoyed) is as effective as longer screening tools to identify maternal depression.
Healthy parenting strategies result in parents who are positive in tone and regard for the child, responsive to the child’s autonomy and individuality, neutral in response to unwanted behavior, and attentive to the child’s needs (Box 19-1 and see Chapters 4 and 16). Parents who have not experienced this type of nurturing often need education and coaching in positive parenting behaviors from a pediatric provider (McDonough, 2005).
BOX 19-1 Positive Parenting Strategies
Attend to the Child Individually
Allow the child to make reasonable choices.
Respond to child’s bids for attention with eye contact, smiles, and physical contact.
Comment on child’s appropriate and desirable behavior frequently and positively throughout the day.
Provide guaranteed special time daily: no interruptions, no directions, no interrogations.
Prevent secondary gains for the child’s minor transgressions by having no discussion, physical contact, perhaps even eye contact; be neutral and simply state the preferred behavior.
Listen Actively
Paraphrase or describe what the child is saying.
Share the child’s affect by matching the child’s body posture and tone of voice.
Avoid giving commands, judging, or editorializing.
Convey Positive Regard
Communicate positive feelings (e.g., love) directly.
Give directions positively, firmly, and specifically.
Provide notice before requiring the child to change activities.
Label the behavior, not the child.
Praise competency and compliance; say thank you.
Avoid shaming or belittling the child.
The development of trust and a sense of security in the world begins with effective, timely parental response to the infant’s needs. Contrary to popular belief, responsive parenting results in children who are able to self-regulate their behavior and who are confident and competent rather than clingy. As children become more mobile and autonomous late in the first year, parents should begin to use limit-setting strategies that include reasoning, explanations, and distractions. Effective use of discipline and a teaching-based style enhance the development of self-regulation and foster a strong self-concept and social competence (see Chapters 4 and 16). Through anticipatory guidance, pediatric providers assist parents to handle predictable life events that are likely to influence children, such as changes in daycare, moves, or changes in schools. Increasing the parent’s awareness of the child’s developmental and temperamental needs can facilitate the identification of strategies to effectively facilitate transitions. Providers should assist parents to find ways to help their children use developmentally appropriate coping strategies. For example, parents can encourage symbolic play in preschoolers, or use discussion about developmentally appropriate books or movies with older children to help them express feelings and worries and gain control of their situation.
Secondary Prevention
Secondary prevention, or early detection and intervention, addresses unanticipated life events. Social, emotional, or behavioral problems may emerge even in the context of positive parenting approaches. Early recognition of pediatric mental illness is easier when parents have a realistic understanding of their child’s development and primary care providers actively screen for developmental red flags. Secondary prevention involves working collaboratively with parents to identify and implement appropriate management strategies or to explain and reinforce the value of mental health recommendations.
Medication may be necessary to manage some pediatric mental health problems. However, most mental health problems require a combined approach of psychotherapy and medication. Studies show medication combined with psychotherapy is superior to medication alone.
Use of medication to treat mental health problems in children is increasing, but there are concerns about pharmacological interventions of which primary providers must be aware. There are few randomized control trials involving children that demonstrate pharmacotherapeutic safety and efficacy. Existing research shows that medications that are effective in the management of adult mental health conditions are less effective or may be completely ineffective in children with similar diagnoses, likely due to differences in the organization and function of the developing brain of children at different ages. Many drugs used to treat mental health conditions have serious adverse side effects and require ongoing physiological monitoring (Table 19-1). Primary care providers assess for interactions between medications used in treating mental health conditions and commonly prescribed medications also used in primary care, such as antibiotics and contraceptives, which may result in impaired drug effectiveness or toxic side effects.
Tertiary Prevention
Tertiary prevention and intervention address major losses and trauma (e.g., victimization through sexual or physical abuse, parental marital problems, divorce, substance abuse, and parental psychopathological conditions). Even in the absence of behavioral manifestations of distress, a referral to a mental health specialist for further assessment and intervention is suggested because of the short- and long-term problems that result from traumatic experiences. In these cases, parents may not understand the need for referral. It is most helpful for the pediatric provider to frame the behavior problem as a “normal response to an unusual or stressful situation” with the goal of referral being to maximize the child’s development and growth. A release of information allows direct contact with the consultant to ensure follow-through. Ongoing follow-up is essential with children, families, and other professional providers.
Approaches to Children by Developmental Level
Special Approaches from Infancy Through Early Childhood
The early child years are the most critical for mental wellness. It is important for infants, toddlers, and preschoolers to have nurturing, supportive environments with ample opportunities for physical, emotional, and social growth. Healthy attachment is critical to the development of healthy, happy, and self-confident children. Infants and young children with good attachments develop the confidence to explore their world and learn cognitive and social skills. Parental strategies that foster good attachment include using loving verbal and nonverbal communication, providing consistent routines, having frequent “fun” and play time, accurately reading child signals, and providing timely response to the child’s needs (Report on Healthy Development, 2009).
By early infancy, attentive parents describe their baby’s likes and dislikes, sensitivities, and signals. Many babies comfort themselves for brief periods. Babies who receive prompt responses to their needs typically provide less intense distress signals and develop the ability to wait for care (Hagan et al, 2008). Parents face the challenge of becoming effective, adaptive teachers for their changing baby.
Parents should provide older infants, toddlers, and preschoolers the opportunity to develop an “emotional IQ.” This can be achieved by allowing the child to express and recognize the full spectrum of human emotion, from good to bad, and to develop skills to cope with negative emotions. Children learn empathy when the child receives sensitive empathic care. By this stage, signs of parenting that impede mental wellness include difficulty with limit setting, frustration and negativity with toddler behavior, limited or absent verbal communication with the child, hurtful teasing, and multiple bruises and injuries suggesting inadequate supervision, abuse, or neglect of the child (Hagan et al, 2008).
Physical, emotional, and verbal abuse are especially toxic to the young child who is developing self-identity and learning how to relate to others (Report on Healthy Development, 2009). Therefore, it is important for primary care providers to educate parents about strategies that can be used when they are overwhelmed, and how to communicate with their child in a developmentally appropriate manner. Nurse home visitation programs are effective for improving parenting skills, enhancing parental social support, and improving parent-infant attachment in at-risk families (Council on Community Pediatrics, 2009).
Special Approaches During the School-Age Years Through Adolescence
Normal children at this age have significant abilities to control their emotions, behavior, and attention. The child’s social roles and behavior expectations change dramatically at home, at school, and among peers. The child’s self-concept and self-esteem face daily challenges in comparisons with peers’ performance in academics, sports, and social interactions. Parents should support their child’s self-esteem and exploration of a wide range of interests, and protect the child from early engagement in competition for which he or she is not emotionally ready (Hagan et al, 2008).
Stress is a known risk factor for mental illness. It is important to allow older children and adolescents opportunities for “downtime” and relaxation. Healthy parenting during these ages involves modeling and teaching healthy ways to deal with stress. Primary care providers can improve coping by using strategies to improve resilience and communication skills (AAP, 2009). Special care should be paid to avoid child “overscheduling.” All children and adolescents need time to relax and to mentally recharge from the stresses of school, work, and extracurricular activities. Family interventions that improve communication and foster healthy coping include family game nights and shared, sit-down meals.
It is important for parents to recognize that although adolescents’ cognitive skills are nearly at adult levels, their ability to make good decisions under the influence of strong emotions is not as developed. Girls are especially vulnerable to affective disorders. Social roles and behavior expectations change dramatically with sexual maturation. On the positive side, altruism and idealism emerge, leading many adolescents to significant achievements. Parents are challenged to provide accurate and timely information, sensitive support, and appropriate limits to their adolescent.
High-risk adolescent behaviors include sexual activity, alcohol and drug use, driving while intoxicated, tobacco use, aggressive or hostile behavior, depressed mood, and school absenteeism or academic failure (Hagan et al, 2008). Failure to set appropriate limits and expectations, lack of pride in the adolescent’s achievements, negative affect toward the adolescent, frustration or anger with the normal level of adolescent mood lability, and failure to support the adolescent’s positive engagement in the community and school signal problems in the parent-adolescent relationship.
Temperament Influences on Mental Health
Temperament is a foundation for coping. Temperament involves an individual’s characteristic style of emotional and behavioral response across situations and has generally come to be accepted as inborn. Although biological in origin, temperament characteristics evolve and develop over time and are influenced by and patterned in significant ways by the social environment. This view of temperament is clinically important because both short- and long-term psychosocial adjustments are shaped by the goodness-of-fit between the individual’s temperament and the social environment. (Goodness-of-fit refers to the congruence of a child’s temperament with the expectations, demands, and opportunities of the social environment, including those of parents, family, and daycare or school setting.) (See Table 4-2 for information about temperament types.)
Temperament Types
Three temperament types are clinically significant and cross-culturally generalizable: difficult, easy, and slow to warm up. Children with difficult temperaments tend to have an intense and negative mood, slow adaptability, withdrawal from new situations, and irregular biological functions. Children with easy temperaments typically exhibit a positive mood, low intensity, easy adaptability, and regular and predictable biologic and behavioral patterns. These children are often described as being easygoing. Children with slow-to-warm-up temperaments are characterized by initial quiet alertness and subdued emotionality. Although reserved in new situations and with new stimuli, once the initial novelty wears off, slow-to-warm-up children demonstrate behaviors similar to children with easy or difficult temperaments. There is no absolute standard for any of these classifications, and all features of temperament must be considered in the context of the parents’ evaluations.
Temperament as a Risk Factor
Difficult temperaments are most often associated with behavior disorders, although temperament alone is not a risk factor for maladjustment. Rather, temperament exerts an influence on children’s psychosocial adjustment by affecting caretaker-child interactions. Difficult temperamental features tend to engender parental criticism and irritability, power struggles, and restrictive parenting. Critical mediators of the role of temperament in the development of behavioral disorders include parental psychological functioning, marital adjustment, childrearing attitudes and practices, and social support factors. Although temperament is unrelated to intelligence quotient (IQ), it affects academic outcomes, and some children are clearly disadvantaged by their more difficult temperaments in the majority of school environments.
Temperament Management
The goal for the primary care provider is to help parents achieve goodness-of-fit for their children. Specific strategies for intervening with temperament issues have been developed for parents (Table 19-2). Those who care for children (e.g., parents, teachers, other caregivers) should:
• Recognize the child’s innate behavioral qualities as expressions of temperament. This recognition can be facilitated by interview about child responses (e.g., changes in activities, new situations, changes in routines, new people) or by completing a standard temperament questionnaire.
• Understand how temperament is related to behavior and is not amenable to change. Allow parents to express their feelings about their child or their child’s behavior and assisting them to reframe their assessment more positively. Members of the extended family who often advise parents may need to be included to help alleviate parental feelings of failure.
• Develop temperament-based management strategies, especially ways to deal with the more challenging areas of temperament. Such strategies can be applied to new situations as the child develops and becomes more autonomous, including those that occur in toddlerhood and preschool, such as mealtime and bedtime, or during school-related activities, such as doing homework.
TABLE 19-2 Strategies to Help Parenting of Children With Different Temperaments
| Temperament Characteristic | Strategy |
|---|---|
| Activity | Recognize the child’s activity level and plan high-energy activities (such as long walks, family outings) with naps and child’s energy levels in mind. Plan for activities to keep high-energy children busy in situations when quiet is required (such as during religious services). |
| Rhythmicity | Take the child’s normal sleep, wake, and feeding schedule in mind when planning activities and outings. Avoid activities during “normal” naptimes. Use normal elimination patterns as a guide during toilet training. |
| Approach or withdrawal | Help teach young children skills to deal with discomfort felt while meeting new people or having new experiences. Provide opportunities for children with approach/withdrawal problems to experience new situations and to meet new people in a supporting and loving environment. Recognize that new situations may be stressful. |
| Adaptability | Teach young children how to deal with disappointment. Provide reassurance when things don’t go as planned. |
| Threshold of response | Recognize that not all children require the same amount of stimulation for calming. Adapt redirection strategies to the child’s personal response threshold. Modify approaches to the situation, i.e., serious situations require a more firm approach (e.g., when the child is in danger) and use care to not overrespond to more mild situations (e.g., when juice spills or things break). |
| Intensity of reaction | Help children to recognize their responses to positive and negative emotions. When an overresponse occurs, teach children how to modify their behavioral response to their feelings. Do not avoid situations in which frustrations may occur; part of developing emotional maturity is experiential. |
| Quality of mood | Use positive reinforcement for good mood responses to situations. Ignore negative mood responses. |
| Distractibility and attention span/persistence | Take a child’s development and distractibility into consideration when doing tasks that require concentration (i.e., homework, quiet time). Teach the child strategies to help stay on track. Help parents set realistic expectations of the child’s attention span. |
Assessment and Management of Mental Health Disorders
The definition of a mental health disorder is a sustained behavior change that results in functional impairment. Because mental health problems cover a broad range of behavioral, emotional, and psychological disorders, many of which include genetic influences, the accurate identification of emotional, social, behavioral, and mental health status requires a thorough history and a physical examination. The physical examination detects underlying physical conditions that can result in behavioral or emotional changes. Primary care providers must recognize that common illness symptoms, such as fever, can change a child’s behavior because of malaise, arthralgias, or other physical symptoms. A series of laboratory, developmental, and psychological tests may also be required. Suggested areas to explore with relation to mental health problems (or coping/stress problems as defined by Gordon’s Functional Health Patterns) are reviewed below.
Assessment
Approaches to Children of Different Ages
During all health visits the primary care provider should assess the quality of the verbal and nonverbal exchanges between infants, children, and adolescents and their parents and the health care provider (Hagan et al, 2008). Specific attention should be paid to assess the emotions and energy the child displays, and the presence or absence of interaction among those present in the examination room. Additionally, Bright Futures and the AAP call for assessment of the family psychosocial functioning at all routine health supervision visits and routine screening for mental health issues using validated instruments (Foy et al, 2010; Hagan et al, 2008).
The manner in which the provider conducts the history and physical examination is as important as the information obtained. Many parents share their concerns only after a long period of trying to solve the problem themselves. They may be upset, worried, or frustrated. Many people are reluctant to discuss symptoms because of social stigmas against mental illness.
Providers are more likely to get a clear picture of what is happening and gain the family’s trust if they take the time to sit down and actively listen at length to both the parent’s and child’s concerns and perceptions. It is critical to avoid rapidly firing questions, restricting the history to a preprinted schedule of questions, or taking notes that detract from giving full attention to the child and family. Sufficient time should be scheduled for the history and physical. If a potentially significant but nonemergent problem is uncovered in the course of an episodic visit, a lengthier appointment should be scheduled to avoid hurrying the assessment and potentially missing important data. It is essential to obtain information from the child’s perspective and to use age-appropriate strategies.
Infants
Observations of babies and toddlers with their parents in structured and unstructured situations offer valuable clues to the strengths and limitations of each partner in the interaction. Understanding each partner provides guidance in developing a plan of care for any identified problems and is a way to follow progress in the relationship over time. Even unstructured observations allow the observer to appreciate the emotional exchanges and the presence or absence of sensitive and contingent interactions between the infant and parent.
Toddlers and Young Preschoolers
Playing with figures, dolls, and toys gives older toddlers and young preschoolers a way to express their feelings and emotions. Having a variety of dolls and toys on hand and allowing the child to play spontaneously provide the opportunity for the professional to ask questions within the nonthreatening context of play. This also helps to direct probing with parents. If the parent has already identified situations or people who provoke troubled behavior, the provider may select toys that are likely to elicit the child’s story in play. For example, if the concerning behaviors began shortly after the birth of a new sibling, a baby doll, mother and father dolls, and a doll the age and gender of the child could be selected.
School-Age Children
Older preschoolers and young school-age children can be assessed by offering them the opportunity to draw a picture of themselves and their family, and asking them to tell a story about their picture. This allows the professional the opportunity to evaluate the child’s feelings and emotions and, if problems and concerns become apparent, clarify details from the child’s perspective in a nonthreatening and familiar way.
Adolescents
The primary care provider should separately interview the school-age child and adolescent. Allow 20 to 30 minutes for the school-age child and 30 minutes or more for the adolescent to share their perspectives and feelings. Most children are comfortable talking about their feelings and experiences if they have a supportive listener. It is important to clarify issues related to confidentiality with both the adolescent and caregiver prior to initiating a mental health assessment. Tailor questions to the child’s or adolescent’s level of understanding, keeping questions simple and providing examples to younger children. Sample questions include:
• “Tell me about some of the things you do very well. What types of things do you have a hard time doing?”
• “You look very sad to me. Would you share with me what is making you sad?”
• “Many children have things they worry about. What worries you most?”
• “How are things going in your family?”
• “How are your relationships with other people? Do you feel like other people understand you and see you for who you really are?”
• “Everyone feels angry at times. What makes you angry? What do you do when you are angry?”
• “If you could change one thing in your life, what would it be?”
• “Tell me what you think the problem is from your point of view.”
History
Correctly pinpointing mental health disorders requires a more thorough history than does the diagnosis of many physical health problems. Following the comprehensive health history model found in Box 2-2 will be helpful as daily living (functional health), disease, developmental, and family domains must all be addressed.
The Symptom Analysis: Behavioral Manifestations
Parents are keen observers of their children, so it is wise to listen carefully to their observations and concerns. Behaviors that concern a parent may include those that are developmentally normal for the child, or they may represent extremes of the range of normal behavior. By obtaining a clear idea of the parent’s concerns, the provider can assess the parent’s level of knowledge about child development and behavior, clarify which behaviors are developmentally normal (but distressing to the parent), and confirm which behaviors fall outside the range of normal. Eliciting information from teachers and other caregivers reinforces parental reports and provides a contextual understanding of child behavior.
Family Domain: Common Family-Related Stressors
Common stressors that should be identified through the history are discussed in this section. Questions and specific examples of stressors are found in Table 19-3.
• Recent Changes. When inquiring about recent changes in the child’s life, it is helpful to specifically ask about changes in the family, work, school, and other settings because parents may not perceive some changes as sources of stress for their child. For example, parents may welcome a job promotion that includes the need for travel and a significant pay increase. However, this same change may stress the child, who is old enough to worry about how life will change with a traveling parent. Most recognize that the addition of a new family member is life changing for children already in the home, but other family changes like having a grandparent move in or an older sibling move out can be equally stressful. It is important to consider the developmental context of events and whether most children of a similar age would find the incident threatening or upsetting.
• Contextual Changes in the Family. Contextual changes are more enduring changes in life circumstances, either for better or worse, which provoke changes in the child’s perception of self, family, or feelings of relationship security. These changes may result in self-blame or stem from the actions of other family members, especially parents, creating a sense of betrayal.
• Parent Stress and Mental Illness. All parents face stress and feelings of being overwhelmed. It is important to assist parents to identify situations in which they know risk of stress is greatest. For example, certain developmental stages are commonly more taxing than others and many young children have increasing behavioral problems in the late afternoon hours as fatigue increases and energy levels lag. Primary care providers provide anticipatory guidance to develop interventions to help parents predict and minimize these “at-risk” times. Parents with mental illness are at risk for increased role strain and parenting difficulties because of how their condition affects their perceptions and coping skills.
• Impaired Parenting. Impaired parenting occurs when there is a mismatch between parenting behaviors and a child’s developmental or situational needs. This may result in inappropriate stimulation, inconsistent care, inappropriate supervision, developmentally inappropriate behavioral expectations, harsh words, child abuse or neglect, or child rejection. It is important to explore parenting influences. Parents face a tremendous challenge to adapt their parenting skills to the individual development and behavior of each child in their family. This may be evidenced by parental verbalization of dissatisfaction with their role, exacerbation, or inappropriate communication with the child. Child behaviors that may indicate impaired parenting include acting-out, developmental regression, and other aberrant behaviors.
• Parents’ Personal History of Being Parented. A significant body of research confirms the effect of the parents’ personal history of being parented on the quality of parenting provided to children. Parents’ recollections of how they were parented are powerful influences on parental perceptions of child behavior, beliefs about children and childrearing, and ultimately the parenting behaviors used in the home (Lieberman and Van Horn, 2009). It is important to have the parents share memories, good and bad, of their childhood and what they liked and disliked about the parenting they experienced (see Table 19-3).
• Family Health History. A thorough history of mental and developmental disorders in family members should be conducted, including school failure, delinquency, substance abuse, learning disorders, reading problems, mood disorders, personality disorders, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), autism, genetic syndromes, and birth defects.
TABLE 19-3 History Taking: Areas for Assessment of Mental Health
| Topic | Sample Question | Potential Stressors |
|---|---|---|
| Behavioral manifestations: symptom analysis | “Please describe your child’s behavior. What seems to make it better or worse? How have you tried to help your child? How does the behavior make you feel? How do think your child feels?” | |
| Recent changes | “What events or changes have occurred in your family in the past year?” | |
| Contextual changes within the family | “Who lives in your home? Have there been any recent changes at home or changes in family relationships?” | |
| Recurring experiences | “Tell me about the things you find difficult or stressful as a parent, especially in caring for this child.” | |
| Parents’ personal history of being parented | “Tell me about your most favorite and least favorite memories of growing up. How is your parenting similar to and different from the parenting you received as a child? What are your expectations for your child?” | |
Disease Domain
• Prenatal and Birth History. Was the pregnancy planned and wanted; maternal illnesses and discomforts during the pregnancy; problems with the pregnancy; when prenatal care began; maternal alcohol, drug, and tobacco use; occupational or environmental exposures; results of prenatal testing; maternal weight gain during pregnancy; response of significant others to the pregnancy; presence of social support during the pregnancy; and maternal depression during pregnancy. Also, spontaneous or induced labor, length of labor, complications or medical conditions arising during labor, type of delivery, and delivery complications.
• Postnatal History. Gestational age, birthweight and length, problems after delivery (including hypoglycemia and hyperbilirubinemia), problems in the first 2 weeks of life, difficulty feeding, excessive irritability or lethargy, maternal postpartum depression, and results of newborn screening.
• Past Medical History. Childhood illnesses and traumatic injuries, especially neurological injuries and soft neurological signs of developmental significance (e.g., delayed speech).
Developmental Domain: Developmental Progress
Achievement of milestones, level of social skills, relationships with peers, emotional maturity (e.g., ability to deal with the full spectrum of emotions)
Physical Examination
The practitioner should complete a thorough physical examination with particular attention to recognition of physical anomalies and neurological system evaluation. Also important is evaluation of affect, cognition, and mental status.
Diagnostic Studies
Laboratory Studies
Pertinent laboratory tests (hemoglobin, ASO titer, blood lead level, serum electrolytes, drug tests for alcohol or illicit substances, or urinalysis) can rule out physical health problems with behavioral manifestations. The family history and findings on the physical examination may warrant chromosomal studies.
Imaging Studies
Imaging of the central nervous system may be recommended depending on family history, developmental, and neurological findings.
Behavioral/Developmental Screening and Assessment Tools
A structured developmental screening or assessment should be included in the assessment. If warranted by suspicious or ambiguous findings, a referral for a thorough developmental evaluation by a skilled psychologist or multidisciplinary developmental assessment team is appropriate. Behavioral rating scales or checklists are valuable screening tools, especially those with established reliability and validity that provide norms as a basis for comparison. Screening instruments with sound reliability and validity include the Ages & Stages Questionnaire for developmental screening; the Ages & Stages Social-Emotional Screen for social and emotional concerns; the 10-minute Brief Infant-Toddler Social-Emotional Assessment (BITSEA) screen and its companion in-depth assessment, Infant-Toddler Social-Emotional Assessment (ITSEA), for use as a follow-up assessment if problems arise on the BITSEA screen. The Achenbach Child Behavior Checklist has excellent reliability and validity and has been used successfully with a wide variety of clinical populations. Available in English and Spanish, it provides separate checklists for assessment of children 1.5 to 5 years old and 6 to 18 years old, with norms provided by age and gender, and separate report forms for parents and teachers. Other checklists with clinical utility include the Pediatric Symptom Checklist (PSC) for children at least 11 years old (Hagan et al, 2008). Even if children’s scores do not reach a clinical level by normative standards, attention must be paid to notably high scores, stable problem behavior, and attending circumstances.
Maternal postpartum depression (PPD) can negatively affect infant development, so routine screening for symptoms of PPD is merited during episodic health visits in early infancy (Hagan et al, 2008). Standardized screening tools like the Edinburgh Postnatal Depression Scale (EPDS) are easy to use in the clinical setting. Mothers with positive screens should be referred to adult mental health professionals for further evaluation and treatment.
Temperament assessment can be useful for infants, toddlers, preschoolers, and school-age children. Parent reports of temperament reflect the parents’ perception, which may not accurately reflect objective reality. However, accurate or not, the parents’ perceptions influence their behavior and feelings toward the child and must be taken seriously.
A behavioral diary or log kept by parents, by the school-age child or adolescent, and by the teacher informs the practitioner and family about the situational context for and severity of the behavior. Often this monitoring process itself serves as an effective intervention.
Making Mental Health and Behavioral Diagnoses
Making mental health diagnoses is often difficult. One must decide whether behaviors are within normal limits for age, temperament, family, health, and other factors. Comorbidities are common. In practice, several diagnoses may need to be addressed: the behavior, the family effects, nutrition, sleep, and other interrelated issues. In many cases, a mental health specialist such as a clinical psychologist or psychiatrist may be required to assist in diagnostic decision-making.
Strategies for Management
After the diagnostic list is made, the primary care provider will need to decide how to manage and/or co-manage problems with other pediatric specialists. Pediatric primary care providers manage more mental health problems than ever before, largely because the scarcity of mental health services or inadequate insurance coverage makes mental health care out of reach for many families. However, many primary care providers lack adequate education to manage complex problems. In addition, it is financially difficult for many busy primary care practices to offer the extended appointments needed for high-quality mental health care.
As a rule, if the cause of the problem is a life event with acute, short-term consequences, such as the death of a pet or a friend moving away, or a common developmentally normal but troublesome behavior (e.g., temper tantrums or sibling rivalry), it can be managed in the primary care setting. More enduring problems, such as loss of a parent or major depression, require referral to or consultation with a pediatric mental health specialist.
Appropriate care of pediatric mental illness always requires an interdisciplinary approach. Pharmacotherapy alone is never appropriate, nor should it be used without a thorough mental health evaluation (AACAP, 2009a). Clinical practice guidelines further emphasize the need for treatments to be evidence-based and inclusive of short- and long-term follow-up plans. All ethical issues regarding consent and assent are especially important in mental health care. Parents and patients should be aware of treatment risks, benefits, and alternative options (AACAP, 2009a).
Common Mental Health Problems
Special Problems of Infancy and Early Childhood
For many years it was believed that infants and young children could not have mental health problems. It was as though pediatric health care providers believed that young children were protected from even the most adverse experiences. Research since the 1940s clearly demonstrates that this is not the case. Today, despite a growing body of knowledge about children’s mental health problems, frameworks used to identify and treat disorders in older children, adolescents, and adults still provide little guidance in the care of the very young. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3R) defines conditions that affect the youngest children (Zero to Three, 2005).
At first glance the diagnoses seem to address familiar issues in infant and early childhood development, and are commonly addressed in pediatric primary care. Closer examination of the diagnostic criteria demonstrates that these diagnoses address more serious degrees of maladaptive behaviors, often with a significant parental dysfunction and distress. These issues are beyond the management abilities of most primary care providers who do not have extensive preparation in the field of infant mental health. One of the most common classifications (feeding disorders) is presented here, while regulation disorders are discussed in Chapter 15. The purpose of including them is to increase the primary care provider’s awareness of the range of conditions that are best treated by the infant mental health specialist.
Feeding Disorders
Feeding the infant and young child is a key parental task. Parents feel successful and competent when their infant or young child feeds vigorously and grows well. Conversely, feeding problems result in parental frustration and failing child growth and can provoke feelings of failure in many parents. Feeding problems are among the most stubborn challenges primary care providers encounter (see Chapter 10). A serious problem exists when an infant or young child fails to establish a regular feeding pattern based on hunger and satiety. The potential diagnoses cover problems in:
• State regulations that interfere with the infant’s ability to feed well
• Lack of reciprocity between the caregiver and infant during the feeding
• Infantile anorexia associated with a very active infant or young child who refuses food
• Sensory food aversions that are so numerous and extreme they result in nutritional deficiencies (Zero to Three, 2005)
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