Addressing Childhood Mental Disorders

Childhood ADHD

Difficulty with attention or hyperactivity can be common, but problematic if severe and persistent 

Conditions that start birth → 6 years 

• effects of prenatal substances 

• learning difficulties 

• Autism Spectrum Disorder

• ADHD

• Oppositional-Defiant Disorder

• some anxiety disorders

Conditions that start 7 → 12 years

• most anxiety disorders

• PTSD

• Conduct disorder

• OCD

Conditions that start 13 → 18 years

• substance use disorder

• MDD

• BPD

• Eating disorders 

• schizophrenia 

Diagnosis for ADHD in children

• must experience 6+ sypmtoms

  • poor concentration, poor listening, disorganization, losing needed things easily distracted, forgetful, fidgety, interruptive, excessive talking, unable to wait

• occur in 2 or more settings (home, school, community) 

• inconsistent with developmental level, several symptoms prior to age 12 

Epidemiology

The study of determinants and distribution of health and disorder

population and public health level

All children

clinical level

children with problems, receiving services

cornerstone of public health and healthcare 

• shaping policy and practice by identifying risks and strengths

• targets for prevention and treatment

prevalence

number of “all cases” in the specific population at any given time, or over a defined period

incidence

number of “new cases” in the specific population during a given period

purpose of accurate estimates

• informing program and service planning

• evaluating the outcomes of public policy investments 

• informing research on causation and interventions 

What does practice aim for

communicating reliably, predicting outcomes, planning and evaluating prevention and treatment interventions

What does research aim for

establishing reliable and valid population norms for understanding causation and informing/evaluating new interventions

challenges in measuring childrens mental health

• dynamic 

• relational 

• definitions and measures

Dynamic challenge

disorders manifest differently at different ages and stages so measures must change as development unfolds 

• many disorders are undefines in their early stages 

relational challenge

childrens mental health is relational

• children are highly dependent on parents, teachers, community members

• always must consider family, school, community

definition and measures challenge

definitions and measures of social and emotional wellbeing is still not agreed upon

• information differs by informant source 

Implications for interventions

• meeting basic needs

• promoting mental wellness

• preventing mental disorders

Meeting basic needs

ensuring that childrens basic needs are met

• safety, stability, and support 

• positive relationships with adults, peer, and community

• successful school, work, community experiences

• has recreational opportunities - sports, art, music, the outdoors

• availability for effective services

Promoting mental wellness

mental health is more than the absence of mental illness 

• mental health promotion is a goal throughout the lifespan and across a range of settings

• building on social determinants of health to strengthen protective factors, lessen risk facks

Primary prevention

reducing the incidence

• goal for childrens mental health 

Secondary prevention (early treatment)

reducing recurrences or exacerbations of existing cases

tertiary prevention (treatment and rehabilitation)

reducing duration or degree of disability

Childhood anxiety disorders

• separation anxiety

• phobias

• panic disorder

• generalized anxiety

separation anxiety

fear of leaving primary caregiver

phobias

severe anxiety when exposed to eg meeting new people, seeing spiders, etc.

panic disorder

extreme fear with physical symptoms and reccurent attacks without triggers 

• palpitations

• nausea

• chest pain, shortness of breath 

generalized anxiety disorder

pervasive feelings of restlessness, fatigue, poor concentration, irritability, muscle tension, insomnia

• without other causes

How to prevent childhood anxiety disordrs

• make sure childrens basic needs are met 

• give families and children skills to cope

  • CBT and RCT

Treating childhood anxiety disorders

psychosocial treatment

• CBT → 12 RCT’s

medication 

• fluoxetine and sertraline when CBT does not success → 2 RCTs each

CBT for Childhood anxiety 

• learn about fear

• learn to relax 

• learn to fight your fear 

• increase activities that promote pleasure and accomplishment for your people 

• educate parents/caregivers and support workers

Major depression in children 

• persistently sad or irritable mood or diminished intrests or pleasures

• 4+ added symptoms over 2+ weeks 

  • changes in appetite

  • changes in sleep 

  • low energy, fatigue

  • reduced concentration 

  • excessive guilt or feeling worthless

  • suicidal thoughts or behaviours

preventing childhood depression

• make sure childrens needs are met 

• give families and children skills to cope 

treating childhood depression

psychosocial treatments

• CBT and interpersonal psychotherapy (IPT)

  • IPT focuses on strengthening relationships and problem solving

medication

• fluoxetine when CBT or IPT do not succeed

preventing suicide in children

• make sure childrens needs are met

• prevent and treat depression

• prevent and treat problematic substance use 

PTSD

experiencing serious adverse events directly or witnessing or learning of these indirectly

• eg. emotional or physical or sexual abuse, family violence, community violence, fires, earthquakes, loss of a parent, etc, 

Diagnosis for PTSD in children

• impaired functioning and symproms for over 1+ months

• symptoms 

  • recurrent involuntary and highly distressing memories and dreams 

  • flahsbacks 

  • intense/prolonged distress on exposure to cues about events 

  • re-enacting trauma

  • negative thoughts 

  • marked hyper-activity 

Preventing PTSD in children

• make sure childrens needs are met 

• give families and children skills to cope 

Treating PTSD

CBT → 3 RCTs

Children behaviour disorders

• oppositional defiant disorder

• conduct disorder 

• substance use disorder 

oppositional defiant disorder 

pattern of angry or argumentative behaviour involving 4+ symptoms over 6+ months 

• loses tempter a lot

• easily annoyed, angry, resentful

• actively defies or refuses requests or breaks rules

• deliberately annoys others 

• blames others 

conduct disorder

repetitive and persistent pattern of antisocial behaviour involving 3+ symptoms over 12+ months 

• being agressive to people or animals 

• destroying property like setting fires 

• deceiving people or stealing 

• violating serious rules 

preventing behaviour disorder 

• make sure childrens needs are met 

• give familes and children skills to cope 

  • parent training → 10 RCTs

Treating behaviour disorders

psychosocial treatments

• parent training → 2 RCTs

• multicomponent programs including CBT, parent training and/or child social skills training → 4 RCTs

medication

• risperidone, an antipsychotic when psychosocial interventions do not succeed → 3 RCTs

  • serious side effects like weight gain, hypertension, type 2 diabetes, etc

Substance use disorder

problematic use leading to clinically significant impairment with 2+ symptoms over 12+ months

Substance use disorder symptoms

• using in larger amounts than intended

• persistent desire but fialed efforts to cut down 

• much time spent obtaining, using, recovering

• continued use depsite failure to meet major obligations 

• cravings, tolerance, withdrawal 

preventing childhood substance misuse

• make sure childrens needs are met

• control availability and ensure positive role models 

• give families and children skills to cope 

What is PreVenture

prevention program for “high risk” adolescents

• designed to target four personality risk factors that are motives for substance misuse and related problems 

  • hopelessness

  • anxiety sensitivity

  • impusivity 

  • sensation seeking 

treating childhood substance misuse

• control availability and ensure positive role models

• give children/youth and familes skills to cope 

preventing childhood ADHD 

• Make sure childrens basic needs are met 

• give families and children skills to cope 

  • parent training → 4 RCTs

treating childhood ADHD

psychosocial treatment

• parent training

• multicomponent interventions

medication 

• methylphenidate, dextroamphetamine, atomoxetine → multiple RCTs for each

Autism spectrum disorder (ASD)

• impaired social communication 

• restricted and repetitive behaviours and interests 

• not simply due to intellectial disability

treating ASD

• Intensive family supports are crucial

OCD

• Obsessions → Recurrent intrusive / unwanted thoughts, urges or images → marked anxiety or distress → repeated attempts to ignore or suppress, e.g., by performing compulsions

• Compulsions→ Repetitive behaviours or mental rituals, e.g., washing, checking, counting, repeating; rituals aimed at reducing distress or preventing dreaded event, e.g., illness, harm to family

OCD diagnosis in children 

• Symptoms significantly interfere with development + functioning, i.e., consume > 1 hour per day

• Children may not recognize that symptoms are excessive, so may not be distressed by them

• Families can be greatly affected, e.g., by child’s fears + rituals

Treating childhood OCD

Psychosocial treatment

• Cognitive-behavioural therapy (CBT) → 9 RCTs

Medications

• Fluoxetine, sertraline, paroxetine, clomipramine (serotonergic antidepressants) when CBT is not enough → 2–3 RCTs for each

Family supports + education are crucial

• Reinforcing symptoms can make them more entrenched

Prevention of childhood eating disorders

Multicomponent interventions including, e.g., discouraging unhealthy weight control practices, encouraging positive body image, healthy lifestyle planning, media literacy training → 5 RCTs

treatment of childhood eating disorders

Psychosocial treatment

• Family therapy→ 5 RCTs

• Hospitalization to stabilize those who are very ill

Bipolar disorder

Manic episode(s) often preceded by or interspersed with “hypomanic” and / or major depressive episodes

Manic episode

Markedly elevated, expansive or irritable mood + abnormally increased energy / activities

• 3+ persistent symptoms, e.g., grandiosity, greatly reduced need for sleep, pressured speech, racing thoughts, excessive pursuit of high-risk activities, e.g., spending

Schizophrenia

• 2+ psychotic and/or “negative” symptoms over 4+ weeks, i.e.,

  • Delusions, hallucinations, grossly disorganized speech, grossly disorganized or catatonic behaviour

  • Reduced emotional expression + motivation + concentration

BPD treatment

Psychosocial treatment

• Multicomponent interventions including, e.g., communication skills, family education + problem-solving → 4 RCTs

• Adjunctive to medications

Medication 

• Lithium → 2 RCTs

• Many serious side effects which need close monitoring, e.g., sedation, gastrointestinal symptoms, excessive thirst

Intensive child + family supports are crucial

• Usually a chronic relapsing + remitting condition

Treatment for schizophrenia

Medications

• Aripiprazole + olanzapine (antipsychotics) → 2 RCTs each

• But there are serious side effects, e.g.,

  • Substantial weight gain, changes to blood lipid profiles, type 2 diabetes, hypertension, sedation

Intensive child + family supports are crucial

• Usually a chronic relapsing + remitting condition

Intellectual disability

Impairment in general mental abilities, affecting adaptive functioning in conceptual, social + practical domains

fetal alcohol spectrum disorder 

Persistent deficits in neurocognitive functioning, self-regulation + adaptive functioning

Intellectual disability examples

• Genetic syndromes, e.g., Down, Fragile X, Prader-Willi

• Prenatal infections, e.g., cytomegalovirus

• Prenatal toxins, e.g., alcohol

• Perinatal trauma, e.g., resulting in cerebral palsy

Covid-19 impact on childrens learning

High impact of school closures

• Education is a determinant of health

• Schools allow parents / families to work, earn income

• Most children with developmental needs rely heavily on schools

• Disadvantaged children rely on school supports including food

• Schools provide mental health help + detect maltreatment

Covid-19 impact on childrens mental health

Children’s mental health symptoms changed

• Anxiety and depression symptoms increased

• Emotional problems, mental distress

• Not at a level that caused clinically significant distress

Additional challenges for children facing socioeconomic disadvantage, fewer supports, inconsistent routines:

• Poorer mental health

Covid-19 impact on childrens physical wellbeing

Global data show that during the public health restrictions, children were

• Being less active, playing fewer sports

• Eating less healthy foods + eating more overall

• Spending more time on “screens”

Who was disproportionately affected by Covid-19

Disadvantaged parents / families

• increased stresses coupled with reduced incomes plus reduced job + housing + food security

• forcing some to accept precarious work, placing them + their children at higher C19 risks

• Contributing to worsening extremes of disadvantage affecting Indigenous, Black + other “racialized” communities

• Contributing to overt attacks, e.g., on Asian communities