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Childhood Mental Health Issues: An Epidemic Warranting Physician Focus

Issue: June 2010

By: Gayatri Mahajan, M.D.

Mrs. M is a single mother who is in your office with her 14-year-old son Joshua for his annual physical. She is worried because Joshua is unusually withdrawn and his grades have been falling. He used to be an A student, and he is now getting Cs and Ds. He often lashes out at his mother and is disrespectful and defiant. His mother is worried that he may be depressed and using drugs. She is crying and distressed in the office.

Is this just the teenage years and “hormones”? Is Joshua really depressed and does he need counseling or a referral to a psychiatrist? What should you do?

The first step is to talk to Joshua in private and establish a confidential relationship with him. Communication is often difficult with adolescents and it may take more than one encounter to really establish rapport. Assure Mrs. M that a confidential interview is better in the long run; most parents are willing to accept this advice.

Ask Joshua about suicidal thoughts, risky behaviors and why he is angry or depressed. Ask him who he trusts and what he likes to do outside of school. Does he want to seek professional counseling or take medication? You should be honest about when this confidentiality will be broken: when he is a danger to himself or others. Talk to his teachers. Encourage Joshua to talk to his mother. Use a depression-screening tool like the ones at www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp to decide if he needs a referral.

Stats and signs

It is estimated that one in five children and adolescents have an emotional, behavioral or developmental mental health disorder. Despite these startling statistics, the National Institute of Mental Health estimates that only 20% of those affected receive treatment, in part due to a lack of specialist availability, social stigma or cost.

Half of adults with mental health problems can be identified by age 14. Childhood mental health issues can produce a profoundly negative effect on long-term quality of life, so early identification and treatment are important. The economic impact alone of untreated mental health concerns is staggering, since it leads to higher rates of juvenile incarceration, school dropout, family dysfunction, drug abuse and unemployment.

In younger children, you can look for these signs:

Marked fall in school performance
Poor grades in school despite trying very hard
Severe worry or anxiety, as shown by regular refusal to go to school, sleep or take part in normal activities
Frequent physical complaints
Hyperactivity, fidgeting or constant movement beyond regular playing
Persistent nightmares
Persistent disobedience or aggression (longer than 6 months) and provocative opposition to authority figures
Frequent, unexplainable temper tantrums
Attempts to harm or kill themselves

In pre-adolescents and adolescents, the following can point to mental health issues:

Marked decline in school performance
Inability to cope with problems and daily activities
Marked changes in sleeping and/or eating habits
Extreme difficulties in concentrating that get in the way at school or home
Sexual acting out
Depression shown by sustained, prolonged negative mood and attitude, often accompanied by poor appetite, difficulty sleeping or thoughts of death
Severe mood swings
Strong worries or anxieties that get in the way of daily life
Repeated use of alcohol and/or drugs
Intense fear of becoming obese with no relationship to actual body weight; excessive dieting, throwing up, or using laxatives to lose weight
Persistent nightmares
Threats of self-harm or harm to others
Self-injury or self-destructive behavior
Frequent outbursts of anger or aggression
Repeated threats to run away
Aggressive or non-aggressive consistent violation of others’ rights; opposition to authority, truancy, thefts or vandalism
Strange thoughts, beliefs, feelings or unusual behaviors

What physicians can do

As a primary care or specialty provider, it’s necessary to know where to make a referral when mental health issues are suspected. Most pediatricians and family practice doctors are comfortable treating ADHD, but are not so confident about treating childhood anxiety disorders, depression and eating disorders.

If you feel you need to ask for an expert opinion, ask the child’s parents to call their insurance company to get a list of mental health providers. Encourage them to talk to schools and friends. There are many resources in the community, including psychiatrists, clinical psychologists, school counselors, licensed clinical social workers, developmental-behavioral pediatricians and trained nurse practitioners.

There is a nationwide shortage of trained mental health professionals and the most needy patients are often the ones who have the least access to care. As primary care providers, we need to become better at diagnosing and treating mental health disorders in children. The AAP established a mental health task force in 2004 to address this issue (www.aap.org/mentalhealth/mh9et.html) and a toolkit for primary care providers was due to be released in June. We need to advocate for better parity in the payment structure for dealing with these time-consuming and poorly reimbursed mental health issues. We also must develop referral networks in the community and schools, and advocate for school-based mental health programs and crisis intervention services. Training for identifying and “rescuing” youth with high-risk behavior is one way to prevent potentially disastrous events.

Our most important effort should be directed toward preventing childhood mental health problems. Children are not born with these disorders; a complex interplay of genetic factors, neuro-chemical imbalances and environmental factors puts them at risk, including teenage pregnancy, domestic violence, maternal depression, poverty, discrimination, long-term physical disability, and parental death or divorce. These “high- risk” children should be nurtured in loving homes with ample community support and given access to high-quality preschool and early head-start programs. We must direct our efforts to provide not just quality medical care, but an environment to raise optimistic, successful children.

Board-certified pediatrician Gayatri Mahajan, M.D., is a member of Solano Regional Medical Group and practices at Sutter Medical Foundation’s Vallejo Care Center. She would like to dedicate this article to her friend and classmate, S. S. Shreeram, a wonderful child psychiatrist who passed away in November 2009 at the age of 42.

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